Adolescent Well Care : Making Every Opportunity Count

1. Adolescent Well Care:Making Every Opportunity Count Michele Dritz, MD, MS Adolescent Medicine Clinic Wright-Patterson AFB Medical Center

2. Overview • Background data on adolescent preventive care provision • Adolescent preventive care guidelines • Ohio and national statistics • Current guidelines • Setting the stage for providing quality care to adolescents

3. The rewards of caring for Adolescents • Many adult chronic diseases have origins in childhood and adolescence • Most adolescent morbidity and mortality is preventable and related to personal health behavior – unintentional injuries, reproductive health issues, co-morbidities related to obesity • Adolescence is a time of developing independence and establishment of long-term health behaviors Preventable problems related to personal behaviors where providers can help make a difference!

4. Preventive Care Services • Only 38% of adolescents had a preventive care visit in the past year • Only 35% of adolescents receive the recommended preventive care services • On average, adolescents have non-preventive care visits 1-1.5 times per year, versus 0.15-0.28 times per year for preventive care visits • Only 40% of adolescents had time alone with their provider at their last preventive care visit

5. Adolescent Preventive Care Guidelines • Lots of opinions… • Guideline for Adolescent Preventive Services (GAPS) • American Medical Association (AMA) • Bright Futures (BF) • American Academy of Pediatrics (AAP), Maternal & Child Health Bureau (MCHB), US Public Health Services • Guide to Clinical Preventive Services • United States Preventive Services Task Force (USPSTF) • Recommendations for Pediatric Preventive Health Care • American Academy of Pediatrics (AAP) • Age Charts for Periodic Health Examinations • American Academy of Family Physicians (AAFP) • Adolescent Immunization updates • Advisory Committee on Immunization Practices (ACIP)

6. Not always a lot of consensus Elster, AB, “Comparison for Recommendations for Adolescent Clinical Preventive Services Developed by National Organizations”, Arch PediatrAdolesc Med, 1998, 152:193-198.

7. What’s a doctor to do?

8. Making the most of the visit • Medical history • Psychosocial history with screening and counseling for high risk behaviors • Adolescent exam and pelvic exam • Screening and labs • Immunizations • Health guidance

9. Medical History

10. Medical History • Chronic medical conditions • Medications and supplements • Prescription, Over-the-counter, nutritional supplements • Past hospitalizations • Medical, Psychiatric • Surgical history • Injury history • Concussions, Sports injuries • Family medical history • Cardiovascular risk • Psychiatric illnesses • Substance abuse • Mental health history • Hospitalizations, counseling, suicide attempts, medications • Review of systems • Current concerns

11. Gynecological History • Last Menstrual Period – An adolescent vital sign • Age of menarche • Median = 12.4 years • Cycle length • Mean length = 21-45 days • Menstrual flow • Normal length ≤7 days • Typical menstrual products = 3-6 pads/tampons per day • Ovulatory cycle symptoms • Dysmenorrhea, headaches, PMS, PMDD • Pregnancies and/or abortions

12. Psychosocial History and High Risk Behaviors

13. Taking a Psychosocial History • H: Home • E: Education and Employment • E: Eating • A: Activities • D: Drugs • S: Sexuality • S: Suicide and Depression • S: Safety from Injury and Violence

14. Eating Behaviors and Weight:Ohio & National Statistics • 33% of Ohio teens are overweight or obese • Over ½ of female teens and ⅓ of male teens use unhealthy weight control behaviors such as skipping meals, fasting, smoking, vomiting or using laxatives • Eating disorders have the highest mortality rate of any other mental illness

15. Eating Behaviors and Weight • Important to screen both girls and boys • Be cognizant of high risk categories for eating disorders: • Involvement in weight-specific sports (wrestling, gymnastics, dance) and competitive athletes • Frequent dieters • Recent or significant weight loss; or being overweight • Diabetes and other chronic illnesses • Co-morbid psychiatric and personality disorders • Family history (eating disorder, obesity) • Ask about typical meal intake, exercise, body image and diets/other weight loss behaviors • Plot BMI on a growth chart • Ask about their weight goals and help develop with them healthy weight plans • Opportunity to engage in motivational interviewing

