Asking about Substance Use in the Biopsychosocial Interview

Division of Adolescent/Young Adult Medicine Department of Pediatrics UCSF Benioff Children’s Hospital University of California, San Francisco January 2014

Disclosure

• • • Neither I nor any member of my immediate family has a financial relationship or interest with any proprietary entity producing health care good or services related to the content of this CME activity My content will not include discussion/reference to any commercial products or services I do not intend to discuss an unapproved/investigative use of commercial products/devices

Overview of Presentation

• • • • • Adolescent Health Risk taking Review of substance use by age and trends Adolescent Development & how it fits with substance use Clinical practice

Adolescent Health

Accidents & injury Mental health & well being Sexual health Substance use Chronic illness Obesity & eating disorders Prevention - early intervention - clinical care

Risk Taking – Background

• • • Majority of morbidity/mortality during adolescence is preventable Behaviors/Disorders responsible for leading causes of morbidity/mortality during adolescence & adulthood - initiated or onset during second decade of life Co-occurrence of risk behaviors is common

Leading Causes of Death in U.S.: Ages 10-19 & Ages 25-44, 2010

Source: National Center for Injury Prevention & Control, WISQARS database, 2012

Risky Behaviors During Adolescence

Specific Behaviors & Outcomes

• • • • •

Substance Use:

Habituation & Trauma

Sexual Activity:

STI ’ s & Pregnancy

Injury Related Behavior:

Trauma & Disability

Eating Behaviors:

Eating Disorders, Obesity & Chronic Physical & Mental Health Disorders

Mental Health Disorders:

Disability

Health Risk Behaviors - Trends

Injury-related behavior Unsafe sexual behavior Inadequate physical activity Tobacco use Alcohol use Marijuana use Poor nutritional habits Prescription & OTC use Violence

Arrows denote trends in prevalence over past decade

Covariation of Behaviors

• Injury-related Behavior & Substance Use • Violent behaviors & Substance Use • Substance Use/Substance Use - Sequence & Developmental Trajectory by Gender • Sexual Behavior & Substance Use • Eating Behaviors & Other Risk Behaviors (including Substance Use ) • Certain Behaviors as Markers (e.g., Sexual Activity, Substance Use , etc.)

Single & Multiple Risk-Taking Among 7th 12th Graders, by Behavior

Illicit Drug Use Binge Drinking Regular Alcohol Use Regular Tobacco Use Marijuana Use 0% 5% 5% 7% 10% 11% 11% Single Risk-Takers Multiple Risk-Takers 14% 15% Source: Urban Institute, 2000, analysis of 1995 Add Health data 20%

Covariation of Risk Behaviors Among Adolescents (% of Sx, N=1241)

Sexually Active Tobacco Alcohol Marijuana Dangerous Vehicle Use 16.7

Sexually Active

100.00

83.0

88.0

74.2

Tobacco Alcohol Marijuana 44.7

40.0

56.2

100.0

77.8

93.8

91.7

100.0

95.3

66.5

57.4

100.0

Dangerous Vehicle Use 58.0

82.3

90.8

71.9

* Dangerous vehicle users include subjects who reported driving or riding in vehicles when the driver is under the influence of alcohol or other substances.

12.8

12.0

15.6

100.0

Source: Irwin et. al. 1998

Covariation of Behaviors

Summary of Covariation of Behaviors

• High Prevalence Rate • Early Age of Onset • Gender Specificity • Peers/Family • Behaviors/Not Isolated

Overview of Substance Use

• • Substance Used Marijuana Tobacco Alcohol Smokeless Tobacco Nonmedical Use of Prescription Drugs By Age Group (MTF data) 8 th , 10 th & 12 th graders

Source

Sources of Substance Use Data

Website Frequency Organization Age Location Recent Data

2011 Youth Risk Behavior Surveillance System (YRBSS) http://www.icpsr.u

mich.edu/icpsrweb /SAMHDA/studies/ 34481 Every Other Year Centers for Disease Control and Prevention (CDC) High School Students Schools Monitoring the Future (MTF) National Survey on Drug Use and Health (NSDUH) http://www.monit

oringthefuture.org

/ Every Year https://nsduhweb.

rti.org/ Every Year University of Michigan Substance Abuse and Mental Health Services Agency (SAMHSA) 8 th , 10 th , 12 th Grade Students & Follow-up sample of graduating seniors Individuals ages 12 and older Schools 2012 Homes 2011

Trends in 30-Day Prevalence of Substance Use among 8th Grade Students, 2002-2012

20 15 10 5 0 35 30 25 50 45 40 Marijuana Alcohol (Any Use) Alcohol (Been Drunk) Cigarettes Smokeless Tobacco 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

Year Source: Monitoring the Future, 2012; NSDUH,2011

Trends in 30-Day Prevalence of Substance Use among 10th Grade Students, 2002-2012

20 15 10 5 0 50 45 40 35 30 25 Marijuana Alcohol (Any Use) Alcohol (Been Drunk) Cigarettes Smokeless Tobacco 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

Year Source: Monitoring the Future, 2012; NSDUH,2011

Trends in 30-Day Prevalence of Substance Use among 12th Grade Students, 2002-2012

20 15 10 5 0 50 45 40 35 30 25 Marijuana Alcohol (Any Use) Alcohol (Been Drunk) Cigarettes Smokeless Tobacco 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

