David S. Rosen
Lawrence S. Neinstein
The goals of preventive health care for adolescents are to promote optimal physical and mental health and to support healthy physical, psychological, and social growth and development. Because the most common morbidities and mortalities of adolescence today are preventable health conditions associated with behavioral, environmental, and social causes, preventive services for adolescents should reflect these shifts in etiology. Therefore, visits to a health care provider should reinforce positive health behaviors, such as exercise and nutritious eating, while discouraging health-risk behaviors such as those associated with unsafe sexual behaviors, unsafe driving, and use of tobacco or other drugs. Although the incidence of serious medical problems during adolescence is low, adolescence is a time during which lifelong health habits are established. Furthermore, numerous issues and concerns may emerge during adolescence that affect overall health and well-being. Therefore, adolescence becomes an ideal period for health professionals to invest time in health promotion and preventive services.
In the current health care environment, characterized by increasingly limited resources, managed care, and evidence-based medicine, it is essential to determine what constitutes appropriate, cost-effective, and relevant preventive services for any age-group. Unfortunately, little empirical research demonstrates the effectiveness of preventive services for adolescents. Furthermore, methodological issues makes it unlikely that future research will provide robust evidence for the value of preventive services (Downs and Klein, 1995). Therefore, expert opinion drives most of our preventive services recommendations; and a variety of preventive services guidelines have been proposed.
Elster (1998) comprehensively reviewed recommendations for adolescent clinical preventive services developed by national organizations (Table 4.1). In 1989, the U.S. Preventive Services Task Force (USPSTF) (1996), convened by the Office of Disease Prevention and Health Promotion, U.S. Department of Health and Human Services, developed recommendations on periodic health examination based on the health risks of specific age-groups (available at http://www.ahrq.gov/clinic/uspstfix.htm#About). To the extent possible, these recommendations have been evidence-based, but they also rely on expert opinion. Since 1998, the USPSTF has been sponsored by the Agency for Healthcare Research and Quality (AHRQ), and its recommendations are considered the “gold standard” for clinical preventive services. The recommendations have been periodically updated. A recent analysis of preventive services recommended by the USPSTF considered the cost-effectiveness and the clinically preventable disease burden to produce rankings of relative health impact. Among services relevant for adolescents and young adults, the highest ranking preventive services were the childhood immunization series, screening for tobacco use and brief interventions for tobacco users, screening for “problem drinking” and brief intervention for those at risk, cervical cancer screening with cervical cytology (Pap smears), and Chlamydia screening in sexually active women younger than 25 years. Of these, tobacco use screening, screening for problem drinking, and Chlamydia screening were all estimated to occur <50% of the time (Maciosek et al., 2006). Rankings and article are also available online at: http://www.prevent.org/content/view/49/99/.
In 1992, the American Medical Association (AMA, 1992) released Guidelines for Adolescent Preventive Services (GAPS). GAPS is a comprehensive package of recommendations aimed at the delivery of preventive services in primary care settings (Table 4.2). The GAPS recommendations were developed by the AMA's Division of Adolescent Health, with the assistance of a national scientific advisory board, to address highly prevalent health issues and those most likely to cause serious morbidity. GAPS recommendations cover both the content and delivery of health care to adolescents (Fig. 4.1). Information on these recommendations can be found at the AMA Web site (http://www.ama-assn.org/ama/pub/category/1980.html).
The Bright Futures guidelines for the health care supervision of infants, children, and adolescents were published in 1994 and represent the work of expert panels convened through a collaboration of the Maternal and Child Health Bureau of the Health Resources and Services Administration, and the Medicaid Bureau of the Health Care Financing Administration (http://brightfutures.aap.org/web/). The guidelines are both evidence-based and based on expert opinion. Issues related to normal and abnormal development, nutrition, and mental health are highlighted in the Bright Futures guidelines. A comprehensive revision of Bright Futures is currently underway.
The American Academy of Family Physicians (AAFP) offers age-specific recommendations for periodic health examinations for healthy patients (available at http://www.aafp.org). The AAFP recommendations are derived from
the USPSTF report by the Commission on Public Health and Scientific Affairs of the AAFP.
