Approach to the Unique Care of Adolescents

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Approach to the Unique Care of Adolescents
Charles E. Irwin, Jr., M.D. Department of
Pediatrics Division of Adolescent
Medicine University of California, San Francisco
July 2013
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I see no hope for the future of the world if
they are dependent on the frivolous youth of
today , for certainly all youth are reckless
beyond words. When I was a boy we were taught to
be respectful of elders but the present youth are
exceedingly wise and impatient of restraint.
Hesiod, 8th Century B.C.
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I would there were no age between ten and
three-and-twenty, or that youth would sleep out
the rest, for there is nothing in the between but
getting wenches with child, wronging the
ancientry, stealing, fighting...
The Winters Tale, Shakespeare
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The grain of heedlessness
The time from the 18th to the 24th year is best
suited to military service. The body is then
quite vigorous enough to endure hardships, and
the soldier is as yet free and unfettered. The
grain of heedlessness, a quality peculiar to the
freshness of youth, is an excellent incentive to
martial achievement
Baron Colmar von der Goltz The Nation in Arms 1883
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• Until recently, the pediatrician has been
  preoccupied with premature babies, transfusions,
  feeding problems, running ears The internist has
  also been busy with the ills of adulthood and
  advancing age and has still to come to the period
  of adolescence. Yet this field is particularly
  important, marking as it does the transition from
  boy to man and from girl to woman.
• - James Roswell Gallagher

Gallagher, 1954.
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Granville Stanley Hall1844 - 1924

• Adolescence its psychology and its relation
  to physiology, anthropology, sociology, sex,
  crime, religion and education (1904)

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March 2007
April 2012
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Adolescent Health
Substance use
Accidents injury
Mental health well being
Sexual health
Chronic illness
Obesity eating disorders
Prevention - early intervention - clinical care
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Brain Development

• Grey matter volume peaks in early adolescence
• Selective pruning proceeds from back to front
• Greater efficiency of neurotransmission results
  from myelination
• Neuromaturation underpins emotional regulation
  control

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A Model of Development
Late adolescence 20-24 yrs
Early adolescence 10-14 yrs
Mid adolescence 15-19 yrs
Maturation of brain facilitates regulatory
competence
Period of heightened vulnerability to risk
taking, problems in terms of affect behaviour
Puberty heightens emotional arousability,
sensation-seeking, reward orientation
Steinberg
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Biopsychosocial Development During Adolescence/
Emerging Adulthood Early Adolescence (Age 10 14
Years)
Characteristics Impact
1) Onset of puberty, becomes concerned with developing body. Questions concerning normality of physical maturation, stages of development and how process relates to peers of same gender. Important to normalize differences.
2) Begins to expand social relationships beyond family. Encourage teens to begin to take responsibility for own health - in consultation with parents. Begin time alone with patient.
3) Begin transition from concrete to abstract thinking. Continue anticipatory guidance to parents add prevention education for teen. Concrete thinking requires straight forward explicit messages.
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Biopsychosocial Development During Adolescence/
Emerging Adulthood Middle Adolescence (Age 14
18 years)
Characteristics Impact
1) Pubertal development usually complete, sexual drives emerge. Explores ability to attract others. Sexual experimentation (same and opposite sex) begins.
2) Peer group sets behavioral standards, family values usually persist. Peer group influences engagement in positive and negative health behaviors peers offer key support. Emphasize making good choices and taking responsibility.
3) Conflicts over independence. Increased assumption of independent action, with desire for parental support/ guidance. Encourage negotiation. Increase involvement of teen in setting health goals how to manage health situations. Reinforce adolescents growing competencies.
4) Emergence of abstract thinking with new cognitive competencies. Increased ability to process information and reflect. Leads to questioning adult behavior. May consider broader range of possibilities/options, but not able to integrate into real life.
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Biopsychosocial Development During Adolescence/
Emerging Adulthood Late Adolescence/Emerging
Adulthood (Age 18 24 Years)
Characteristics Impact
1) Physical maturation complete. Body image and gender role definition clearer. Begins to feel comfortable with relationships and decisions regarding sexuality and preference. Individual relationships become more important than peer group.
2) Individuals less ego-centric able to understand others. More open to questioning regarding behavior. More able to work with clinician on setting goals and changing behavior.
3) Idealistic Idealism may lead to conflict with family or authority figures.
4) Identity Exploration/Life roles begin to be defined Interested in discussion of life goals how they impact health.
5) Cognitive development nearing completion Most are capable of understanding a full range of options for health issues. Important to help them become competent in negotiating the health care system.
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Tips on Development

