Transcript No Slide Title

Approach to the
Unique Care of Adolescents
Charles E. Irwin, Jr., M.D.
Department of Pediatrics
Division of Adolescent Medicine
University of California, San Francisco
July 2013
I see no hope for the future of the world
if they are dependent on the frivolous
youth of today , for certainly all youth
are reckless beyond words. When I was
a boy we were taught to be respectful of
elders but the present youth are
exceedingly wise and impatient of
restraint.
Hesiod, 8th Century B.C.
I would there were no age between ten
and three-and-twenty, or that youth
would sleep out the rest, for there is
nothing in the between but getting
wenches with child, wronging the
ancientry, stealing, fighting...
The Winter’s Tale, Shakespeare
The grain of heedlessness…
“The time from the
18th to the 24th year is best suited to
military service. The body is then quite
vigorous enough to endure hardships,
and the soldier is as yet free and
unfettered. The grain of heedlessness, a
quality peculiar to the freshness of youth,
is an excellent incentive to martial
achievement”
Baron Colmar von der Goltz
The Nation in Arms
1883
“Until recently, the pediatrician has been
preoccupied with premature babies,
transfusions, feeding problems, running ears…
The internist has also been busy with the ills of
adulthood and advancing age and has still to
come to the period of adolescence. Yet this field
is particularly important, marking as it does the
transition from boy to man and from girl to
woman.”
- James Roswell Gallagher
Gallagher, 1954.
Granville Stanley Hall
1844 - 1924
“Adolescence: its
psychology and its
relation to physiology,
anthropology,
sociology, sex, crime,
religion and education”
(1904)
March 2007
April 2012
Adolescent Health
Accidents
& injury
Mental
health &
well
being
Sexual
health
Substance Chronic
use
illness
Obesity
& eating
disorders
Prevention - early intervention - clinical care
Brain Development
• Grey matter volume peaks in early
adolescence
• Selective pruning proceeds ‘from
back to front’
• Greater efficiency of
neurotransmission results from
myelination
• Neuromaturation underpins
emotional regulation &control
A Model of Development
Early adolescence
10-14 yrs
Mid adolescence
15-19 yrs
Puberty heightens
emotional
arousability,
sensation-seeking,
reward
orientation
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
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.
Encourage teens to begin to take responsibility for
own health - in consultation with parents. Begin
time alone with patient.
3) Begin transition
from concrete to
abstract thinking.
Continue anticipatory guidance to parents & add
prevention education for teen. Concrete thinking
requires straight forward explicit messages.
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 Peer group influences engagement in positive and
standards, family values
negative health behaviors; peers offer key support.
usually persist.
Emphasize making good choices and taking
responsibility.
3) Conflicts over
independence.
Increased assumption of independent action, with desire
for parental support/ guidance. Encourage negotiation.
Increase 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
Late Adolescence/Emerging Adulthood (Age 18 – 24 Years)
Characteristics
Impact
1) Physical maturation
complete. Body image and
gender role definition
clearer.
Begins to feel comfortable with relationships and
decisions regarding sexuality and preference. Individual
relationships become more important than peer group.
2) Individuals less egocentric; able to understand
others.
More open to questioning regarding behavior. More able
to work with clinician on setting goals and changing
behavior.
3) Idealistic
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.
Tips on Development
• Early - be very specific; focus on youth’s
concerns; be on alert for early
developers; counsel parents
• 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
The Clinical Visit
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
HEEADSSS ASSESSMENT
for Psychosocial Concerns – Screening History
Home
Education
Eating
Activities
Drugs
Sexuality
Suicidality
Strengths
HEEADSSS ASSESSMENT
for Psychosocial Concerns – Screening History
Home
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?
Education (or
Employment)
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?
Eating
(incorporates
body image)
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
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?
Drugs
(including
alcohol and
tobacco)
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
Sexuality
Is the patient comfortable with his/her 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?
Suicidality
(including general
mood assessment)
What is the patient's mood from day to day? Has
he/she thought about/attempted suicide?
Strengths
Inquire about assets.