Finally, the American Academy of Pediatrics (AAP) also reviewed preventive care for children and adolescents and published revised recommendations in 1995. These recommendations represent “a consensus by the Committee on Practice and Ambulatory Medicine in consultation with national committees and sections of the American Academy of Pediatrics.” Guidelines for Health Supervision III, published by the AAP in 1996 and revised and updated
in 2002, more comprehensively describes the elements of health supervision visits for children and adolescents (American Academy Pediatrics, 1996). Updated guidelines for health supervision will be part of the revised Bright Futures guidelines on which the AAP is collaborating. Information is available on their Web site (http://www.aap.org).
The various recommendations for adolescent preventive services are compared in Table 4.1. There appear to be more similarities than differences. All of the recommendations support the immunization schedule of the Advisory Committee on Immunization Practices (ACIP), and all advocate health guidance for teens. The GAPS, Bright Futures,
and AAP recommend health guidance for parents also, as a strategy to assist them in supporting the growth, development, and changing needs of their adolescent. Screening and counseling for various health risks are also a common feature of the recommendations from each of the five organizations, although there is some variability in the specific recommendations for screening. Periodicity may be the most important distinction among the five sets of recommendations. GAPS, Bright Futures, and the AAP specifically recommend annual visits for preventive services, whereas the USPSTF and AAFP recommend visits every 1 to 3 years based on the specific needs of the individual.
FIGURE 4.1 Recommended frequency of GAPS preventive services. (From American Medical Association. Guidelines for adolescent preventive services [Recommendations monograph]. Chicago: American Medical Association, 1995.)
Although guidelines help standardize and provide structure to the range of preventive services offered to adolescents, service delivery remains an even more challenging issue. Research in the last 2 decades has clearly demonstrated both the limitations of the current delivery system and the value of offering services in a wide range of settings and formats. Still, preventive services remain inconsistently delivered, and in some settings they are delivered at dangerously low rates. These findings are easy to understand but difficult to resolve. It is well known, for example, that adolescents are generally considered “healthy,” that they are reluctant health care consumers, and that their access to health care is limited by issues related to reimbursement, confidentiality, transportation, and the training of the providers who care for them.
Solving these problems remains even more vexing. Establishing a broader context for adolescent “health” is a matter for public and professional education. Adolescents report issues that they want and need to discuss with their health care providers but that they often do not. To better serve adolescents, preventive services must be available in a wide range of health care settings. These include private physicians' offices within managed care organizations; community-based adolescent health, family planning, and public health clinics; and as part of school-based and school-linked health services. Simple, skills-based training for clinicians in adolescent preventive services has been convincingly shown to increase the likelihood of appropriate screening and counseling as well as provider self-efficacy in a variety of clinical settings. Reimbursement for these services will continue to be problematic.National standards of care such as those discussed in this chapter may increase the likelihood that payers will begin to provide reimbursement for adolescent preventive services. However, for adolescent preventive services to become routinely available to all adolescents a dramatic shift in both health care provider and health care consumer expectations—from a reactive, acute care orientation to a proactive view that values health promotion and disease prevention—will be required.
Preventive Care for Adolescents
Many of the most effective health promotion and disease prevention strategies aimed at adolescents are straightforward and consistent among the various recommendations and guidelines discussed earlier (GAPS, Bright Futures, USPSTF, AAP, and AAFP). Furthermore, because health-risk behaviors and health habits have their genesis in adolescence, healthy behaviors and lifestyle choices established during adolescence have the potential to persist into adult life and to have a strongly positive impact on adult health as well. In this context, the Society for Adolescent Medicine has endorsed the use of guidelines as a strategy to improve the delivery of adolescent preventive services (information available at http://www.adolescenthealth.org). The Society for Adolescent Medicine's major recommendations include the following:
In addition, in the Society's position paper on adolescent immunizations, it recommended that three distinct adolescent vaccination visit/platforms be developed including 11–12, 14–15, and 17–18 year visits. These would be used to integrate and emphasize the role of vaccinations in the recommended comprehensive health care screening and provision visits. The first visit would be used for ACIP-recommended vaccines, the second visit for catch-up on missed vaccines, and the third as catch-up before college graduation or for newly recommended vaccines while the teen is still covered by third-party payers.