16. Drugs & Substance Use:Ohio Statistics • 29% report binge drinking (5 or more alcoholic drinks within a few hours) • 20% report having their first drink before the age of 13 • 34% report using marijuana one or more times in their life • 22% report smoking in the past month

17. Drugs & Substance Use • Increased risk-taking behavior is developmentally appropriate in adolescence, but can still be dangerous and lead to negative long-term consequences • Screening tools developed to help providers assess risk category • CRAFFT (alcohol and drugs) • Know your local resources

18. Sex and Sexuality:Ohio Statistics • 45% of Ohio teens have had sexual intercourse • 40% did not use a condom during their last sexual encounter • 5 to 6% of US students identify themselves as gay, lesbian, bisexual or transgender

19. Sex and Sexuality • Importance of asking questions and not assuming anything • In order to determine STD risk, you need to know what and where to screen • May need to be specific in your questions: kissing, touching, oral sex, anal sex, penile-vaginal intercourse? • When was the last time they had sex? • Asking about safe sex: • Did they use a condom? • Have they ever had an STD? Have they ever been tested? • Contraception: • Have they ever been pregnant or had an abortion? • Are they trying to get pregnant?

20. Suicide & Depression:Ohio Statistics • 25% of teens report feeling depressed • 13% of teens had suicidal ideations in the past year • 7% attempted suicide in the past year • 91% of parents were unaware of their teen’s suicide attempts

21. Suicide & Depression • 2009 USPSTF recommendation for routine depression screening if systems in place for treatment • Use screening tools such as PHQ-9, SIGECAPS or BDI to adequately assess risk • Other important questions to ask: • History of counseling? • Psychiatric hospitalizations? • Recent suicidal ideation? • History of suicide attempt in past? • Non-suicidal self-injurious behaviors • If concern, assess current safety, presence of reliable adult support, if there are guns in the home • Know your local resources

22. Safety, Violence and Injury:Ohio Statistics • 30% of teens said they were in a physical fight in the past year • 28% reported being harassed or bullied on school grounds • In Ohio, there were 47,444 confirmed cases of child abuse or neglect – 26% higher than the national average • 23% of teen reporting riding in a vehicle driven by someone who had been drinking

23. Violence and Injury • Important to screen both boys and girls • Either can be victim or perpetrator • Screening tools available: • FISTS • Ask about history of physical or sexual abuse, dating violence or witnessing domestic violence • MVAs are the leading cause of morbidity in adolescents and young adults ages 10 to 24 • Discuss use of seatbelts • Discuss risks of drinking and driving or getting into car with driver that has been drinking

24. High Risk Behaviors • Most risks are taken by “multiple-risk” teens who have many points of contact and therefore many possible intervention sites • Nearly all teens, even multiple risk-taking adolescents participate in positive behaviors • So what should a physician do? • Celebrate and praise teens who are avoiding high-risk behaviors • Encourage and support participation in positive behaviors, especially in risk-taking teens • Target the risk-taking behaviors as a whole and work with the teen to minimize negative outcomes

25. AdolescentExam

26. Physical Exam • Vitals, including last menstrual period (LMP) • Height, weight, BMI • Plot height, weight & BMI • Overweight = BMI 85th – 95th percentile • Obese = BMI ≥ 95th percentile • Underweight = BMI <5th percentile • Comprehensive physical • Importance of having teen change into a gown to be able to do thorough skin and genitourinary (GU) exam

27. Male GU Exam • Determine Sexual Maturity Rating (SMR) • Look for signs of STIs • Penile discharge, warts, vesicles • Examine testicles • Hydrocele, hernia, varicocele, mass

