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Delivery of Healthcare to Adolescents


Healthcare providers play an important role in nurturing healthy behaviors among adolescents, because the leading causes of death and disability among adolescents are preventable. Adolescence provides a unique opportunity to prevent or modify health conditions arising from behaviors that develop in the 2nd decade of life and that can lead to substantial morbidity and mortality, such as trauma, cardiovascular and pulmonary disease, type 2 diabetes, reproductive health disease, and cancer (see Chapter 132 , Table 132.4 ).

Health systems in each community should be in place to ensure comprehensive and high-quality care to adolescents. Health insurance coverage that is affordable, continuous, confidential, and not subject to exclusion for preexisting conditions should be available for all adolescents and young adults. Comprehensive, coordinated benefits should meet the developmental needs of adolescents, particularly for reproductive, mental health, dental, and substance abuse services. Safety net providers and programs that provide confidential services, such as school-based health centers, federally qualified health centers, family planning services, and clinics that treat sexually transmitted infections ( STIs ) in adolescents and young adults, need to have assured funding for viability and sustainability. Quality-of-care data should be collected and analyzed by age so that the performance measures for age-appropriate healthcare needs of adolescents are monitored. Affordability is important for access to preventive services. Family involvement should be encouraged, but confidentiality and adolescent consent are critically important. Healthcare providers , trained and experienced in adolescent care, should be available in all communities. Healthcare providers should be adequately compensated to support the range and intensity of services required to address the developmental and health service needs of adolescents. The development and dissemination of provider education about adolescent preventive health guidelines have been demonstrated to improve the content of recommended care ( Table 137.1 ). The ease of recognition or expectation that an adolescent's needs can be addressed in a setting relates to the visibility and flexibility of sites and services. Staff at sites should be approachable, linguistically capable, and culturally competent. Health services should be coordinated to respond to goals for adolescent health at the local, state, and national levels. The coordination should address service financing and delivery in a manner that reduces disparities in care.

Table 137.1
Bright Futures/American Academy of Pediatrics Recommendations for Preventive Healthcare for 11-21 Yr Olds
Adapted from Hagan JF, Shaw JS, Duncan PM, editors: Bright Futures: guidelines for health supervision of infants, children, and adolescents, ed 4, Elk Grove Village, IL, 2017, American Academy of Pediatrics.
PERIODICITY AND INDICATIONS
HISTORY Annual
MEASUREMENTS
Body mass index Annual
Blood pressure Annual
SENSORY SCREENING
Vision At 12 yr and 15 yr visits or if risk assessment positive
Hearing Screen with audiometry, including 6,000 and 8,000 Hz high frequencies once at 11-14 yr, once at 15-17 yr, and once at 18-21 yr.
DEVELOPMENTAL/BEHAVIORAL ASSESSMENT
Developmental surveillance Annual
Psychosocial/behavioral assessment Annual
Depression screening Annual for 12 yr and older
Tobacco, alcohol, and drug use assessment If risk assessment positive
PHYSICAL EXAMINATION Annual
PROCEDURES
Immunization * Annual
Hematocrit or hemoglobin If risk assessment positive
Tuberculin test If risk assessment positive
Dyslipidemia screening Once at 9-11 yr, and once at 17-21 yr
STI screening If sexually active
HIV screening † Once between ages 15 and 18 yr
Discuss and offer at earlier age and annually if risk assessment positive.
Cervical dysplasia screening ‡ Beginning at age 21 yr
ORAL HEALTH Annual; refer to dental home
ANTICIPATORY GUIDANCE Annual §
HIV, Human immunodeficiency virus; STI, sexually transmitted infection.

* Schedules per the Advisory Committee on Immunization Practices, published annually at http://www.cdc.gov/vaccines/schedules/hcp/index.html and http://redbook.solutions.aap.org/SS/Immunization_Schedules.aspx .

† CDC recommends universal, voluntary HIV screening of all sexually active people, beginning at age 13 yr. The American Academy of Pediatrics recommends offering routine HIV screening to all adolescents at least once by 16-18 yr of age and to those younger if at risk. US Preventive Services Task Force recommends offering routine HIV screening to all adolescents age 15 yr and older at least once and to those younger if at risk. Patients who test positive for HIV should receive prevention counseling and referral to care before leaving the testing site.