Year Source: Monitoring the Future, 2012; NSDUH,2011

Reported 30-Day Substance Use by Grade, 2012

50 45 40 35 30 25 20 15 10 5 0 Marijuana Alcohol 8th Grade 10th Grade 12th Grade Alcohol (Been Drunk) Cigarettes Smokeless Tobacco

Source: Monitoring the Future, 2012

Nonmedical Use of Prescription-Type Psychotherapeutics in Lifetime, Past Year, And Past Month, by Detailed Age Category, 2011

25 20 15 10 5 0 TOTAL 12 13 14 Lifetime Past Year Past Month 15 16 17 18 19

Age Source: National Survey on Drug Use and Health, 2011

By 8

th

grade

• Cigarettes: 16% • Alcohol: 30% • Been Drunk: 13% • Marijuana: 15% • Smokeless Tobacco: 8% • Prescription Drugs: 4.%

Source: Monitoring the Future, 2012; NSDUH, 2011

By 10

th

grade

• Cigarettes: 28% • Alcohol: 54% • Been Drunk: 35% • Marijuana: 34% • Smokeless Tobacco: 15% • Prescription Drugs: 11%

Source: Monitoring the Future, 2012; NSDUH,2011

By 12

th

grade

• Cigarettes: 40% • Alcohol: 69% • Been Drunk: 54% • Marijuana: 45% • Smokeless Tobacco: 17% • Prescription Drugs: 21%

Source: Monitoring the Future, 2012

Biopsychosocial Development

Biopsychosocial

• Asynchrony of physiologic/psychosocial development - early vs. late maturation • Developmental drives during adolescence – stage of adolescence • Ongoing Brain Development • Attitudes/beliefs – – Sense of competence/invulnerability Lack of awareness of consequences • Male gender

Adolescent Brain Development

• Brain development now extends into the adolescent years • Most of this development occurs in the frontal lobe Executive functions - Planning - Reasoning - Impulse control

Characteristics of Concrete Thinking

• Present orientation • Seeing is believing/my (my friend’s) experience is what counts • Ability to project into future limited • Cannot perceive long-range implications of current decisions

Characteristics of Abstract Thinking

• Ability to: – Envision alternatives – Evaluate alternatives – Engage in perspective taking – Reason about chance and probability – PRIORITIZE!

Socioenvironmental

• Peer group known to be engaging in problem behavior • Role of Parents/Families – Authoritarian/permissive vs. Authoritative – – Family history of alcoholism/substance abuse Parental/family use of substances • Life transitions • School transitions • Ready availability of substances, vehicles

Behavioral

• Lack of skills to resist peer pressure • Sensation-seeking drives • Mental health disorders • Anxiety • ADHD • Depression

A Model of Development

Early adolescence 10-14 yrs Puberty heightens emotional rousability, sensation-seeking, reward orientation Mid adolescence 15-19 yrs Period of heightened vulnerability to risk taking, problems in terms of affect & behaviour Late adolescence 20-24 yrs Maturation of brain facilitates regulatory competence Steinberg

Early Adolescence

Biopsychosocial Development During Adolescence/ Emerging Adulthood Early Adolescence (Age 10 –14 Years)

Characteristics Impact 1) Onset of puberty developing body. , becomes concerned with Questions concerning normality of physical maturation, stages of development and how process relates to peers of same gender. Important to normalize differences.

2) Begins to expand social relationships beyond family.

3) Begin transition from concrete to abstract thinking. Encourage teens to begin to take responsibility for own health - in consultation with parents. Begin time alone with patient.

Shift in health provider’s focus from anticipatory guidance to parents to prevention education for teen. Concrete thinking requires straight forward explicit messages.

Biopsychosocial Development During Adolescence/ Emerging Adulthood Early Adolescence (Age 10 –14 Years)

Characteristics Impact

1) Onset of puberty, becomes concerned with developing body. Questions concerning normality of physical maturation, stages of development and how process relates to peers of same gender. Important to normalize differences.

2) Begins to expand social relationships beyond family.

3) Begin transition from concrete to abstract thinking.

Encourage teens to begin to take responsibility for own health - in consultation with parents. Begin time alone with patient.

Shift in health provider’s focus from anticipatory guidance to parents to prevention education for teen. Concrete thinking requires straight forward explicit messages.

Biopsychosocial Development During Adolescence/ Emerging Adulthood Early Adolescence (Age 10 –14 Years)

Characteristics Impact

1) Onset of puberty, becomes concerned with developing body. Questions concerning normality of physical maturation, stages of development and how process relates to peers of same gender. Important to normalize differences.

2) Begins to expand social relationships beyond family.

3) Begin transition from concrete to abstract thinking.

Encourage teens to begin to take responsibility for own health - in consultation with parents. Begin time alone with patient.

Shift in health provider’s focus from anticipatory guidance to parents to prevention education for teen. Concrete thinking requires straight forward explicit messages.

Middle Adolescence

Biopsychosocial Development During Adolescence/ Emerging Adulthood Middle Adolescence (Age 14 – 18 years)

Characteristics 1) Pubertal development usually complete , sexual drives emerge.

2) Peer group sets behavioral standards, family values usually persist.

Impact Explores ability to attract others. Sexual experimentation (same and opposite sex) begins.

Peer group influences engagement in positive and negative health behaviors; peers offer key support. Important to emphasize making good choices and taking responsibility. 3) Conflicts over independence.