28. Female GU Exam • Determine Sexual Maturity Rating (SMR) – breast and genitals • Look for signs of STIs • Vaginal discharge, warts, vesicles • Is a pelvic exam necessary? • AAP: All sexually active females • ACOG: Not necessarily at 1st visit, but with annual STD screen • GAPS: No, can do STD screening via vaginal or urine sample for females, urine sample for males • Bright Futures: If “clinically warranted” • Do a pelvic exam if: • Symptomatic • Vaginal symptoms, abdominal or pelvic pain, abnormal bleeding • Question about pubertal development or primary amenorrhea • Due for a pap smear • Current ACOG recommendations, 21 years or older • Pelvic exam includes external exam, speculum and bimanual

29. Screening and Labs

30. Screening and Labs:Ohio Statistics • 26% of US female adolescents had at least one of the most common STIs (HPV, Chlamydia, Trichomonas, HSV) • Syphilis rates in Ohio teens have more than tripled since 2005 • Approximately 10% of US teens have elevated cholesterol levels • The incidence rate of Type II Diabetes in Cincinnati children has increased 10-fold

31. Screening and Labs • Sexually Transmitted Infections: 1High Risk = >1 sex partner in past 6 months, history of STI, IV drug use, sex for money, homeless, sex with high risk partner 2MSM = men who have sex with men 3WSW = women who have sex with women 4Pap Smear = ACOG: 21 yo; American Cancer Society: 3 years after sex or by 21 yo 5Based on risk due to sexual practices

32. Screening and Labs • Sexually Transmitted Infections: • If asymptomatic: • Males: • Urine GC/CT NAAT (“1st catch” urine) • Females: • Vaginal GC/CT NAAT (self-obtained) – preferred method • urine GC/CT NAAT also option (“1st catch” urine) • Trichomonasvaginal swab (can be self obtained) • If symptomatic: • Male: • Urine GC/CT NAAT (“1st catch” urine) • Female: • Endocervical, Vaginal or urine GC/CT NAAT • Trichomonasvaginal swab (physician obtained) • Pelvic exam with bimanual

33. Screening and Labs • Tuberculosis: • PPD • Recommendation: Selective screening based upon risk factors • Suspected contact with TB • Clinical or radiographic findings suspicious for TB • Emigration from TB endemic area • Travel to TB endemic countries or close contact with travel to those areas • Live in high prevalance TB area as determined by local health department • HIV positive • Live with someone who is HIV positive • Incarcerated adolescents • Exposure to HIV positive individuals, homeless persons or nursing home residents • Institutionalized adolescents • Illicit drug use • Migrant farm worker • Exposure to high-risk adult

34. Screening and Labs • Dyslipidemia: • Fasting lipid panel • No recommendation for universal screening, but selective screening by most guidelines • Concern is that targeted screening misses up to ½ of all affected teens, but recommended intervention is typically only diet and exercise • Selective screening if any of the following: • Family history of premature CHD (<55 yo) • Parent with total cholesterol of > 240 mg/dl • Family history unknown • Obesity • High blood pressure • Diabetes • Heart disease • If results normal, repeat every 3-5 years

35. Screening and Labs • Diabetes: • Fasting plasma glucose: • No recommendation for universal screening and no pediatric specific recommendations by any of the adolescent guidelines • Concern is due to increasing rates of adolescent obesity and associated co-morbidities and insulin resistance • American Diabetes Association “consensus statement” for screening adolescents: • Overweight/Obese PLUS 2 OF THE FOLLOWING: • 1st or 2nd degree relative with Type 2 DM • Native American, African American, Hispanic American, Asian/South Pacific Islander • Signs or conditions associated with insulin resistance (PCOS, acanthosisnigricans, HTN, dyslipidemia) • Retest every 2 years

36. Screening and Labs • Anemia: • High prevalence of iron deficiency anemia due to poor diet, rapid growth and menstrual losses • Only recommended by AAP • Hemoglobin or Hematocrit • With 1stvisit, end of puberty or both • Vision Screen: • Mixed opinions • Recommendation: • At initial visit, and then every 2-3 years • Hearing Screen: • Mixed opinions • Recommendation: • At least once during adolescence