‡ Screening for cervical cancer, April 2012, US Preventive Services Task Force. http://www.uspreventiveservicestaskforce.org/uspstf/uspscerv.htm .

§ Refer to specific guidance by age as listed in Bright Futures guidelines.

Although most adolescents in the United States have seen a healthcare provider in the past year and report a usual source of healthcare, adolescents are less likely to receive preventive care services. According to the 2011 National Health Interview Survey, an estimated 90% of 12-17 yr old U.S. adolescents had 1 or more contacts with a healthcare professional in the past year, 98% identify a usual source of care at a physician's office or clinic, and 17% made at least 1 emergency department visit in the past year. Uninsured adolescents are the least likely to receive care. In 2015, 63% of people under age 19 yr were covered at some point during the year by private insurance, and 43% of children had public health insurance at some point during 2015. However, even among adolescents who are fully insured with a usual source of care, most do not receive preventive healthcare. An analysis of claims data from a large Minnesota health plan with approximately 700,000 members found that among patients age 11-18 yr who were enrolled for at least 4 yr between 1998 and 2007, few received preventive care visits. One third of adolescents had no preventive care visits from age 13 through 17 yr, and another 40% had only a single such visit. Nonpreventive care visits were more frequent in all age-groups, averaging about 1 per yr at age 11 yr, climbing to about 1.5 per yr at age 17 yr. Among older adolescents, females had both more preventive care and more nonpreventive care visits than did males.

The Patient Protection and Affordable Care Act (ACA) , enacted in March 2010, has expanded access to both commercial health plans and Medicaid for young adults age 19-26 yr ( Fig. 137.1 ). From June 2010 through June 2012, the proportion of young adults with insurance increased from 65.7% to 73.8%. Currently, ACA provisions require that commercial health plans (1) continue dependent coverage to 26 yr, regardless of the young adult's financial or dependent status, marriage, or educational enrollment; (2) mandate university and college student health plans to enhance consumer protections for students; (3) provide financial assistance for young adults to enroll into health insurance exchanges with incomes ranging from 133–399% of the federal poverty level in Medicaid expansion states ; and (4) offer preventive healthcare services free of any cost sharing, deductibles, or copayments. In states that have expanded Medicaid coverage, all adults with incomes <133% of the federal poverty level are eligible to enroll.

Fig. 137.1
Percentage of adults age 19-25 yr with health insurance by coverage type and percentage uninsured at the time of the interview: United States, 1997–September, 2012. Note: Estimates for 2012 are based on data collected in January through September. Data are based on household interviews of a sample of the civilian noninstitutionalized population.

(Data from CDC/NCHS, National Health Interview Survey, 1997–2012, Family Core Component.)

The complexity and interaction of physical, cognitive, and psychosocial developmental processes during adolescence require sensitivity and skill on the part of the health professional (see Chapter 132 ). Health education and promotion, as well as disease prevention, should be the focus of every visit. In 2017 the American Academy of Pediatrics (AAP) in collaboration with the U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau, published the 4th edition of Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents , which offers providers a strategy for delivery of adolescent preventive health services with screening and counseling recommendations for early, middle, and late adolescence ( Table 137.2 ). Bright Futures is rooted in the philosophy of preventive care and reflects the concept of caring for children in a “medical home.” These guidelines emphasize effective partnerships with parents and the community to support the adolescent's health and development.