4) Emergence of abstract thinking with new cognitive competencies. Increased assumption of independent action, with desire for parental support/ guidance. Encourage negotiation. Increased involvement of teen in setting health goals & how to manage health situations. Reinforce adolescents’ growing competencies. Increased ability to process information and reflect. Leads to questioning adult behavior. May consider broader range of possibilities/options, but not able to integrate into real life.

Biopsychosocial Development During Adolescence/ Emerging Adulthood Middle Adolescence (Age 14 – 18 years)

Characteristics

1) Pubertal development usually complete, sexual drives emerge.

2) Peer group sets behavioral standards, family values usually persist.

Impact

Explores ability to attract others. Sexual experimentation (same and opposite sex) begins.

Peer group influences engagement in positive and negative health behaviors; peers offer key support. Important to emphasize making good choices and taking responsibility.

3) Conflicts over independence. Increased assumption of independent action, with desire for parental support/ guidance. Encourage negotiation. Increased involvement of teen in setting health goals & how to manage health situations. Reinforce adolescents’ growing competencies. 4) Emergence of abstract thinking with new cognitive competencies. Increased ability to process information and reflect. Leads to questioning adult behavior. May consider broader range of possibilities/options, but not able to integrate into real life.

Biopsychosocial Development During Adolescence/ Emerging Adulthood Middle Adolescence (Age 14 – 18 years)

Characteristics

1) Pubertal development usually complete, sexual drives emerge. 2) Peer group sets behavioral standards, family values usually persist.

3) Conflicts over independence.

4) Emergence of abstract thinking with new cognitive competencies.

Impact

Explores ability to attract others. Sexual experimentation (same and opposite sex) begins. Peer group influences engagement in positive and negative health behaviors; peers offer key support. Important to emphasize making good choices and taking responsibility.

Increased assumption of independent action, with desire for parental support/ guidance. Encourage negotiation. Increased involvement of teen in setting health goals & how to manage health situations. Reinforce adolescents’ growing competencies.

Increased ability to process information and reflect. Leads to questioning adult behavior. May consider broader range of possibilities/options, but not able to integrate into real life.

Biopsychosocial Development During Adolescence/ Emerging Adulthood Middle Adolescence (Age 14 – 18 years)

Characteristics

1) Pubertal development usually complete, sexual drives emerge.

Impact

Explores ability to attract others. Sexual experimentation (same and opposite sex) begins. 2) Peer group sets behavioral standards, family values usually persist.

3) Conflicts over independence.

4) Emergence of abstract thinking with new cognitive competencies.

Peer group influences engagement in positive and negative health behaviors; peers offer key support. Important to emphasize making good choices and taking responsibility. Increased assumption of independent action, with desire for parental support/ guidance. Encourage negotiation. Increased involvement of teen in setting health goals & how to manage health situations. Reinforce adolescents’ growing competencies.

Increased ability to process information and reflect. Leads to questioning adult behavior. May consider broader range of possibilities/options, but not able to integrate into real life.

Late Adolescence

Biopsychosocial Development During Adolescence/ Emerging Adulthood Late Adolescence/Emerging Adulthood (Age 18 – 24 Years)

Characteristics 1) Physical maturation complete.

Body image and gender role definition clearer. Impact Begins to feel comfortable with relationships and decisions regarding sexuality and preference. Individual relationships become more important than peer group.

2) Individuals less ego-centric; able to understand others. 3) Idealistic More open to questioning regarding behavior. More able to work with clinician on setting goals and changing behavior. Idealism may lead to conflict with family or authority figures. 4) Identity Exploration/Life roles begin to be defined Interested in discussion of life goals & how they impact health. 5) Cognitive development nearing completion Most are capable of understanding a full range of options for health issues. Important to help them become competent in negotiating the health care system.

Biopsychosocial Development During Adolescence/ Emerging Adulthood Late Adolescence/Emerging Adulthood (Age 18 – 24 Years)

Characteristics

1) Physical maturation complete. Body image and gender role definition clearer.

2) Individuals less ego centric; able to understand others.

3) Idealistic 4) Identity Exploration/Life roles begin to be defined

Impact

Begins to feel comfortable with relationships and decisions regarding sexuality and preference. Individual relationships become more important than peer group.

More open to questioning regarding behavior. More able to work with clinician on setting goals and changing behavior.

Idealism may lead to conflict with family or authority figures. Interested in discussion of life goals & how they impact health. 5) Cognitive development nearing completion Most are capable of understanding a full range of options for health issues. Important to help them become competent in negotiating the health care system.

Biopsychosocial Development During Adolescence/ Emerging Adulthood Late Adolescence/Emerging Adulthood (Age 18 – 24 Years)

Characteristics

1) Physical maturation complete. Body image and gender role definition clearer.

Impact

Begins to feel comfortable with relationships and decisions regarding sexuality and preference. Individual relationships become more important than peer group. 2) Individuals less ego centric; able to understand others.

3) Idealistic.

More open to questioning regarding behavior. More able to work with clinician on setting goals and changing behavior.

Idealism may lead to conflict with family or authority figures.

4) Identity Exploration/Life roles begin to be defined Interested in discussion of life goals & how they impact health. 5) Cognitive development nearing completion Most are capable of understanding a full range of options for health issues. Important to help them become competent in negotiating the health care system.

