Enhancing Adolescent Health Counseling; Healthy Teens PDA Screening

1. Enhancing Adolescent Health Counseling; Healthy Teens PDA Screening Ardis L. Olson, MD Cecelia Gaffney, Med Zsolt Nagakaldi, PhD* Department of Pediatrics & Community and Family Medicine Dartmouth Medical School *Oklahoma Health Sciences University CECH primary care research Network Ardis.Olson@dartmouth.edu O

2. Are Adolescents healthy? • Wide range of psychosocial and health risk behaviors exist in adolescence • Health and social choices adolescents make place them at risk and establish adult habits • Increased stress and mental health issues impact health

3. The health visit; missed opportunity • 74% of teens had a health check up in the past 2 years • Wished to discuss an average of 6.7 topics • 1/3 had not discussed any of the topics they wanted to talk about • Only 12% discussed all their desired topics • Only 50% had counseling when risk factors present • 28% counseled if used alcohol • 38% counseled if inadequate exercise • 40% counseled if smoking JD Klein et al., J Adol Health 25;120-130 & 30:190-195

4. Rethinking Adolescent Primary Care • Better ways to efficiently assess the wide range of current health behaviors and risks • More effective counseling Better ways to motivate teens to make changes to improve their health

5. Challenges • Wide range of health risks and key issues missed in clinical interviews or a few questions • Existing screening with GAPS • AMA Guidelines for Adolescent Preventive Services • Screening surveys for younger/older teens and parents (70-80 questions). Initial and follow up forms • Assesses health risk and protective factors • Comprehensive content • Cumbersome to maintain paper survey system Does not address key issues like anxiety, alcohol, strengths

6. “Healthy Teens” Projects • Robert Wood Johnson Foundation Prescription for Health National Program • Funded in both Round One and Round Two • Develop new approaches to health counseling in the preventive health visit • Only adolescent focused project • Utilize technology to optimize time available to clinician to discuss issues • Comprehensive health history/screening adapted from GAPS • Branching question path, if positive for risk behaviors • Additional assessments such as CRAFFT, eating disorders, sports risk screening • Assessed motivation and self-efficacy for change for 5 health behaviors • Confidentiality and Health Messages included during screening

7. CECH: Clinicians Enhancing Child Health • Northern New England practice based research network • NH, VT and southern Maine • Communities range from 2,000 to 150,000 • 45 Pediatric and Family Medicine practitioners • Network research in primary care involves common child and family health issues • Adolescent health, parental depression, obesity prevention

8. John, 14 yr old for a health visit His doctor had cared for him for years He found him a shy kid with no problems who was hard to get talking. • What his PDA revealed: Sad thoughts, no recent fun, no friends or adults he felt he could talk with, guns in the home, didn’t feel his parents really listened to him, school performance worse than last year. Concerned about problems in his family. Binge drinking and CRAFFT positive. Otherwise screener topics negative. • What happened with his provider: The provider knew it was important to talk with John alone. With review of his PDA answers and John opened up and talked about personal and family problems. He acknowledged recent increased drinking at parties and drinking alone recently.

9. Issues covered with the PDA Screener • Health Concerns, Social and Medical History • Nutrition, Physical Exercise and Eating disorders • School, Home Environment and Safety Issues • Tobacco, Alcohol and Drug Use • Sexuality and Relationships • Mental Health, Abuse, and conduct issues • 66 Questions • Up to 25 additional questions if have risks

10. Lessons learned using the PDA screeners • Used in over 4000 adolescent encounters by clinicians in NH • 2 studies of adolescents • Exit surveys of teens about how they see their visit using the PDA* • Follow up of teens for 6 months after their visit** * Olson, AL, Gaffney, CA, Hedberg,VA, Gladstone, GR. Use of inexpensive technology to enhance adolescent health behavior and screening approach, Archives of Child and Adolescent Medicine, 163(2):172-177, 2009. **Olson, AL, Gaffney, CA, Lee, PW, Starr P. Changing adolescent health behaviors; The Healthy Teens Counseling Approach, American Journal of Preventive Medicine, 35(5S):S359-S364, 2008