Table 137.2
Adolescent Screening Recommendations
Adapted from Hagan JF, Shaw JS, Duncan PM, editors: Bright Futures: guidelines for health supervision of infants, children, and adolescents, ed 4, Elk Grove Village, IL, 2017, American Academy of Pediatrics; and Bright Futures/American Academy of Pediatrics: Recommendations for Preventive Pediatric Health Care (Periodicity Schedule), 2017. https://www.aap.org/en-us/Documents/periodicity_schedule.pdf .
11-14 YR OLD VISIT 15-17 YR OLD VISIT 18-21 YR OLD VISIT
Universal Screening Action Action Action
Cervical dysplasia * N/A N/A Pap smear all young women at 21 yr visit
Depression Adolescent depression screen beginning at 12 yr visit Adolescent depression screen Adolescent depression screen
Dyslipidemia Lipid screen once at 9-11 yr Lipid screen once at 17-21 yr Lipid screen once at 17-21 yr
Hearing Once at 11-14 yr
Audiometry, including 6,000 and 8,000 Hz high frequencies		 Once at 15-17 yr
Audiometry, including 6,000 and 8,000 Hz high frequencies		 Once at 18-21 yr
Audiometry, including 6,000 and 8,000 Hz high frequencies
HIV † Selective screening (see below) HIV test once at 15-18 yr HIV test once at 15-18 yr
Tobacco, alcohol, or drug use Tobacco, alcohol, or drug use screen Tobacco, alcohol, or drug use screen Tobacco, alcohol, or drug use screen
Vision At 12 yr visit
Objective measure with age-appropriate visual-acuity measurement using HOTV or Lea symbols, Sloan letters, or Snellen letters		 At 15 yr visit
Objective measure with age-appropriate visual-acuity measurement using HOTV or Lea symbols, Sloan letters, or Snellen letters		 N/A

11-14 YR OLD VISIT 15-17 YR OLD VISIT 18-21 YR OLD VISIT
Selective Screening Risk Assessment (RA) Action If RA+ Action If RA+ Action If RA+
Anemia + on risk screening questions Hemoglobin or hematocrit Hemoglobin or hematocrit Hemoglobin or hematocrit
Dyslipidemia (if not universally screened at this visit + on risk screening questions and not previously screened with normal results Lipid profile Lipid profile Lipid profile
HIV † + on risk screening questions HIV test HIV test (if not universally screened at this visit) HIV test (if not universally screened at this visit)
Oral health (through 16 yr visit) Primary water source fluoride deficient Oral fluoridation supplementation Oral fluoridation supplementation N/A
STIs

  • Chlamydia

  • Gonorrhea

Sexually active females
Sexually active males and + on risk screening questions		 Chlamydia and gonorrhea NAAT (use tests appropriate for population and clinical setting) Chlamydia and gonorrhea NAAT (use tests appropriate for population and clinical setting) Chlamydia and gonorrhea NAAT (use tests appropriate for population and clinical setting)

  • Syphilis

Sexually active and + on risk screening questions Syphilis test Syphilis test Syphilis test
Tuberculosis + on risk screening questions Tuberculin skin test Tuberculin skin test Tuberculin skin test
Vision at other ages + on risk screening questions at 11, 13, and 14 yr visits Objective measure with age-appropriate visual-acuity measurement using HOTV or Lea symbols, Sloan letters, or Snellen letters Objective measure with age-appropriate visual-acuity measurement using HOTV or Lea symbols, Sloan letters, or Snellen letters Objective measure with age-appropriate visual-acuity measurement using HOTV or Lea symbols, Sloan letters, or Snellen letters

NA, Not applicable; NAAT, nucleic acid amplification test; STIs, sexually transmitted infections.

* Screening for Cervical Cancer. April 2012. U.S. Preventive Services Task Force. http://www.uspreventiveservicestaskforce.org/uspstf/uspscerv.htm .

† Centers for Disease Control and Prevention recommends universal, voluntary HIV screening of all sexually active people, beginning at age 13 yr. American Academy of Pediatrics recommends routine HIV screening offered to all adolescents at least once by 16-18 yr of age and to those younger if at risk. U.S. Preventive Services Task Force recommends routine HIV screening offered to all adolescents age 15 yr and older at least once and to those younger if at risk. Patients who test positive for HIV should receive prevention counseling and referral to care before leaving the testing site.

The Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices (ACIP) currently recommends routine adolescent vaccines for universal administration beginning at the 11-12 yr old visit, or as soon as possible, (a) tetanus–diphtheria–acellular pertussis vaccine (Tdap), (b) the meningococcal conjugate vaccine (MCV4) with a booster at age 16 yr, and (c) the human papillomavirus vaccine (HPV) series (see Chapter 197 ). ACIP recommends annual influenza vaccination and hepatitis A virus (HAV) vaccination to adolescents and young adults who have not previously received the HAV vaccine series if immunity against HAV is desired or for those at increased risk for infection, such as men who have sex with men (MSM), injection drug users (IDU), and those with chronic liver disease or clotting factor disorders, or who live in areas that target older children for HAV vaccine.