• Early - be very specific focus on youths
  concerns be on alert for early developers
  counsel parents
• Middle trusting friendly relationships are key
  concrete still best emphasize adult connections,
  health promotion harm reduction support/advise
  parents.
• Late - abstract reasoning - understanding
  consequences of actions include partners in
  office visits transition planning

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The Clinical Visit
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Structure of Visit

• Elicit Concerns of Adolescent/Family
• Discuss How visit will go
• Use Development to guide process
• Time alone depending on cultural norms
• Physical Exam guided by concerns
• Feedback to Adolescent and Family at conclusion

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HEEADSSS ASSESSMENT for Psychosocial Concerns
Screening History
Home
Education
Eating
Activities
Drugs
Sexuality
Suicidality
Strengths
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HEEADSSS ASSESSMENT for Psychosocial Concerns
Screening History
Home How is the adolescent's home life? How are his/her relationships with family members? Where and with whom does the patient live? Is his/her living situation stable?
Education (or Employment) How is adolescent's school performance? Is he/she well-behaved, or are there discipline problems at school? If he/she is working, is he/she making a living wage?
Eating (incorporates body image) Does patient have a balanced diet? Is there adequate calcium intake? Is the adolescent trying to lose or gain weight, and (if so), is it in a healthy manner? How does he/she feel about his/her body? Has there been significant weight gain/loss recently?
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HEEADSSS ASSESSMENT for Psychosocial Concerns
Screening History
Activities How does patient spend his/her time? Are they engaging in dangerous or risky behavior? Are they supervised during their free time? With whom do they spend most of their time? Do they have a supportive peer group?
Drugs (including alcohol and tobacco) Does the patient drink caffeinated beverages (including energy drinks)? Does the patient smoke? Does the patient drink? Has the patient used illegal drugs? If there is any substance use, to what degree, and for how long?
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HEEADSSS ASSESSMENT for Psychosocial Concerns
Screening History
Sexuality Is the patient comfortable with his/her sexual development? Have they had a sexual relationship? Does the patient get routine reproductive health checks? Are there any symptoms of a sexually transmitted infection? Does the patient have questions about sexual behavior?
Suicidality (including general mood assessment) What is the patient's mood from day to day? Has he/she thought about/attempted suicide?
Strengths Inquire about assets.
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Recommendations for Adolescent Preventive Health
Care
Age 11 y 12 y 13 y 14 y 15 y 16 y 17 y 18 y 19 y 20 y 21 y
History (initial/interval) X X X X X X X X X X X
Measurements
Height and weight X X X X X X X X X X X
Body Mass Index X X X X X X X X X X X
Blood Pressure X X X X X X X X X X X
Sensory Screening
Vision X X X
Hearing
Development/Behavioral Assessment X X X X X X X X X X X
Psychosocial/Behavioral Assessment
Alcohol Drug Use Assessment
Physical Examination X X X X X X X X X X X
Procedures
Immunization X X X X X X X X X X X
Hematocrit or Hemoglobin
Tuberculin Test
Dyslipidemia Screening ?
STI Screening
Cervical Dysplasia Screening
Anticipatory Guidance X X X X X X X X X X X
X To be performed Risk assessment to be
performed, with appropriate action to follow
? Range during which a service
may be provided with the symbol indicating the
preferred age
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Recommendations for Adolescent Preventive Health
Care
Age1 11 y 12 y 13 y 14 y 15 y 16 y 17 y 18 y 19 y 20 y 21 y
History (initial/interval) X X X X X X X X X X X