Recommendations for Adolescent Preventive Health Care
Age
11 y
12 y
13 y
14 y
17 y
18 y
19 y
20 y
21 y
X
X
X
X
X
X
X
X
X
X
X
Height and weight
X
X
X
X
X
X
X
X
X
X
X
Body Mass Index
X
X
X
X
X
X
X
X
X
X
X
Blood Pressure
X
X
X
X
X
X
X
X
X
X
X
Vision
*
X
*
*
X
*
*
X
*
*
*
Hearing
*
*
*
*
*
*
*
*
*
*
*
Development/Behavioral
Assessment
X
X
X
X
X
X
X
X
X
X
X
Psychosocial/Behavioral
Assessment
*
*
*
*
*
*
*
*
*
*
*
X
X
X
X
X
X
X
X
X
X
X
Immunization
X
X
X
X
X
X
X
X
X
X
X
Hematocrit or Hemoglobin
*
*
*
*
*
*
*
*
*
*
*
Tuberculin Test
*
*
*
*
*
*
*
*
*
*
*
Dyslipidemia Screening
*
*
*
*
*
*
*
STI Screening
*
*
*
*
*
*
*
History (initial/interval)
15 y 16 y
Measurements
Sensory Screening
Alcohol Drug Use Assessment
Physical Examination
Procedures
Cervical Dysplasia Screening
Anticipatory Guidance
X
X
X
X
X
X
X

*
*
*
*
X
X
X
X
X = To be performed; * = Risk assessment to be performed, with appropriate action to follow;

= Range during which a service may be provided with the symbol indicating the preferred age
Recommendations for Adolescent Preventive Health Care
Age1
11 y 12 y 13 y 14 y 15 y 16 y 17 y 18 y 19 y 20 y 21 y
History
X
(initial/interval)
Measurements
Height and
X
weight
Body Mass Index X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Blood Pressure
Sensory
Screening
Vision
Hearing
X
X
X
X
X
X
X
X
X
X
X
*
*
X
*
*
*
*
*
X
*
*
*
*
*
X
*
*
*
*
*
*
*
X = To be performed; * = Risk assessment to be performed, with appropriate action to follow
Adapted from Hagan JF, Shaw JS, Duncan PM. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, 3rd
Ed. Elk Grove Village; IL: American Academy of Pediatrics, 2008.
Recommendations for
Adolescent Preventive Health Care
Age1
Development/
Behavioral
Assessment
Psychosocial/
Behavioral
Assessment
Alcohol Drug Use
Assessment
Physical
Examination2
11 y 12 y 13 y 14 y 15 y 16 y 17 y 18 y 19 y 20 y 21 y
X
X
X
X
X
X
X
X
X
X
X
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
X
X
X
X
X
X
X
X
X
X
X
X = To be performed; * = Risk assessment to be performed, with appropriate action to follow
Adapted from Hagan JF, Shaw JS, Duncan PM. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, 3rd
Ed. Elk Grove Village; IL: American Academy of Pediatrics, 2008.
Recommendations for
Adolescent Preventive Health Care
Age1
Procedures
Immunization3
Hematocrit or
Hemoglobin4
Tuberculin Test5
Dyslipidemia
Screening6
STI Screening7
Cervical Dysplasia
Screening8
Anticipatory Guidance9
11 y 12 y 13 y
14 y 15 y 16 y 17 y
18 y 19 y 20 y 21 y
X
*
X
*
X
*
X
*
X
*
X
*
X
*
X
*
X
*
X
*
X
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*

*
*
*
*
*
*
*
*
*
*
*
*
X
X
X
X
X
X
X
X
X
X
X
X = To be performed; * = Risk assessment to be performed, with appropriate action to follow;

= Range during which a service may be provided with the symbol indicating the preferred age
Adapted from Hagan JF, Shaw JS, Duncan PM. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents,
3rd Ed. Elk Grove Village; IL: American Academy of Pediatrics, 2008.
1Age
if an adolescent/young adult comes under care for the first time at any point on the
schedule, or if any items are not accomplished at the suggested age, the schedule should
be brought up to date at the earliest possible time.
2At each visit, age-appropriate physical examination is essential.
3Schedules per the Committee on Infectious Diseases, published annually in the January
issue of Pediatrics. Every visit should be an opportunity to update and complete an
adolescents immunization.