The time spent on various elements of the screening will vary with the issues that surface during the assessment. For gay and lesbian youth (see Chapter 134 ), emotional and psychological issues related to their experiences, from fear of disclosure to the trauma of homophobia, may direct the clinician to spend more time assessing emotional and psychological supports in the young person's environment. For youth with chronic illnesses or special needs , the assessment of at-risk behaviors should not be omitted or deemphasized by assuming they do not experience the “normal” adolescent vulnerabilities.

Legal Issues

Gale R. Burstein

The rights of an individual, including those of adolescents, vary widely between nations. In the United States, the right of a minor to consent to treatment without parental knowledge differs between states and is governed by state-specific minor consent laws . Some consent laws are based on a minor's status, such as minors who are emancipated, parents, married, pregnant, in the armed services, or mature. In some states, minors can be considered emancipated if they are or have served in the armed services or are living apart from parents and are economically independent through gainful employment. A mature minor is a minor who is emotionally and intellectually mature enough to give informed consent and who lives under the supervision of a parent or guardian. Courts have held that if a minor is mature, a physician is not liable for providing beneficial treatment. There is no formal process for recognition of a mature minor. The determination is made by the healthcare provider.

Some minor consent laws are based on services a minor is seeking, such as emergency care, sexual healthcare, substance abuse, or mental healthcare ( Table 137.3 ). All 50 states and the District of Columbia explicitly allow minors to consent for their own health services for STIs . Approximately 25% of states require that minors be a certain age (generally 12-14 yr) before they can consent for their own care for STIs. No state requires parental consent for STI care or requires that providers notify parents that an adolescent minor child has received STI services, except in limited or unusual circumstances.

Table 137.3
Types of Minor Consent Statutes or Rules of Common Law That Allow for Medical Treatment of a Minor Patient Without Parental Consent
Data from American Academy of Pediatrics: Consent for emergency medical services for children and adolescents, Pediatrics 128:427–433, 2011.
LEGAL EXCEPTIONS TO INFORMED CONSENT REQUIREMENT MEDICAL CARE SETTING
The “emergency” exception

  • The child is suffering from an emergent condition that places his or her life or health in danger.

  • The child's legal guardian is unavailable or unable to provide consent for treatment or transport.

  • Treatment or transport cannot be safely delayed until consent can be obtained.

  • The professional administers only treatment for emergent conditions that pose an immediate threat to the child.

The “emancipated minor” exception

  • Married

  • Economically self-supporting and not living at home

  • Active-duty status in the military

  • In some states, a minor who is a parent or pregnant

  • Some states might require a court to declare the emancipation of a minor.

The “mature minor” exception Most states recognize a mature minor, in which a minor, usually ≥14 yr, displays sufficient maturity and intelligence to understand and appreciate the benefits, risks, and alternatives of the proposed treatment and to make a voluntary and reasonable choice on the basis of that information. States vary or whether a judicial determination is required.
Exceptions based on specific medical condition (state laws vary) Minor seeks:

  • Mental health services

  • Pregnancy and contraceptive services

  • Testing or treatment for HIV infection or AIDS

  • Sexually transmitted infection testing and treatment

  • Drug and alcohol addiction treatment

Minors' right to consent for contraceptive services varies from state to state. Almost 50% of states and the District of Columbia explicitly authorize all minors to consent for their own contraceptive services; and 50% of states permit minors to consent for their own contraceptive services under specific circumstances, such as being married, a parent, currently or previously pregnant, over a certain age, or a high school graduate, or per physician's discretion.

A minor's right to consent for mental healthcare and substance abuse treatment services vary by state and age of minor, whether care is medical vs nonmedical (e.g., counseling), and whether care is delivered as an inpatient vs outpatient basis. Minor consent laws often contain provisions regarding confidentiality and disclosure, even when general state consent laws do not have such provisions.

The confidentiality of medical information and records of a minor who has consented for his or her own reproductive healthcare is governed by numerous federal and state laws. Laws in some states explicitly protect the confidentiality of STI or contraceptive services for which minors have given their own consent and do not allow disclosure of the information without the minor's consent. In other states, laws grant physicians discretion to disclose information to parents.