Biopsychosocial Development During Adolescence/ Emerging Adulthood Late Adolescence/Emerging Adulthood (Age 18 – 24 Years)

Characteristics

1) Physical maturation complete. Body image and gender role definition clearer. 2) Individuals less ego-centric; able to understand others. 3) Idealistic

4) Identity Exploration /Life roles begin to be defined

5) Cognitive development nearing completion

Impact

Begins to feel comfortable with relationships and decisions regarding sexuality and preference. Individual relationships become more important than peer group. More open to questioning regarding behavior. More able to work with clinician on setting goals and changing behavior. Idealism may lead to conflict with family or authority figures.

Interested in discussion of life goals & how they impact health.

Most are capable of understanding a full range of options for health issues. Important to help them become competent in negotiating the health care system.

Biopsychosocial Development During Adolescence/ Emerging Adulthood Late Adolescence/Emerging Adulthood (Age 18 – 24 Years)

Characteristics

1) Physical maturation complete. Body image and gender role definition clearer. 2) Individuals less ego-centric; able to understand others. 3) Idealistic 4) Identity Exploration/Life roles begin to be defined

5) Cognitive development nearing completion Impact

Begins to feel comfortable with relationships and decisions regarding sexuality and preference. Individual relationships become more important than peer group. More open to questioning regarding behavior. More able to work with clinician on setting goals and changing behavior. Idealism may lead to conflict with family or authority figures. Interested in discussion of life goals & how they impact health.

Most are capable of understanding a full range of options for health issues. Important to help them become competent in negotiating the health care system.

The Clinical Visit

• Time Alone • Using Development for Interview • Structure of visit • Substance Use Guidelines • Introductory Question • B.S.A.F.E.

Tips on Development

• • • Early - be very specific; focus on youth counsel parents ’ s concerns; be on alert for early developers; Middle – trusting friendly relationships are key; concrete still best; emphasize adult connections, health promotion & harm reduction; support/advise parents.

Late - abstract reasoning - understanding consequences of actions; include partners in office visits; transition planning

Structure of Visit

• • • • • • Elicit concerns of adolescent/family Discuss how visit will go Use development to guide process Time alone depending on cultural norms Physical exam guided by concerns Feedback to adolescent and family at conclusion

“

We

’

re running a little behind, so I

’

d like each of you to ask yourself,

‘

Am I really that sick, or would I just be wasting the doctor

’

s valuable time?

’”

Age Groups Alcohol

Substance Use Guidelines

Bright Futures USPSTF Tobacco Other ("Illicit Drugs") Adolescent Ages 11-21

√

Adolescent Ages 11-18

No recommendation

Young Adult Ages 18-26

√ √ √ √ √ No recommendation No recommendation

ASK & ADVISE

• • Health related issues not social issues Many doctors do not ask about substance use • • • 54% of teens were asked about drinking 40% of teens were advised about harms 17% of teens were advised to reduce/stop • Many doctors were better with • • Smoking Marijuana Hingson et al, Pediatrics 2013; Ozer et al, JAH, 2012.

Introduction

• Sometimes young people do things that might be considered risky, or they take chances even when they know the choices are not the best.

• Today, I am going to ask you a series of questions these questions are private and remain between the two of us.

SCREENING ADOLESCENTS FOR RISKY BEHAVIOR

B

ehavior?

S

tart?

A

mount?

F

requency?

E

nvironment?

TOBACCO

•

Behavior?

Do you ever smoke cigarettes or cigars, or chew tobacco? • • •

Start?

How long have you been smoking/chewing?

When was the last time you smoked/chewed tobacco?

Has a doctor ever told you that you have asthma?

TOBACCO

•

Amount?

How many cigarettes (or snuff) do you usually smoke (or chew) in a day?

•

Frequency?

How often do you smoke/chew tobacco?

• •

Environment?

Do your friends use tobacco? Does anyone in your family or household use tobacco?

TOBACCO

KEY MESSAGES

•

Message 1

Avoiding tobacco is very important for your health •

Message 2

Smoking/Chewing tobacco becomes a habit that is hard to break •

Message 3 – for teens who smoke/chew only

When you decide to stop using tobacco, I can help you and there are resources to help you

ALCOHOL & DRUGS

Behavior?

• Have you ever drunk alcohol/used drugs?

• What kind of alcohol/drugs do you use?

Start?

• How long have you been using alcohol/drugs?

Amount?

• How much do you usually drink?

• How much (quantify for specific drug) do you usually use/take/smoke?

• Have you ever had 5 or more drinks of alcohol in a row or engaged in binge drinking?

ALCOHOL & DRUGS

•

Frequency?

How often do you drink/use drugs?

• • •

Environment?

Do any of your friends or family drink alcohol/use drugs?

Have you ever been in a car with a driver after he/she was drinking/using drugs? Have you ever driven after drinking/using drugs?