4See AAP Pediatric Nutrition Handbook, 5th Edition (2003) for a discussion of universal
and selective screening options.
5Tuberculosis testing per recommendations of the Committee on Infectious Diseases,
Testing should be done on recognition of high-risk factors.
6“Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on
Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult
Treatment Panel III) Final Report” (2002)
[URL:http://circ.ahajournals.org/cgi/content/full/106/25/3143] and “The Expert
Committee Recommendations on the Assessment, Prevention, Treatment of Child and
Adolescent Overweight and Obesity.” Supplement to Pediatrics. In press.
7All sexually active patients should be screen for sexually transmitted infections (STIs).
8All sexually active girls should have screening for cervical dysplasia as part of a pelvic
examination beginning within 3 years on onset of sexual activity or age 21 (whichever
comes first).
9Refer to the specific guidance by age as listed in Bright Futures Guidelines.
Physical Examination
• General Appearance
• Affect, Mood, Dress,
Energy Level
• Vital Signs
• BMI, VS, BP,
Orthostatics if low BMI,
Audiogram, Visual
Acuity
BMI
•
•
•
•
Assess height and weight EVERY visit
Calculate BMI
Look for trends
Consider the context of growth and
development
• Record on the appropriate Growth/BMI chart
BMI Charts 2-17 year olds
Physical Exam, cont.
•
•
•
•
•
•
Skin
Breasts
Lymph nodes
Chest/Cardiovascular
Rectal
GU
•
•
•
•
•
•
Acne, striae, cuts
Tanner stage, BSE
Palpate for size
Palpation/Auscultation
Symptomatic –GI/GU
Tanner/SMR Staging
• Sy
Physical Exam, cont.
• Genitalia, Males
• Genitalia, Females
• Teach Testicular Self Exam: R/O
• Pelvic if indicated
Physical Exam, cont.
• Genitalia, Males
• Genitalia, Females
• Teach Testicular Self Exam: R/O
• Pelvic if indicated
PUBERTY
Sequence of Pubertal Events
Height Spurt
FEMALES
MALES
Breast Development :
2
3
4
5
Menarche :
2
Female Pubic Hair :
3
4
Male Public Hair :
2
Testicular Volume :
9
5
>4
10
11
12
3
10
13
4
5
16
14
15
16
Timing and Sequence of Pubertal
Events in Females
Timing of Pubertal Onset--Females
• Timing of onset is variable
• Average age of onset of breast development is
8.9 years in African American girls and 9.9
years in white girls. Average age of onset of
breast development for Mexican American
girls appears to be in between.
Sequence of Pubertal Events-Females
1.
2.
3.
4.
Breast bud
Pubic hair
Peak height velocity
Menarche
Tanner Staging--Females
• Breast staging
• Pubic hair staging
Marshall WA, Tanner JM. Variations in the Pattern of Pubertal
Changes in Girls. Arch Dis Child. 1969:44(235):291-303.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2020414/
Timing of Pubertal Onset--Males
• Timing of onset is variable
• Average age of onset is 11.6 years (range: 9.5
to 14 years).
• Onset appears to be earliest in African
American males, latest in white males.
Mexican American males are in between.
Sequence of Pubertal Events-Males
1.
2.
3.
Testicular enlargement
Sexual hair, phallic and scrotal changes
Peak height velocity
Tanner Staging (Sexual Maturity
Ratings)--Males
• Genital staging
• Pubic hair staging
Marshall WA, Tanner JM. Variations in the Pattern of Pubertal
Changes in Boys. Arch Dis Child. 1970:45(239):13-23.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2020414/
Sequence of Pubertal Events
Height Spurt
FEMALES
MALES
Breast Development :
2
3
4
5
Menarche :
2
Female Pubic Hair :
3
4
Male Public Hair :
2
Testicular Volume :
9
5
>4
10
11
12
3
10
13
4
5
16
14
15
16
Height Spurt
• 25% of adult height is accounted for during pubertal
growth
• Growth spurt in females:
– at average age of 11.5
– average Tanner stage of 2-3
– peak velocity of 8.3 cm/year
• Growth spurt in males
– at average age of 13.5 years
– average Tanner stage of 4
– peak velocity of 9.5 cm/year
Pubertal timing and behavior
• Early pubertal timing
– In females: associated with poor self esteem and negative
body image. Associated with early onset of sexual activity
and older partners.