The confidentiality of medical information and records of a minor who has consented for his or her own healthcare is also governed by numerous federal and state laws. Laws in some states explicitly protect the confidentiality of STI, contraceptive, or mental health services for which minors have given their own consent, and do not allow disclosure of the information without the minor's consent. In other states, laws grant physicians discretion to disclose information to parents. Title X and Medicaid both provide confidentiality protection for family planning services provided to minors with funding from these programs.

Federal regulations issued under the Federal Health Insurance Portability and Accountability Act of 1996, known as the HIPAA Privacy Rule , defer to state and “other applicable laws” with respect to the question of whether parents have access to information about care for which a minor has given consent. Thus, both the state laws that either prohibit or permit disclosure of confidential information and the federal Title X and Medicaid laws that protect the confidentiality of care for adolescents are important under the HIPAA Privacy Rule in determining when confidential information about health services for minors can be disclosed to parents.

Billing for confidential services is complex. Commercial health plans send home an explanation of benefit (EOB) to the primary insured or the primary beneficiary, listing services rendered by the provider and reimbursed by the health plan. An EOB documenting that confidential health services were rendered to their adolescent dependent that is received by a parent may disclose those services. In addition, copayments automatically generated with certain billing codes for office visits and medications can be a barrier for adolescents receiving care, including treatment.

Providers may elect to establish a policy of discussing with their adolescent patients when medical records and other information will be disclosed and developing a mechanism to alert office staff as to what information in the chart is confidential. For legal and other reasons, a chaperone should be present whenever an adolescent female patient is examined by a male physician.

Bibliography

  • American Academy of Pediatrics Committee on Pediatric Emergency Medicine and Committee on Bioethics : Policy statement: consent for emergency medical services for children and adolescents. Pediatrics 2011; 128: pp. 427-433.
  • Coleman DL, Rosoff PM: The legal authority of mature minors to consent to general medical treatment. Pediatrics 2013; 131: pp. 786-793.
  • Ford C, English A, Sigmond G: Confidential healthcare for adolescents: position paper of the Society for Adolescent Medicine. J Adolesc Health 2004; 35: pp. 1-8.
  • National Institute for Health Care Management Foundation : Protecting confidential health services for adolescents and young adults: strategies and considerations for health plans. NIHCM Foundation Issue in Brief. May 2011. http://www.nihcm.org/images/stories/NIHCM-Confidentiality-Final.pdf
  • The Alan Guttmacher Institute : An overview of minors' consent laws. State policies in brief, July 2017, Guttmacher Institute. http://www.guttmacher.org/statecenter/spibs/spib_OMCL.pdf
  • Weiss C: Protecting minors' health information under the federal medical privacy regulations.2003.American Civil Liberties UnionNew York http://www.aclu.org/files/FilesPDFs/med_privacy_guide.pdf

Screening Procedures

Gale R. Burstein

Interviewing the Adolescent

The preparation for a successful interview with an adolescent patient varies based on the history of the relationship with the patient. Patients (and their parents) who are going from preadolescence to adolescence while seeing the same provider should be guided through the transition. Although the rules for confidentiality are the same for new and continuing patients, the change in the physician–patient relationship , allowing more privacy during the visit and more autonomy in the health process, may be threatening for the parent as well as the adolescent. For new patients, the initial phases of the interview are more challenging given the need to establish rapport rapidly with the patient in order to meet the goals of the encounter. Issues of confidentiality and privacy should be explicitly stated along with the conditions under which that confidentiality may need to be altered, that is, in life- or safety-threatening situations. For new patients, the parents should be interviewed with the adolescent or before the adolescent to ensure that the adolescent does not perceive a breach of confidentiality. The clinician who takes time to listen, avoids judgmental statements and the use of street jargon, and shows respect for the adolescent's emerging maturity will have an easier time communicating with the adolescent. The use of open-ended questions, rather than closed-ended questions, will further facilitate history taking. (The closed-ended question, “Do you get along with your father?” leads to the answer “yes” or “no,” in contrast to the question, “What might you like to be different in your relationship with your mother?” which may lead to an answer such as, “I would like her to stop always worrying about me.”)