ALCOHOL & DRUGS

KEY MESSAGES

•

Message 1

Avoiding alcohol and drugs is very important for your health and safety •

Message 2

Avoid driving a car, riding a bike, skateboarding, swimming, boating, riding a scooter, or doing any activity that is dangerous under the influence of alcohol/drugs or with someone who is under the influence

Screening for Other Behaviors

• • • • • Helmet/Seatbelt Use Sexual Behavior Nutrition/Sugared Drinks Nutrition/Fast Food Physical Activity

General Principles of working with teens

• • • •

•

Assess strengths & assets as well as risks & problems Reinforce and bolster connections Educate about importance of protecting your

Brain

during adolescence/young adulthood Engage and support family during adolescence

Be Authoritative not Authoritarian

Five Principles of Prevention/Intervention

Generic approach Single behavior as marker Delay onset of behavior – anticipatory guidance Provide alternatives Insulate from most negative outcomes

Adolescent Health ,2007

“ Adolescence is a time in life that harbours many risks and dangers, but also one that presents great opportunities for sustained health and well being ” ,

The Lancet, 2007

Appendix: Screening Tools for Other Risk Behaviors

Screening for Other Behaviors

• • • • • Helmet/Seatbelt Use Sexual Behavior Nutrition/Sugared Drinks Nutrition/Fast Food Physical Activity

HELMET/SEATBELT

• •

Behavior?

Do you use a seatbelt when riding in/driving a car?

Do you wear a helmet when riding/biking/ skateboarding/blading/using a scooter?

•

Start?

Have you ever driven/biked/skateboarded/ bladed/scooted after drinking or using drugs?

HELMET/SEATBELT

•

Amount?

Do you own a helmet?

• •

Frequency?

How often do you use your seatbelt when riding in a car?

How often do you wear your helmet when riding/biking/skateboarding/blading/using a scooter?

• •

Environment?

Do your friends wear seatbelts?

Do your friends wear helmets?

SEATBELT USE

KEY MESSAGES

•

Message 1

Wear a seatbelt

every

time you ride in a car (for teens 15 ½ and older add: and every time you drive a car)

HELMET USE

KEY MESSAGES

•

Message 1

Wear a helmet

every

time you blade/board/ bike/scooter •

Message 2

If you don ’ t have a helmet, don ’ t blade/ board/bike/scooter until you get one

SEXUAL BEHAVIOR

• •

Behavior?

Have you had vaginal sex? Oral sex? Anal sex?

Have you had sex with guys, girls, or both?

• • • • • •

Start?

When did you most recently have sex?

Do you think you or your partner could be pregnant?

Have you ever been pregnant or had a partner who became pregnant?

Do you think you or your partner could have a sexually transmitted infection or STI?

Have you ever had an STI?

Has a partner of yours ever had an STI?

SEXUAL BEHAVIOR

• •

Amount?

Have you had sex with anyone other than your current/most recent partner? When?

How many sexual partners have you had?

•

Frequency?

How often do you have sex?

• • • • •

Environment?

Do you use any form of birth control/STD prevention when having sex?

If yes: What type of birth control/STI prevention do you use?

How often do you use (fill in) method of birth control/STD prevention? Have you ever felt pressure to have sex? Were you using alcohol/drugs when you had sex?

SEXUAL BEHAVIOR

KEY MESSAGES

•

Message 1

Avoiding sex is the safest way to prevent pregnancy and sexually transmitted infections or HIV/AIDS •

Message 2

If you choose to have sex, be responsible: – Use a condom

every

time you have sex – – If you don ’ t have a condom, don To ensure you don ’ contraceptives or Depo Provera ’ t have sex t get pregnant or get your partner pregnant, and as a backup to a condom, use another form of birth control such as oral – If you have unprotected intercourse, you may obtain emergency contraception

NUTRITION, SUGARED DRINKS

•

Behavior?

Do you drink regular soda/other sweetened beverages/juice? (examples below) –

Regular soda

: Coke, Pepsi, Mountain Dew, 7-up, Sprite, etc. (not diet soda) –

Other sweetened beverages

: lemonade, Hawaiian Punch, Nestea, Kool-aid, Tampico, Horchata, Sunny-D, etc.

–

Juice

: all juices, even 100% fruit juices including apple, orange, grape, cranberry, etc.

NUTRITION, SUGARED DRINKS

•

Amount?

When you do drink a regular soda/other sweetened beverage/ juice, how much do you have? (one cup = 8 oz, 1 can = 12 oz, 1 glass = 12-16 oz, 1 bottle from vending machine = 20 oz) •

Frequency?

How many regular sodas/other sweetened beverages/juices do you drink per day/week?

• •

Environment?

Are there sodas/sweetened beverages/juice at home?

Where else do you get soda/sweetened beverages/juice? (school, corner store, mall, day care/after school program, etc.)

NUTRITION, FAST FOOD

•

Behavior?

Do you ever have fast food? (include going out, drive through and take-home from McDonald In and Out, Wendy ’ s, etc.) ’ s, Burger King, •

Amount?

When you have fast food, what do you normally order?

NUTRITION, FAST FOOD

•

Frequency?

How many times per day/week do you have fast food?

• • •

Environment?

Do you get fast food with your family/friends?

Do they serve fast food at school?

Do you go out for lunch (open campus)?

NUTRITION

KEY MESSAGES

•

Sugared Beverages

Message 1

Cutting down on soda, sugared beverages and juice is important for weight control and health •

Additional Message

Drink water and low fat milk (2%, 1% or fat free) most of the time (have diet soda, if you must)

NUTRITION

KEY MESSAGES

•

Fast Food

Message 1

Limit fast food to no more than once a week •

Additional Message

When you do have fast food, order a smaller sized meal (like a hamburger instead of a double cheeseburger) and drink water instead of soda, or diet soda if you must

PHYSICAL ACTIVITY

•

Behavior?

What activities or sports do you like to play/do? (include organized sports such as soccer and basketball, in addition to unstructured activities like walking to school and dancing) •

Amount?