Measurements
Height and weight X X X X X X X X X X X
Body Mass Index X X X X X X X X X X X
Blood Pressure X X X X X X X X X X X
Sensory Screening
Vision X X X
Hearing
X To be performed Risk assessment to be
performed, with appropriate action to
follow Adapted from Hagan JF, Shaw JS, Duncan PM.
Bright Futures Guidelines for Health Supervision
of Infants, Children, and Adolescents, 3rd Ed.
Elk Grove Village IL American Academy of
Pediatrics, 2008.
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Recommendations for Adolescent Preventive Health
Care
Age1 11 y 12 y 13 y 14 y 15 y 16 y 17 y 18 y 19 y 20 y 21 y
Development/ Behavioral Assessment X X X X X X X X X X X
Psychosocial/ Behavioral Assessment
Alcohol Drug Use Assessment
Physical Examination2 X X X X X X X X X X X
X To be performed Risk assessment to be
performed, with appropriate action to
follow Adapted from Hagan JF, Shaw JS, Duncan PM.
Bright Futures Guidelines for Health Supervision
of Infants, Children, and Adolescents, 3rd Ed.
Elk Grove Village IL American Academy of
Pediatrics, 2008.
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Recommendations for Adolescent Preventive Health
Care
Age1 11 y 12 y 13 y 14 y 15 y 16 y 17 y 18 y 19 y 20 y 21 y
Procedures
Immunization3 X X X X X X X X X X X
Hematocrit or Hemoglobin4
Tuberculin Test5
Dyslipidemia Screening6 ?
STI Screening7
Cervical Dysplasia Screening8
Anticipatory Guidance9 X X X X X X X X X X X
X To be performed Risk assessment to be
performed, with appropriate action to follow ?
Range during which a service may be
provided with the symbol indicating the preferred
age Adapted from Hagan JF, Shaw JS, Duncan PM.
Bright Futures Guidelines for Health Supervision
of Infants, Children, and Adolescents, 3rd Ed.
Elk Grove Village IL American Academy of
Pediatrics, 2008.
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1Age if an adolescent/young adult comes under
care for the first time at any point on the
schedule, or if any items are not accomplished at
the suggested age, the schedule should be brought
up to date at the earliest possible time. 2At
each visit, age-appropriate physical examination
is essential. 3Schedules per the Committee on
Infectious Diseases, published annually in the
January issue of Pediatrics. Every visit should
be an opportunity to update and complete an
adolescents immunization. 4See AAP Pediatric
Nutrition Handbook, 5th Edition (2003) for a
discussion of universal and selective screening
options. 5Tuberculosis testing per
recommendations of the Committee on Infectious
Diseases, Testing should be done on recognition
of high-risk factors. 6Third Report of the
National Cholesterol Education Program (NCEP)
Expert Panel on Detection, Evaluation, and
Treatment of High Blood Cholesterol in Adults
(Adult Treatment Panel III) Final Report (2002)
URLhttp//circ.ahajournals.org/cgi/content/full/
106/25/3143 and The Expert Committee
Recommendations on the Assessment, Prevention,
Treatment of Child and Adolescent Overweight and
Obesity. Supplement to Pediatrics. In press.
7All sexually active patients should be screen
for sexually transmitted infections (STIs). 8All
sexually active girls should have screening for
cervical dysplasia as part of a pelvic
examination beginning within 3 years on onset of
sexual activity or age 21 (whichever comes
first). 9Refer to the specific guidance by age
as listed in Bright Futures Guidelines.
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Physical Examination

• General Appearance
• Vital Signs

• Affect, Mood, Dress, Energy Level
• BMI, VS, BP, Orthostatics if low BMI, Audiogram,
  Visual Acuity

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BMI

• Assess height and weight EVERY visit
• Calculate BMI
• Look for trends
• Consider the context of growth and development
• Record on the appropriate Growth/BMI chart

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BMI Charts 2-17 year olds
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Physical Exam, cont.