11. Does the Teen Health VisitChange with the PDA? Outcomes Assessed with post health visit exit surveys • 65 teens pre- PDA screening/counseling • 98 teens during PDA screening/counseling Assessed • Visit satisfaction, perceived confidentiality and whether clinician listened to them carefully • Topics discussed by clinician during the visit • How valuable teens found the clinician discussion Analysis • Chi square comparison of proportions pre vs post • No significant differences by practice site in outcomes

12. Outcomes: Interaction with teen More teens felt their discussion was confidential • 84% with PDA vs. 61% prior to PDA* More teens felt their provider listened very carefully to them during the visit • 88% during PDA use vs. 63% before PDA* rated their provider as listening very carefully to them (1 on a 7 point likkert scale) More teens were very satisfied overall with the visit • 88% during PDA use vs. 64% before PDA* rated visit satisfaction as 1 on a 7 point scale *p <.01

13. Topics Discussed Comparison of the topics teens reported discussed prior to PDA use and after showed An increase in the proportion who discussed: Prior PDA use Fruit/vegetable intake 42% 61% p <.05 Tobacco Use 40% 57% p .07 Alcohol Use 38% 54% p <.05 No significant change in proportion who discussed ; Television viewing 32% 37% Exercise 64% 67% Milk product intake 45% 52% Drug use 38% 50% Mood issues 40% 42% 60 teens with usual care prior to PDAs vs. 91 teens with PPA use

14. Teen View of Helpfulness of Discussion when Topics Discussed* Prior PDA use Fruit/vegetable intake (n=80) 32% 58% p <.05 Milk product intake ( n=74) 44% 70% p <.05 Exercise (n=99) 40% 57% p .08 No significant change; Tobacco Use (n=74) 63% 70% Alcohol Use (n=73) 60% 61% Mood issues (n=62) 38% 53% Drug use (n=59) 61% 67% TV viewing (n=53) 32% 37% *Among teens with topic discussed the proportion who responded discussion was very helpful vs somewhat/ not helpful

15. Changes in Teen Behaviors • After 6 months adolescents* who had a Healthy Teens visit using the PDA were significantly increased the number of days of exercise/week • After the visit were more likely to list multiple nutrition/exercise changes they were planning *92 teens with usual care vs.136 teens with PPA use

16. Beyond GAPS; what is included on the PDA • Branching question path, if positive for risk behaviors • Additional assessments such as CRAFFT, eating disorders, sports risk screening, strengths • Assessed motivation and self-efficacy for change for 5 health behaviors • Confidentiality Message • Concerns /medical problems • Calculation of BMI and BMI % for age; optional feature

17. Questions or worried about- • Weight/height; • Future plans/job; • Stomach ache/vomiting • Diarrhea/constipation • Masturbation • Trouble peeing • Discharge from penis/vagina • Wetting the bed • Sexual organs/genitals • Wet dreams • Trouble sleeping • Feeling tired a lot • Being stressed out • Violence, bullying or your safety • Anger/temper • Other

18. Have any of the following problems • Allergies or hay fever • Asthma/trouble breathing • Seizures • Heart problem/chest pain Headaches/migraines • I had none of the above

19. Sports Cardiovascular risk screening During exercise have you ever been dizzy or passed out? Have you ever been unconscious or had a concussion? Have any of your family members or relatives died of a heart problem or sudden death before age 50?

20. Eating Disorders • Are you satisfied with your eating habits? If No, then asked- Do you ever eat in secret? • Are you satisfied with the size or shape of your body? If No, then asked- Do you spend a lot of time thinking about ways to be thinner? Do you do things to lose or control your weight (skip meals, try not to eat, vomit, take pills, etc)

21. Screening for alcohol & substance abuse CRAFFT: adolescent alcohol/substance abuse C. Have you ever been in a carwhere the driver (including yourself) has been using drugs or alcohol? R. Do you ever use alcohol/drugs to relax, feel better about yourself or fit in? A. Do you ever use alcohol/drugs while you are by yourself, alone? F. Do your family or friends ever tell you that you should cut down on your drinking or drug use? F. Do you ever forgetthings you did while using alcohol or drugs T. Have you gotten into trouble while you were using alcohol or drugs? • Scoring: 2 or more positive responses is a positive screen • Indicates need for further discussion/counseling • 15% of 12-18 yr olds screen positive*