Do you do any of those activities or sports for at least 20 minutes until you are breathing heavy and breaking a sweat?

PHYSICAL ACTIVITY

•

Frequency?

How many times per week do you play/practice/do these activities or sports for at least 20 minutes? • • • • •

Environment?

Do you do any activities or sports with your family/friends?

Is your neighborhood safe to go outside and play? Do you have a stationary bike or treadmill at home?

Do you have PE class at school?

Is there a neighborhood recreation center where you can go (for example, YMCA, Boys and Girls club, etc.)?

PHYSICAL ACTIVITY SEDENTARY ACTIVITIES

•

Behavior?

Do you watch TV or movies, play video games, or use the computer for fun (such as games, email, instant messaging)? •

Amount?

How many hours per day are you spending in front of the TV, video, computer screen?

•

Frequency?

Are you doing this every day? Mostly on weekends? During vacation? (to estimate average daily screen time)

PHYSICAL ACTIVITY SEDENTARY ACTIVITIES

• • • •

Environment?

Do you have a TV in your room?

Are you eating while watching TV? Do you have a VCR/DVD player at home? Can you use it for an exercise video, like Tae Bo? If you have a treadmill/exercise bike, can you put it in front of the TV so that you can walk/bike while watching?

PHYSICAL ACTIVITY

KEY MESSAGES

•

Physical and Sedentary Activities

Message 1

Find an activity/sport that you like and do it every day (goal is 60 minutes total per day) • • •

Additional Messages

Cut down on TV, computer and video time (this does not count homework) Remove the TV from the bedroom Don ’ t eat in front of the TV

HEEADSSS ASSESSMENT

for Psychosocial Concerns – Screening History

H ome E ducation E ating A ctivities D rugs S exuality S uicidality S trengths

HEEADSSS ASSESSMENT for Psychosocial Concerns – Screening History Home Education

(or

Employment

)

Eating

(incorporates body image) How is the adolescent's home life? How are his/her relationships with family members? Where and with whom does the patient live? Is his/her living situation stable?

How is adolescent's school performance? Is he/she well behaved, or are there discipline problems at school? If he/she is working, is he/she making a living wage? Does patient have a balanced diet? Is there adequate calcium intake? Is the adolescent trying to lose or gain weight, and (if so), is it in a healthy manner? How does he/she feel about his/her body? Has there been significant weight gain/loss recently?

HEEADSSS ASSESSMENT for Psychosocial Concerns – Screening History Activities Drugs

(including alcohol and tobacco) How does patient spend his/her time? Are they engaging in dangerous or risky behavior? Are they supervised during their free time? With whom do they spend most of their time? Do they have a supportive peer group?

Does the patient drink caffeinated beverages (including energy drinks)? Does the patient smoke? Does the patient drink? Has the patient used illegal drugs? If there is any substance use, to what degree, and for how long?

HEEADSSS ASSESSMENT for Psychosocial Concerns – Screening History Sex

uality

Suicidality

general mood assessment) (including

Strengths

Is the patient comfortable with their sexual development? Have they had a sexual relationship? Does the patient get routine reproductive health checks? Are there any symptoms of a sexually transmitted infection? Does the patient have questions about sexual behavior?

What is the patient's mood from day to day? Has he/she thought about/attempted suicide?

Inquire about assets.

• • • • • • • • •

References

Benotsch EG, Snipes DJ, Martin AM, Bull SS: Sexting, Substance Use, and Sexual Risk Behavior in Young Adults.

Journal of Adolescent Health

, 52: 307-313, 2013.

Bernat DH, Klein EG, Forster JL: Smoking Initiation During Young Adulthood: A Longitudinal Study of a Population-Based Cohort.

Journal of Adolescent Health

, 51: 497-502, 2012.

Buckelew SM, Adams SH, Irwin CE, Jr. Gee S, Ozer E. Increasing Clinician Self-Efficacy for Screening & Counseling Adolescents for Risky Behaviors: Results of an Intervention.

Journal of Adolescent Health 43:198–200, 2008.

Califano JA:

How to Raise a Drug-Free Kid.

New York, New York: Fireside. 2009. Catalano RF, Fagan A, Greenberg MT, Irwin CE, Jr, Ross DA, Gain LE, Shek D.T.L. Worldwide application of prevention science in adolescent health.

The Lancet

, 379: 1-12, 2012. Chen P, Jacobson KC: Developmental Trajectories of Substance Use From Early Adolescence to Young Adulthood: Gender and Racial/Ethnic Differences.

Journal of Adolescent Health

, 50: 154-163, 2012. Cho JH, Shin E, Moon S: Electronic-Cigarette Smoking Experience Among Adolescents.

Journal of Adolescent Health

, 49: 542-546, 2011.

Coleman DL, Rosoff PM. The Legal Authority of Mature Minors to Consent for General Medical Treatment. Pediatrics 131:786-793, 2013.

Dandoy C, Gereige RS: Performance Enhancing Drugs. 2012.

Pediatrics in Review,

33: 265-272,

• • • • • • •

References

Dorn LD, Beal SJ, Kalkwarf HJ, Pabst S, Noll JG, Susman EJ: Longitudinal Impact of Substance Use and Depressive Symptoms on Bone Accrual Among Girls Aged 11-19 Years.