• Skin
• Breasts
• Lymph nodes
• Chest/Cardiovascular
• Rectal
• GU

• Acne, striae, cuts
• Tanner stage, BSE
• Palpate for size
• Palpation/Auscultation
• Symptomatic GI/GU
• Tanner/SMR Staging
• Sy

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Physical Exam, cont.

• Genitalia, Males
• Genitalia, Females

• Teach Testicular Self Exam R/O
• Pelvic if indicated

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Physical Exam, cont.

• Genitalia, Males
• Genitalia, Females

• Teach Testicular Self Exam R/O
• Pelvic if indicated

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PUBERTY
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Sequence of Pubertal Events
Height Spurt FEMALES MALES Breast Development
Menarche Female Pubic Hair Male Public Hair
Testicular Volume
2
3
4
5
2
5
4
3
5
4
3
2
gt4
10
16
9 10 11 12 13 14 15 16
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Timing and Sequence of Pubertal Events in Females
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Timing of Pubertal Onset--Females

• Timing of onset is variable
• Average age of onset of breast development is 8.9
  years in African American girls and 9.9 years in
  white girls. Average age of onset of breast
  development for Mexican American girls appears to
  be in between.

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Sequence of Pubertal Events--Females

Breast bud
Pubic hair
Peak height velocity
Menarche
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Tanner Staging--Females

• Breast staging
• Pubic hair staging

Marshall WA, Tanner JM. Variations in the Pattern
of Pubertal Changes in Girls. Arch Dis Child.
196944(235)291-303. http//www.ncbi.nlm.nih.gov
/pmc/articles/PMC2020414/
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Timing of Pubertal Onset--Males

• Timing of onset is variable
• Average age of onset is 11.6 years (range 9.5 to
  14 years).
• Onset appears to be earliest in African American
  males, latest in white males. Mexican American
  males are in between.

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Sequence of Pubertal Events--Males

• 1.
• 2.
• 3.

Testicular enlargement
Sexual hair, phallic and scrotal changes
Peak height velocity
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Tanner Staging (Sexual Maturity Ratings)--Males

• Genital staging
• Pubic hair staging

Marshall WA, Tanner JM. Variations in the Pattern
of Pubertal Changes in Boys. Arch Dis Child.
197045(239)13-23. http//www.ncbi.nlm.nih.gov/p
mc/articles/PMC2020414/
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Sequence of Pubertal Events
Height Spurt FEMALES MALES Breast Development
Menarche Female Pubic Hair Male Public Hair
Testicular Volume
2
3
4
5
2
5
4
3
5
4
3
2
gt4
10
16
9 10 11 12 13 14 15 16
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Height Spurt

• 25 of adult height is accounted for during
  pubertal growth
• Growth spurt in females
• at average age of 11.5
• average Tanner stage of 2-3
• peak velocity of 8.3 cm/year
• Growth spurt in males
• at average age of 13.5 years
• average Tanner stage of 4
• peak velocity of 9.5 cm/year

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Pubertal timing and behavior

• Early pubertal timing
• In females associated with poor self esteem and
  negative body image. Associated with early onset
  of sexual activity and older partners.
• In males associated with early onset of sexual
  activity, but socially desirable.
• Late maturity
• In males associated with poor self-esteem and
  negative body image
• MEDIATORS?
• Actual timing?
• Perceived timing?

