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As the leader for the specialty of Preventive Medicine and physicians dedicated to prevention, ACPM improves the health of individuals and populations through evidence-based health promotion, disease prevention, and systems-based approaches to improving health and health care.
ADOLESCENT WELLNESS EXAM: Overcoming Reluctance on Both Sides by Building Rapport Using Every Opportunity to Promote Healthy Choices
A Resource from the American College of Preventive Medicine
A TIME TOOL FOR CLINICIANS
ACPM's Time Tools provide an executive summary of the most up-to-date information on delivering preventive services to patients in the context of a clinical visit. Information presented is based on evidence presented in peer-reviewed journals. Please refer to the Adolescent Wellness Exam Clinical Reference for more information.
Adolescent Wellness Exam
Adolescence is thought of as the healthiest stage of life. Most infectious disease and developmental issues of childhood are left behind and the chronic illnesses of adulthood have yet to appear.
But adolescents face many challenges that are unique to their stage of life.
Rapid physical growth, changing hormones, and sexual maturity.
Social and behavioral factors that lead to morbidity and mortality.
Over 70% of adolescent deaths are the result of injuries from four causes: motor vehicle crashes and other unintentional injuries, homicide, and suicide.
Three out of four adolescents engage in at least one risk behavior, yet these behaviors all too often remain unidentified until problems develop. They are seldom discussed with health care providers.
Substance abuse, pregnancy, sexually transmitted disease, depression, eating disorders, suicide, and violence, are common issues that can cause health crises for today's adolescents.
These challenges mandate a fundamental change in adolescent health care services—a greater emphasis on addressing psychosocial issues in clinical practice.
The annual wellness exam is the foundation
Both the Guidelines for Adolescent Preventive Services (GAPS) (American Medical Association, 1997) and Bright Futures (American Academy of Pediatrics, 2008) agree:
An annual confidential wellness exam is one vital key to improving adolescent health.
It is needed to keep up with the changing needs of adolescents, but even more importantly, to develop a trusting relationship that fosters the discussion of sensitive issues.
In fact, every visit should be viewed as an opportunity to ask about risky behaviors and provide brief counseling. It's about taking advantage of teachable moments.
Adolescents are not getting preventive health care
Despite the fact that authoritative recommendations have been in place since the early 1990s, implementation of clinical preventive services remains far below recommended levels.
About two out of three adolescents visit a health care provider once a year, but only 1 in 15 visits are for preventive care, and the proportion gets smaller with increasing age.
Only about 1 in 6 visits overall includes any preventive guidance.
Reasons for this trend:
Adolescents are increasingly resistant to health care visits as they age and think they’re not necessary.
Parents become less involved in their children's lives—less likely to prompt them to seek health care.
Adolescents are unwilling to discuss risky behaviors with health care providers; they lack trust in the confidentiality of information they would share.
Providers lack training and confidence to deal with sensitive issues.
Health care providers do not always recognize adolescent health risks -- some believe that these issues are not the responsibility of primary care.
The result: many health care providers are not pushing the major adolescent wellness issues, so they are not consistently addressed.
Psychosocial issues take center stage Change occurs rapidly in adolescence; new challenges develop with each school year:
Adolescents face the need to fit in, to be accepted; the pressure to experiment, to take risks; challenges to self esteem, body image, and coping with sexuality; violence, depression, the extremes of emotions; and being torn between dependence and independence.
Self esteem may be fragile. Some adolescents may be easily overwhelmed.
Difficulties in one area may enhance the chances of difficulties with other issues (e.g. adolescents who are not doing well academically are also more likely to engage in risky behaviors).
Enhancing communication - openness and confidentiality are the keys
A casual and confidential discussion of health issues is often the best approach with adolescents. To make the most of this conversation:
Confirm your role as health advisor and advocate, and your commitment to keeping information confidential.
Affirm positive behaviors.
Stimulate conversation with non-threatening, open-ended or general questions such as, "Many teenagers feel pressure from their friends to use drugs or alcohol. Have you experienced this?"
Speak openly about sensitive issues. Tell the teen that it's okay to discuss these issues.
Look for hidden agendas. The real reason for the visit may not be apparent at first. Be prepared to draw it out.
Ask about functioning at home, school performance, peer relationships, and sleep patterns. These can give clues to emotional issues.
Repeat back your understanding of the issues. This helps ensure clear communication.
Grasp "teachable moments" to address any issue.
Promote the doctor/adolescent/family partnership—the compatible or shared goals.
So … what to cover in the adolescent wellness exam?
Prior to consult: M ake the most of the limited time
Delegate some services to office personnel. Take time to train them.
Instruct patient/family to complete medical/behavioral history forms in waiting room. Some providers and practices use computers or small audio devices with interactive software to help engage adolescents and maintain confidentiality.
Arrange for nurse to review forms, identify and chart screening needs.
Bright Futures screening recommendations: Table 1
Instruct nurse to also review immunization status, identify and chart immunizations due.
Identify issues that adolescent and/or parents would like to discuss with health care provider.
Provider preparation: Scan chart before meeting adolescent/family.
Goal is to maximize time for guidance and counseling.
Greeting and introduction:
Greet each family member, introduce self, and use their names.
Establish rapport.
Review role as adolescent's health adviser and advocate.
Emphasize commitment to a trusting, confidential and unconditional relationship.
"I am your doctor, not your parent's doctor. You can talk to me about anything in your life because it all affects your health. I will respect your privacy, and will only discuss issues with your parents if you give me permission, or if we are concerned that someone is in danger."
What to include in the consult:
Address needs and concerns of adolescent and parents. Use open-ended questions to clarify issues.
Assess concerns; present plan to address them—include when and how
Review forms and chart with adolescent/parent.
Observe patient’s interaction with parent(s), if present.
Identify needs.
Work with adolescent and family to prioritize goals for visit.
Perform a comprehensive physical exam.
Take this opportunity to ask parent(s) to leave the room; adolescents usually prefer privacy from parents.
Use this time to ask about issues teens are uncomfortable discussing in front of parents (i.e. risk behaviors: sex, substance experimentation, etc.).
Exam components that are especially relevant during adolescence include:
Blood pressure status (percentile for age/gender)
Height, weight and BMI status (percentile for age/gender)
Skin
Breast: sexual maturity (females), gynecomastia (males)
Genitalia: sexual maturity, structural abnormalities (males), sexually transmitted diseases (STDs)
Discuss needed screening based on risk assessment forms.
Discuss needed immunizations.
Provide anticipatory guidance counseling. Five areas to address over the course of annual visits: Table 2
Physical growth and development
Physical and oral health, body image, healthy eating, physical activity
Social and academic competence
Connectedness with family, peers and community, relationships, school performance
Seat belt and helmet use, passenger and driver safety, firearms, interpersonal violence (fighting), bullying
Suggest options for addressing unmet needs, additional resources for complex issues.
Acknowledge importance of issue.
Offer resources (handouts, CD, DVD, websites).
Suggest a follow-up visit or phone call.
Provide a referral to a specialist, program, community organization, etc.
Adolescence can be a challenging time, not only for the adolescent but also for his or her health care provider. The challenge for providers is to become proficient at assessing and providing guidance for the unique psychosocial issues of adolescence, and learning how to relate to adolescents in a way that builds a trusting, open relationship. An annual wellness visit should be promoted, but every visit can be used to encourage healthy choices.
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