22. Depression/Anxiety Screening with the PHQ-2 Over the past 2 weeks, how often have you been bothered by any of the following problems: • Little interest or pleasure in doing things Feeling down, depressed or hopeless • Feeling nervous, anxious or on edge Not being able to stop or control worrying • Responses: 0= not at all, 1= several days, 2= More than half the days, 3= Nearly every day • Scoring: 2 answers summed. screen positive = 3 or more Total score given. * added if screen positive

23. Suicidality • Have you ever seriously thought about killing yourself, made a plan, or tried to kill yourself? If answer yes, then asked: • Have you had any thoughts about hurting yourself or suicide in the past couple of weeks?

24. Strengths or Assets • Do you volunteer at your school, church or community? • Do you feel that you have a strong attachment or belonging to a group such as your family, friends, teammates, or others? • Are you allowed to be more independent or make more of your decisions as you get older? • Do you feel that you are particularly good at doing a certain thing like math, or soccer, or theater, or cooking, or hunting, or anything else? • Do you have at least one friend you can really talk with? • Do you think your parent(s) or guardian(s) usually listen to you and take you seriously?

25. Interest in making a change • If a dietary risk, inadequate exercise, current use of tobacco, alcohol or drugs teens then asked: • Are you interested in eating a healthier diet at this time? • How important is it to you to eat healthier? (1-100 • How confident are you that you could eat healthier? (1-10) • Getting more exercise, changing your tobacco use, changing youralcohol use, changing your drug use

26. Risk Groups Requiring Clinician Intervention • Diet: < 5 Fruits/Vegs or < 3 Dairy Products • Exercise : < 3x/wk moderate for 30 minutes • TV >2 hr and computer >1 hr • Emotional: Sad/Depressed or history of suicide or violent when angry • Use of seat belts and helmets if needed • Tobacco use past month • Alcohol problems or drunk • Drugs (Marijuana or OTC) • Unprotected sex • Sports cardiac risks

27. Teen risk profiles • No risks 16% 8% • 1-2 risks 61% 55% • 3-5 risks 22% 32% • 6-10 risks 2% 5% Ages: 11- 14 yrs 15-19 yrs N= 1066 N= 921

28. Incorporating the PDA into Daily Practice • Roles of nursing and administrative staff • Teen completes the screener • Maintaining the PDA • Accessing the results • Summary format on PDA that lists number of risk by topic and allows one to jump to specific questions • Printed summary after synch to website • Changes in Clinician counseling approach • Brief motivational techniques to more effectively counsel

29. Office Flow • PDA given to patient either in the waiting room or when put into the exam room. • Teen completes in 9-10 minutes • Easy for nursing/rooming staff • Clinician reviews patient responses • Summary format on PDA that lists number of risk by topic and allows one to jump to specific questions • Printed summary after synch to website • Clinician reviews results with teen • Uses motivational techniques to discuss importance and confidence for making behavioral changes • Follows up as appropriate

32. Clinician Experiences • Able to set priorities because informed before visit • Joint agenda setting with teen • Address issues teens interested in changing differently than when not interested • Important mental health issues • Cluster of fatigue, stress, parents don’t listen, substance use and depression screen positive • Know all the issues have been asked • Frees up time to explore key issues in more depth and counsel vs only drag out the information. • Difficult for clinicians to consistently assess all topics

33. A pediatrician in practice for over 30 years said, “I thought I knew my kids, but I really didn’t. I learned”

34. Also available at our network website • Individual practice data online with capacity to query and download data on individual or group of patients • Brief PDA screener for 4 to 10 year old well child visit for parents • Covers concerns, development, safety, expanded questions re obesity risk behaviors Software and information available at http://www.cancer.dartmouth.edu/cech/ Palm PDAs can be purchased online from secondary vendors Next year will have web based version available for use on netbooks, I touch and other platforms