Adolescent Health Setting the Stage and the Psychosocial Interview

1. Adolescent HealthSetting the Stage and the Psychosocial Interview Karen Weiss, NP, MS, MPH February 22, 2010

2. 10 My teen years were… • The best years of my life • Fine • Wouldn’t relive them if you paid me $1,000,000! • Teen years – was I ever a teenager?

3. 10 When advised she’s your next patient you are… • Curious and interested in getting to know her • Slightly put off but willing to try • Hopeful that an adolescent fellow is in clinic today and you can take the kid vomiting down the hall

4. Adolescence • Transition between childhood and adulthood • Generally physically healthy period • Needs vary by development and personal circumstances • Experience shaped by race, ethnicity, religion, socioeconomic status, family, peers, etc.

5. Internal Barriers to Care for the Adolescent • Reliance on peers or family member for health information • Perceived or actual negative past experiences with the health care system • Sense of invincibility • Low self esteem • Cultural and linguistic barriers

6. External Barriers to Care • Perceived lack of confidentiality • Poor communication by providers • Insensitive attitude of providers • Lack of knowledge or skills of provider • Lack of money, insurance, transportation • Limited office hours • Inaccessible locations

7. Adolescent Friendly Health Services Include: • Establishing a comfortable, confidential safe space for teens • Staffing office with providers knowledgeable about the care of teens • Office hours and locations convenient for teens • Availability of alternative funding sources to cover costs of services

8. The Adolescent Psychosocial Screen Adolescents are essentially healthy. Threats to health are usually associated with specific behaviors related to social experimentation, developmental pressures and increased risk taking behaviors.

9. Adolescent Mortality • Violence and injury account for 72% of all deaths during adolescence • MVAs are the leading cause of death among teens; > 50% related to drugs or alcohol • Homicide and suicide are the 2nd and 3rd leading cause of death among teens

10. Adolescent Morbidity • One in ten 15-19 year old women become pregnant each year • One in four sexually active adolescents will have an STD before graduating from high school Youth Risk Behavior Survey 2007

11. Youth Risk Behavior Survey 2007 High Risk Behaviors • 11% of teens rarely or never wear a seat belt • 30% rode in a car with a driver who had been drinking alcohol • 45% reported current alcohol use • 20% report current marijuana use • 48% report ever having had sexual intercourse

12. The Heath Care Provider’s Role • Teens want to talk to their provider about sensitive issues. • One large study found that health care providers were the 2nd most common source of health information for teen boys and girls, second only to a parent.

13. The Health Care Provider’s Role • Huge discrepancy between what teens want to talk to their provider about and what actual discussions take place.

15. The Health Care Provider’s Role • Parents want clinicians to discuss health issues with their teens • One 1990s study found that more than 85% wanted clinicians to discuss pregnancy, safe sex, STDS, contraception and depression with their teen

16. Health Care Provider’s Role • The number one reason providers sited for lack of communication was the feeling that they were inadequately trained to deal with these and other adolescent health issues

17. The HEEADSS Screening H: Home E: Education/Employment E: Eating A: Activities D: Drugs/Substance Abuse S: Sexuality S: Suicide

18. Creating the Proper Environment for Collecting Sensitive Information • Separating the teen from the parent • Confidentiality • Verbal and non-verbal cues

19. Separating the Teen from the Parent • Meet together. Listen to concerns of parent and teen • Meet with teen alone • Meet together again. Review info teen has authorized you to disclose

20. Confidentiality • Sexuality • Contraception • Mental Health Services • Substance Use • Laws may vary from state to state

21. Confidentiality • Contraceptive services: 26 states (including Maine) and the District of Columbia allow all minors (12 and older) to consent to contraceptive services. 21 States allow only certain categories of minors to consent to contraceptive services. 4 States have no relevant policy or case law. • STI Services : All states and the District of Columbia allow minors to consent to STI Services. • Source: Guttmacher Institute State Policies In Brief as of November 2009

22. Confidentiality Resources The Alan Guttmacher Institute www.guttmacher.org The Center for Adolescent Health & the Law www.cahl.org Health Privacy Project www.healthprivacy.org

23. Confidentiality • The practitioner is legally required to break confidentiality in instances involving : • Physical abuse • Sexual abuse • Homicidal intent • In some states injuries resulting from violence for example gunshot and stab wounds

24. HOME

25. Home • Who lives at home with you? • How are your relationships with siblings, parents, other relatives? • To whom do you go for advice or to discuss difficult topics? • What are the rules like at home? • Is there a gun in your home? • Have you ever run away? • Is there any violence in your home? Do you feel safe there?