– In males: associated with early onset of sexual activity, but
socially desirable.
• Late maturity:
– In males associated with poor self-esteem and negative body
image
• MEDIATORS?
– Actual timing?
– Perceived timing?
Puberty – great opportunity for
education
• Growth Spurt –25% of adult height is accounted for
during pubertal growth
• Changes in Body Shape and Size
• Voice Change
• Acne
• Body Odor
• Menarche – Menses
• Spermarche – Ejaculation
• Vital Sign Changes
• Bone MASS
Questions Concerning Puberty
by Early Adolescents
General puberty
Growth
Nongenital
characteristics
Females
Males
(n = 114)
(n = 94)
13%
6%
11%
9%
4%
5%
Questions Concerning Puberty
by Early Adolescents
General anatomy
General physiology
Sexuality/reproducti
on
Psychosocial aspects
Females
Males
(n = 114)
(n = 94)
10%
33%
25%
15%
18%
27%
7%
5%
Ryan, Millstein, Irwin. J Adol Health (1996)
C
• “Youth-friendly” care
& services
General Principles of Adolescent Health
Care Delivery
• Availability
• Accessibility
• Approachability
• Acceptability
• Appropriateness
General Principles in Working with Teens
• Rapport and respect are key
• Review the parameters of your relationship,
encounters, discussions up front AND on a
regular basis
• Use their developmental stage and interact with
them accordingly
• Seize every opportunity
• Be up front & genuine: express your concerns
General Principles of working with teens
•
•
•
•
Assess strengths & assets as well as risks & problems
Reinforce and bolster connections
Educate about mind-body connection
Engage and support family during adolescence
• Be Authoritative
Some common findings to address
•
•
•
•
Acne
Gynecomastia in males
Irregular menses
Poorly controlled chronic problems
– Eczema
– Asthma
– Allergic rhinitis
Don’t forget!
• Adolescent morbidity and mortality is
PRIMARILY behaviorally related
• Rarely will you find a physical problem that
hasn’t been illuminated by the history
• INVEST YOUR TIME AND EFFORT IN
THE PSYCHOSOCIAL ASSESSMENT AND
COUNSELING!
The 5 A’s for
Brief Office – Based Interventions
Ask
Advise
Determine the presence of the behavior.
Deliver a clear, personalized message about the need
to change the behavior.
Assess
willingness
to change
Assist the
behavior
change
Determine whether the adolescent is prepared to
change his or her behavior.
Arrange
follow-up
Schedule a follow-up visit or phone call soon after the
date set for the behavior change, ideally within 1 week.
Determine short-term, concrete actions to make the
behavior change; set behavioral goals. Provide adjunct
therapy as appropriate (e.g., nicotine replacement for
tobacco cessation).
“It has been frequently said that
adolescence is the neglected age group;
perhaps it is more sound to say that it is
physicians' training in the care of
adolescents which has been given
relatively little attention”
JR Gallagher. Pediatrics 1957
Inadequate Training in
Adolescent Health
• US primary care physicians (Blum 1990)
– 45% insufficient training is major barrier
• Australian general practitioners (Veit 1995)
– 80% inadequate undergraduate training
– 87% interested in further training
• Swiss primary care doctors (Kraus 2003)
– 62% interested in further training
Postgraduate medical training agenda
Primary care
Psychiatry
Adult
medicine
Core skills,
attitudes &
knowledge
Pediatrics
Obstetrics & gynecology
An integrated approach to clinical skills development for
adolescent health
Sawyer et al, 2007
Make Adolescent Health Visible
• Academic leadership
– Research
– Clinical capacity building
• Policy
Society for
Adolescent Health and Medicine
The Society for Adolescent Health and Medicine (SAHM) is the only national
organization (with members from 30 countries worldwide) dedicated exclusively to
advancing the health and well-being of adolescents
111 Deer Lake Rd, Ste 100, Deerfield, IL 60015
Phone +1-847-753-5226, Fax +1-847-480-9282, [email protected]
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