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Puberty great opportunity for education

• Growth Spurt 25 of adult height is accounted
  for during pubertal growth
• Changes in Body Shape and Size
• Voice Change
• Acne
• Body Odor
• Menarche Menses
• Spermarche Ejaculation
• Vital Sign Changes
• Bone MASS

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Questions Concerning Puberty by Early Adolescents
Females (n 114) Males (n 94)
General puberty 13 11
Growth 6 9
Nongenital characteristics 4 5
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Questions Concerning Puberty by Early Adolescents
Females (n 114) Males (n 94)
General anatomy 10 15
General physiology 33 18
Sexuality/reproduction 25 27
Psychosocial aspects 7 5
Ryan, Millstein, Irwin. J Adol Health (1996)
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C

• Youth-friendly care services

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General Principles of Adolescent Health Care
Delivery

• Availability
• Accessibility
• Approachability
• Acceptability
• Appropriateness

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General Principles in Working with Teens

• Rapport and respect are key
• Review the parameters of your relationship,
  encounters, discussions up front AND on a regular
  basis
• Use their developmental stage and interact with
  them accordingly
• Seize every opportunity
• Be up front genuine express your concerns

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General Principles of working with teens

• Assess strengths assets as well as risks
  problems
• Reinforce and bolster connections
• Educate about mind-body connection
• Engage and support family during adolescence
• Be Authoritative

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Some common findings to address

• Acne
• Gynecomastia in males
• Irregular menses
• Poorly controlled chronic problems
• Eczema
• Asthma
• Allergic rhinitis

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Dont forget!

• Adolescent morbidity and mortality is PRIMARILY
  behaviorally related
• Rarely will you find a physical problem that
  hasnt been illuminated by the history
• INVEST YOUR TIME AND EFFORT IN THE PSYCHOSOCIAL
  ASSESSMENT AND COUNSELING!

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The 5 As for Brief Office Based Interventions
Ask Determine the presence of the behavior.
Advise Deliver a clear, personalized message about the need to change the behavior.
Assess willingness to change Determine whether the adolescent is prepared to change his or her behavior.
Assist the behavior change Determine short-term, concrete actions to make the behavior change set behavioral goals. Provide adjunct therapy as appropriate (e.g., nicotine replacement for tobacco cessation).
Arrange follow-up Schedule a follow-up visit or phone call soon after the date set for the behavior change, ideally within 1 week.
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It has been frequently said that adolescence is
the neglected age group perhaps it is more sound
to say that it is physicians' training in the
care of adolescents which has been given
relatively little attention
JR Gallagher. Pediatrics 1957
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Inadequate Training in Adolescent Health

• US primary care physicians (Blum 1990)
• 45 insufficient training is major barrier
• Australian general practitioners (Veit 1995)
• 80 inadequate undergraduate training
• 87 interested in further training
• Swiss primary care doctors (Kraus 2003)
• 62 interested in further training

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Postgraduate medical training agenda
Primary care
Adult medicine
Core skills, attitudes knowledge
Psychiatry
Pediatrics
Obstetrics gynecology
An integrated approach to clinical skills
development for adolescent health
Sawyer et al, 2007
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Make Adolescent Health Visible

• Academic leadership
• Research
• Clinical capacity building
• Policy

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Society for Adolescent Health and Medicine

• The Society for Adolescent Health and Medicine
  (SAHM) is the only national organization (with
  members from 30 countries worldwide) dedicated
  exclusively to advancing the health and
  well-being of adolescents
• 111 Deer Lake Rd, Ste 100, Deerfield, IL 60015
•  
• Phone [phone], Fax [phone],
  info_at_adolescenthealth.org

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References

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• Blum R. (ed). Young people not as healthy as
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• Buckelew SM, Adams SH, Irwin CE, Jr. Gee S, Ozer
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Adolescent Health ,2007

• Adolescence is a time in life that harbours many
  risks and dangers, but also one that presents
  great opportunities for sustained health and well
  being, The Lancet, 2007

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March 2007
April 2012