The goals of the interview or clinical encounter are to establish an information base, identify problems and issues from the patient's perspective, and identify problems and issues from the perspective of the clinician, based on knowledge of the health and other issues relevant to the adolescent age-group. The adolescent should be given an opportunity to express concerns and the reasons for seeking medical attention. The adolescent as well as the parent should be allowed to express the strengths and successes of the adolescent, in addition to communicating problems.

The effectiveness of an interview can be compromised when the interviewer is distracted by other events or individuals in the office, when extreme time limitations are obvious to either party, or when there is expressible discomfort with either the patient or the interviewer. The need for an interpreter when a patient is hearing impaired or if the patient and interviewer are not language compatible provides a challenge but not necessarily a barrier under most circumstances (see Chapter 11 ). Observations during the interview can be useful to the overall assessment of the patient's maturity, presence or absence of depression, and the parent–adolescent relationship. Given the key role of a successful interview in the screening process, adequate training and experience should be sought by clinicians providing comprehensive care to adolescent patients.

Psychosocial Assessment

A few questions should be asked to identify the adolescent who is having difficulty with peer relationships (Do you have a best friend with whom you can share even the most personal secret?), self-image (Is there anything you would like to change about yourself?), depression (What do you see yourself doing 5 yr from now?), school (How are your grades this year compared with last year?), personal decisions (Are you feeling pressured to engage in any behavior for which you do not feel you are ready?), and an eating disorder (Do you ever feel that food controls you, rather than vice versa?). Bright Futures materials provide questions and patient encounter forms to structure the assessments. The HEADS/SF/FIRST mnemonic, basic or expanded, can be useful in guiding the interview if encounter forms are not available ( Table 137.4 ). Based on the assessments, appropriate counseling or referrals are recommended for more thorough probing or for in-depth interviewing.

Table 137.4
From Dias PJ: Adolescent substance abuse: assessment in the office, Pediatr Clin North Am 49:269–300, 2002.
Adolescent Psychosocial Assessment: HEADS/SF/FIRST Mnemonic

  • H ome. Space, privacy, frequent geographic moves, neighborhood

  • E ducation/School. Frequent school changes, repetition of a grade/in each subject, teachers' reports, vocational goals, after-school educational clubs (e.g., language, speech, math), learning disabilities

  • A buse. Physical, sexual, emotional, verbal abuse; parental discipline

  • D rugs. Tobacco, electronic cigarettes or vaping devices, alcohol, marijuana, inhalants, “club drugs,” “rave” parties, others; drug of choice, age at initiation, frequency, mode of intake, rituals, alone or with peers, quit methods, number of attempts

  • S afety. Seat belts, helmets, sports safety measures, hazardous activities, driving while intoxicated

  • S exuality/ S exual Identity. Reproductive health (use of contraceptives, presence of sexually transmitted infections, feelings, pregnancy)

  • F amily and F riends

    • Family: Family constellation; genogram; single/married/separated/divorced/blended family; family occupations and shifts; history of addiction in first- and second-degree relatives; parental attitude toward alcohol and drugs; parental rules; chronically ill, physically or mentally challenged parent

    • Friends: Peer cliques and configuration (“preppies,” “jocks,” “nerds,” “computer geeks,” cheerleaders), gang or cult affiliation

  • I mage. Height and weight perceptions, body musculature and physique, appearance (including dress, jewelry, tattoos, body piercing as fashion trends or other statement)

  • R ecreation. Sleep, exercise, organized or unstructured sports, recreational activities (television, video games, computer games, internet and chat rooms, church or community youth group activities [e.g., Boy (BSA)/Girl Scouts; Big Brother/Sister groups, campus groups]). How many hours per day, days per week involved?

  • S pirituality and Connectedness. Use HOPE *

    * HOPE, H ope or security for the future; o rganized religion; p ersonal spirituality and p ractices; e ffects on medical care and end-of-life issues.

    or FICA †

    † FICA, Faith beliefs; importance and influence of faith; community support.

    acronym; adherence, rituals, occult practices, community service or involvement

  • T hreats and Violence. Self-harm or harm to others, running away, cruelty to animals, guns, fights, arrests, stealing, fire setting, fights in school

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