26. EDUCATION/EMPLOYMENT

27. Education • What grade are you in? • What kind of student are you? • What are your best and worst subjects? • How many days have you missed in the past year and what was the reason? • Is your school a safe place? • What are your educational and life goals? RED FLAGS: Recent drop in grades

28. Employment • Are you currently working? • Where? • How much? • Do you help pay for things at home? • What are your future career interests?

29. EATING AND EXERCISE

30. Eating and Exercise • What do you like about your body • What do you wish you could change • Have there been any recent changes in your weight • Have you dieted in the past year • How, how often • Have you done anything else to lose weight (e.g. laxatives, vomiting)

31. Eating and Exercise • Does it ever feel like your eating is out of control • How many meals do you eat a day • Calcium, iron, fiber in diet • How often do you exercise • For how long • How vigorously

32. Teen Perception of Weight Majority of teens not happy with their current weight -- whether or not they actually qualify as overweight!

34. 10 Percent of teenfemales and males who perceive themselves as overweight • 19% females; 4% males • 42% females;13% males • 35% females & 24% males

35. Activities • How do you like to spend your free time • What are your hobbies, clubs, religious/spiritual activities • Do you play any sports • Which ones, how many hours per week • How much time spent watching tv or playing video games

36. DRUGS AND SUBSTANCE USE

37. 10 In the past month, how many high school students reported episodic binge drinking? • 7% • 14% • 26% • 41%

39. Drugs, Alcohol,Tobacco • What’s the scene like at your school? Do any of your friends use tobacco? Alcohol? Other drugs? • Does anyone in your family use tobacco? Alcohol? Other drugs? • Do you use tobacco? Alcohol? Other drugs? • Do you ever drink or use drugs when you’re alone? • Have you ever used performance enhancing drugs (steroids, OTC supplements)

41. SEX AND SEXUALITY

42. 10 What percentage of teens have had sexual intercourse by age 13 • 4% females; 10% males • 12% females; 26% males • 15 % females; 4% males • 25% females; 32% males

43. Sex and Sexuality • Have you ever been in a romantic relationship • Have any of your relationships become sexual (if yes, take complete sexual history) • Avoid asking “Are you sexually active?” • Have you ever been forced or pressured to have sex

44. For Sexually Active Teens • Ask about specific sexual behaviors • Number of partners in the past six months; in their lifetime • Age of onset of sexual activity • Sex with boys, girls or both • Be aware that teens who self describe as heterosexual may have same sex encounters • Be aware that teens who self describe as gay or lesbian may have heterosexual encounters • Contraceptive use/condom use

45. LGBQT Youth: 3 Key Constructs • Sexual Orientation • Sexual Behavior • Gender or gender identify

46. Sexual Orientation • One’s pattern of physical and emotional attraction to others. • Moving away from traditional dichotomy – homosexual/heterosexual • Many teens more comfortable with newer terms: questioning, queer, bisexual. • Reflect fact that for many, sexual orientation may lie somewhere between homosexuality and heterosexuality

47. Sexual Behavior • The way in which a teen chooses to express his or her sexual feelings • One study found less than one third of teens who reported same sex experiences actually identified as LGB • Number of youth who self identify as LGB increased with age • For many teens, sexual identify development is a dynamic and fluid process.

48. Gender Identity • A personal and culturally defined construct based on teen’s perception of being male or female. • Transgender youth: teen’s gender identity does not match his or her biologically or anatomically defined sex

49. Sexual Orientation and Behavior Are you romantically interested in boys, girls or both • Are you comfortable with your feelings • Have you talked with family or friends about your sexuality? Are you concerned about their responses or your safety • Have you had sex with someone of the same gender • For younger teens: when you imagine yourself in a relationship in the future, is it with a boy, girl or both

50. Why Ask About Sexual Orientation • 2-5% of teens self identify as gay, lesbian, queer or bisexual • 68% of providers do not include sexual orientation in sexual histories at any age • Asking routinely normalizes idea that there is a range of sexual orientations and behaviors and that you’re open to discussing them