Journal of Adolescent Health,

52: 393-399, 2013. Feinstein EC, Richter L, Foster SE: Addressing the Critical Health Problem of Adolescent Substance Use Through Health Care, Research, and Public Policy.

Journal of Adolescent Health

, 50: 431-436, 2012.

Fiellin LE, Tetrault JM, Becker WC, Fiellin DA, Hoff RA: Previous Use of Alcohol, Cigarettes, and Marijuana and Subsequent Abuse of Prescription Opioids in Young Adults.

Journal of Adolescent Health

, 52: 158-163, 2013.

Friestad C, Pirkis JE, Biehl M, Irwin CE, Jr. Socioeconomic Patterning of Smoking, Sedentary Lifestyle, and Overweight Status Among Adolescents in Norway and the United States.

Journal of Adolescent Health

33:275 – 278, 2003. Hagan JF, Shaw JS, Duncan PM (eds):

Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents,

3 rd Edition

.

Elk Grove Village, IL: American Academy of Pediatrics, 2008.

Halpern-Felsher BL, Ozer EM, Millstein SG, Wibbelsman CJ, Fuster CD, Elster AB, Irwin CE, Jr.: Preventive services in a health maintenance organization: How well do pediatricians screen and educate their adolescent patients?

Archives of Pediatrics and Adolescent Medicine

, 154:173-179, 2000. Hingson RW, Zha W, Ianotti RJ, Simons-Morton B. Physician Advice to Adolescents About Drinking and Other Health Behaviors. Pediatrics 131:249-257, 2013.

• • • • • • • • • •

References

Institute of Medicine and National Research Council:

The Science of Adolescent Risk-Taking: Workshop Report.

Washington, D.C.: The National Academies Press, 2011.

Irwin, CE, Jr.: Can We Fully Implement What We Know About Safe Driving During Adolescence.

American Journal of Preventive Medicine:

35: 313-315, 2008. Irwin CE, Jr.: The Theoretical Concept of At-Risk Adolescents,

Adolescent Medicine: State of the Art Reviews

, 1:1-14. 1990.

Irwin, CE, Jr., Adams, SA, Park, JM, Newacheck PW. Preventive Care For Adolescents: Few Get Visits, and Fewer Get Services.

Pediatrics

123:e565–572.

, 2009.

Irwin CE, Jr., Duncan P; Health Futures of Youth II: Pathways to Adolescent Health.

Journal of Adolescent Health

, 31;(Supp 6): 82 – 89, 2002. Kipke MD (ed):

Risks and Opportunities: Synthesis on Studies of Adolescence.

Washington, D.C.: National Academy Press, 1999. Kuperman S, Chan G, Dramer JR et al., A Model to Determine the Likely Age of An Adolescent's First Drink of Alcohol. Pediatrics 131:242-248, 2013.

Lau JS, Adam SH, Irwin CE, Jr., Ozer EM. Receipt of Preventive Health Services in Young Adults.

J Adolesc Health

52:42-49. DOI: 10.1016/j.jadohealth.2012.04.017. E-pub 09 July 2012.

Levy SJ, Knight JR: Chapter 181, Office Management and Laboratory Testing. In: Fisher M, et al.,

Textbook of Adolescent Health Care.

Elk Grove Village, IL: American Academy of Pediatrics, 2011.

• • • • • • •

References

Levy SJ, Knight JR: Chapter 182, Treatment Options. In: Fisher M, et al.,

Textbook of Adolescent Health Care.

Elk Grove Village, IL: American Academy of Pediatrics, 2011. Levy S, Knight JR, Moore T, Weinstein Z, Sherritt L, Weiss RD: Acceptability of Drug Testing in an Outpatient Substance Abuse Program for Adolescents.

Journal of Adolescent Health

, 48: 229-233, 2011.

McCabe SE, West BT, Boyd CJ: Leftover Prescription Opioids and Nonmedical Use Among High School Seniors: A Multi-Cohort National Study.

Journal of Adolescent Health,

52: 480 485, 2013. Millstein SG, Irwin CE, Jr., Adler NE, Cohn LD, Kegeles SM, Dolcini MM: Health-risk behaviors and health concerns among young adolescents.

Pediatrics

, 89:422-428, 1992.

The National Center on Addiction and Substance Abuse (CASA) at Columbia University. Adolescent substance use: America’s #1 public health problem. New York, New York: CASA, 2011.

National Research Council and Institute of Medicine; Lawrence Rs., Gootman, J.A., Sim, L.J.:

Adolescent Health Services: Missing Opportunities.

Washington, D.C.: National Academies Press. 2009. National Research Council and Institute of Medicine; Bonnie RJ, O’Connell ME (eds),

Reducing Underage Drinking: A Collective Responsibility

. Washington, D.C.: National Academies Press. 2004.

• • • • • • • • •

References

Institute of Medicine and National Research Council:

The Science of Adolescent Risk-Taking: Workshop Report.

Washington, D.C.: The National Academies Press, 2011.

Irwin, CE, Jr.: Can We Fully Implement What We Know About Safe Driving During Adolescence.

American Journal of Preventive Medicine:

35: 313-315, 2008. Irwin CE, Jr.: The Theoretical Concept of At-Risk Adolescents,

Adolescent Medicine: State of the Art Reviews

, 1:1-14. 1990.

Irwin, CE, Jr., Adams, SA, Park, JM, Newacheck PW. Preventive Care For Adolescents: Few Get Visits, and Fewer Get Services.

Pediatrics

123:e565–572.