37. Immunizations

38. Immunizations • 2011 Advisory Committee on Immunization Practice (ACIP) update:

39. Immunizations • Adolescent Specific: • Tdap: • Recommendation: 11-12 years • Catch-up: 13- 18 years • Booster: Td booster every 10 years • MCV4: • Recommendation: 11-12 years • Booster: at age 16 years • Catch-up: • 1 dose at age 13-18 years • Dose 1 at 13-15 years, booster at 16-18 years • 1 dose if previously unvaccinated college freshman living in dorm • HPV: • HPV4 (Gardasil) – HPV 16, 18, 6, 11 – females and males • HPV 2 (Cervarix) – HPV 16, 18 – females only • Recommendation: 3 shot series at 11-12 years

40. Immunizations • Childhood Catch-up: • Varicella • Recommendation: • 2 dose series if no clinical immunity and no previous immunization • 1 dose due for catch-up if previously received only single dose • Hepatitis B: • Recommendation: 3 dose series if not previously vaccinated • Hepatitis A: • Recommendation: 2 dose series if MSM or other high risk group • Catch-up for any other recommended childhood vaccines • IPV, MMR • Continuous: • Influenza: • Recommendation: Yearly

41. Health Guidance

42. Health Guidance • Guidance for parents: • Normative adolescent development • Physical, emotional and sexual development • Discussing health-related behaviors with their teens • Acting as positive role models • Methods to help teens avoid potential injuries: • Safe driving • Avoiding weapons at home • Monitoring their teen’s activities • Maintaining open communication with their teen

43. Health Guidance • Guidance for adolescents: • Normative development • Physical, emotional and sexual development • Importance of becoming actively involved in their health care and medical decisions • How to avoid potential injury: • Safe driving • Use of safety devices (helmets, seatbelts, etc) • Healthy interpersonal relationships • Avoiding weapons • Promotion of physical activity and healthy dietary habits • Responsible sexual behavior including abstinence, condom use, contraception, and STI screening. • Avoidance of tobacco, alcohol, drugs and anabolic steroids

44. Health Guidance • Mixed Opinions: • Breast self-exam (BSE) • USPSTF recommended against routine BSE (2009) • ACOG still recommends • Still recommended in all adolescent preventive services guidelines except GAPS (AMA) • Testicular self-exam (TSE) • USPSTF recommended against routine TSE and physician testicular exam for testicular cancer screening (2004) • American Cancer Society does not recommend • Still recommended in all adolescent preventive services guidelines except GAPS (AMA)

45. So how do we go from here… to there?

46. Setting the Stage

47. Setting the Stage • Capturing every opportunity at every visit • Honoring confidentiality • Asking the right questions to gather a thorough psychosocial history • Fostering behavior change through motivational interviewing

48. Capturing Every Opportunity • Develop processes that automatically allow the right thing to happen every time • Immunization standing orders • “Best Practice” reminders • Consider the use of screening tools to optimize both the reliability of care anduse of time • Risk behaviors, depression, substance use • Have health education tools readily accessible for patients and create a teen-friendly environment • Take a team approach and consider developing a quality improvement team • Track your practices performance over time

49. Honoring Confidentiality • Recognize an adolescent’s legal right to confidential services • Ohio law: • Can consent: STI counseling & treatment, HIV testing, substance abuse evaluation and treatment, limited mental health evaluation and treatment, emergency treatment, sexual assault services, adoption • Cannot consent: abortion, psychiatric medication, inpatient psychiatric hospitalization, HIV treatment • No law either way: contraception including emergency contraception, pregnancy testing, prenatal care • Making confidentiality a part of the discussion from the beginning • “New Patient” letter • Website • Initial and subsequent visits

50. Honoring Confidentiality • Discussing confidentiality with both teens and parents • Stressing importance of open communication • Data showing importance of confidentiality in adolescents seeking care • Stress that both you and parent have the same interest – to keep their teen healthy and safe • Discussing the limits of confidentiality • Concern for harm to self or others, or harm done to them • Areas of possible disclosure (i.e. insurance billing, mental health records) • Acting on that promise • Seeing the teen alone for part of the visit • Getting alternative contact info for teen in case necessary (i.e. cell phone)