, 2009.

Irwin CE, Jr., Duncan P; Health Futures of Youth II: Pathways to Adolescent Health.

Journal of Adolescent Health

, 31;(Supp 6): 82 – 89, 2002. Kipke MD (ed):

Risks and Opportunities: Synthesis on Studies of Adolescence.

Washington, D.C.: National Academy Press, 1999. Lau JS, Adam SH, Irwin CE, Jr., Ozer EM. Receipt of Preventive Health Services in Young Adults.

J Adolesc Health

52:42-49. DOI: 10.1016/j.jadohealth.2012.04.017. E-pub 09 July 2012.

Levy SJ, Knight JR: Chapter 181, Office Management and Laboratory Testing. In: Fisher M, et al.,

Textbook of Adolescent Health Care.

Elk Grove Village, IL: American Academy of Pediatrics, 2011.

References

• • • • • • Patton GC, Coffey C, Lynskey MT et al, Trajectories of adolescent and cannabis use into young adulthood. Addiction, 102:607-615, 2007. Ott MQ, Wypji D, Corliss HL, Rosario M, Reisner SL, Gordon AR, Austin SB: Repeated Changes in Reported Sexual Orientation Identity Linked to Substance Use Behaviors in Youth.

Journal of Adolescent Health,

52: 465-472, 2013. Ozer EM, Adams SH, Lustig JL, Gee S, Garber A, Rieder Gardner L, Rehbein M, Addison L, Irwin CE, Jr.: Increasing the screening and counseling of adolescents for risky health behaviors: A primary care intervention.

Pediatrics

115:960-968, 2005.

Ozer EM, Adams SH, Orrell-Valente J, Wibbelsman C, Lustig J., Millstein SG, Garber A, Irwin CE, Jr. Does Delivering Preventive Health Services in Primary Care Reduce Adolescent Risky Behavior?

Journal of Adolescent Health

, 49: 476-482, 2011. Ozer EM, Urquhart J, Park JM, Brindis CB, Irwin CE, Jr. Young Adult Guidelines: There But Can't Be Found,

Archives of Pediatrics and Adolescent Medicine

, 49: 476-482, 2012. Patnode CD, O’Connor E, Whitlock EP, Perdue LA, Soh C, Hollis J: Primary Care-Relevant Interventions for Tobacco Use Prevention and Cessation in Children and Adolescents: A Systematic Evidence Review for the U.S. Preventive Services Task Force.

Annals of Internal Medicine,

158: 253-260, 2013.

• • • • • • •

References

Pepper JK, Reiter PL, McRee AL, Cameron LD, Gilkey MB, Brewer NT: Adolescent Males’ Awareness of and Willingness to Try Electronic Cigarettes.

Journal of Adolescent Health

, 52: 144-150, 2013.

Pirkis JE, Irwin CE, Jr., Brindis C, Patton GC, Sawyer MG. Adolescent Substance Use: Beware of International Comparisons. Journal of Adolescent Health, 33:279 – 286, 2003.

Salerno J, Marshall VD, Picken EB: Validity and Reliability of the Rapid Assessment for Adolescent Preventive Services Adolescent Health Risk Assessment.

Journal of Adolescent Health

, 50: 595-599, 2012.

Sales JA, Irwin CE, Jr.: Theories of Adolescent Risk Taking: The Biopsychosocial Model. In: Di Clemente RJ, Santelli J, & Crosby RA (eds.),

Adolescent Health: Understanding and Preventing Risk Behaviors.

San Francisco: Jossey-Bass. pp. 31-50, 2009.

Seidenberg AB, Rodgers EJ, Rees VW, Connolly GN: Youth Access, Creation, and Content of Smokeless Tobacco (“Dip”) Videos in Social Media.

Journal of Adolescent Health

, 50: 334 338, 2012.

Sinclair KO, Bauman S, Poteat VP, Koenig B, Russell ST: Cyber and Bias-based Harassment: Associations With Academic, Substance Use, and Mental Health Problems.

Journal of Adolescent Health

, 50: 521-523, 2012.

Steinberg L. Risk taking in Adolescence: New perspectives from the brain and behavioral science. Current Directions in Psychological Science, 16:55-59, 2007.

References

• • • • • • Steinberg L. Risk taking in adolescence: What changes and why?

Annals of the New York Academy of Sciences

, 101: 51-58, 2004.

Steinberg, L:

You and Your Adolescent: The Essential Guide for Ages 10-25.

New York, New York: Simon & Schuster, 2011. Steinberg L, Collins WA: Chapter 6, Adolescent Physical Development and Behavior. In: Fisher M, et al.,

Textbook of Adolescent Health Care.

Elk Grove Village, IL: American Academy of Pediatrics, 2011. Tucker JS, Ellickson PL, Orland M et al. Substance Use Trajectories from Early Adolescence to Emerging Adulthood: A Comparison of Smoking, Binge Drinking, and Marijuana Use.

Journal of Drug Studies.

35:307-332, 2005. U.S. Department of Health and Human Services.

Preventing Tobacco Use Among Youth and Young Adults: A Report of the Surgeon General.

Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2012.

Zamboanga BL, Ham LS, Van Tyne K, Pole N: Alcohol Expectancies among Adolescent Non Drinkers: They May Not Be Drinking Now, But They’re Thinkin’ Bout It’.

Journal of Adolescent Health

49: 105-107, 2013.