Healthy People 2010 provides national objectives aimed at improving health and well-being. Of the 467 Healthy People 2010 objectives, 107 are relevant for adolescents and young adults and 21 have been identified as critical health objectives. These include the following:
Clinical Settings for Adolescent Preventive Services
Improving the delivery of adolescent preventive services depends on the integration of standards and service delivery across multiple systems and points of access, including public clinics, managed care organizations, private physician offices, school-based and school-linked clinics, and community-based agencies. In fact, there is evidence to suggest that traditional office-based care for teens may fall short of the care they receive in other settings. Blum et al. (1996) studied adolescent preventive services in a variety of practice settings and showed that the highest level of preventive care was delivered in teen clinics whereas the lowest level of preventive care occurred in private pediatric or family practices. Potential explanations for these disparities include the specific teen focus of teen clinics and limitations within the private practices related to provider comfort and/or training addressing teen issues, time pressures, limited reimbursement, and so on. Similarly, a study of a California managed care organization demonstrated better performance with adolescent preventive services than that provided by physicians in private practice settings. Success in this managed care setting may have been related to confidentiality policies, frequently reported recommendations for annual visits, or other factors.
School-based and school-linked health resources have become more important in the overall landscape of health services available to adolescents (see http://www.gwu.edu/~mtg and http://www.nasbhc.org). Adolescents who use school-based health services are highly satisfied with the care they receive. Moreover, school-based and school-linked services seem to play a unique and complementary role in meeting the health needs of some teens. For example, there is evidence to suggest that teens may be more willing to access school-health services rather than traditional health resources to address mental health, substance use, and reproductive health concerns.
Preventive Services Visit
General Suggestions for Providing Adolescent Preventive Services
Caring for adolescents requires a different approach, format, and style than does caring for either children or adults, so it is not surprising that many health care providers report discomfort caring for adolescents. This discomfort is exacerbated when sensitive health concerns must be discussed or treated, or when providers feel ill-trained or ill-equipped to manage the specific issues before them. Although there is no substitute for proper training or a teen-friendly office environment, the following general suggestions provide a framework for the delivery of adolescent health services:
Questionnaires and Other Health Screening Tools
Questionnaires and screening forms can be efficient tools for collecting information, thereby reducing the amount of time spent with patients. Some patients also find it easier to disclose sensitive information through questionnaire than face-to-face. Screening questionnaires and personal interviews may therefore be considered complementary, and neither will be adequate in all situations. Many clinics, programs, and practices elect to create their own questionnaires based on their unique knowledge of their individual practice. The AMA's GAPS program has published a series of carefully constructed and updated questionnaires for both adolescents and their parents (Figs. 4.2, 4.3, 4.4, 4.5). There are longer versions best suited to new patients and shorter versions suitable for returning patients. The questionnaires are also available in Spanish and are easily modified for providers who wish to individualize them. They may be obtained from the AMA (http://http://www.ama-assn.org/ama/pub/category/1981.html).
FIGURE 4.2 Comprehensive initial preventive services questionnaire for adolescents. (From American Medical Association. Guidelines for adolescent preventive services[Recommendations monograph]. Chicago: American Medical Association, 1995.)
FIGURE 4.2 (Continued)
FIGURE 4.2 (Continued)
FIGURE 4.2 (Continued)
FIGURE 4.3 Comprehensive initial preventive services questionnaire for parents/guardians. (From American Medical Association. Guidelines for adolescent preventive services[Recommendations monograph]. Chicago: American Medical Association, 1995.)
FIGURE 4.3 (Continued)
Screening tools that have been more formally and rigorously validated can be useful in practice, particularly to screen for behavioral and mental health problems. For example, the Beck Depression Inventory is a well validated and easily administered tool to screen for depression. The 21-question inventory is designed for adolescents and is simple to use and score in a busy clinical setting. A wide variety of other tools are available to screen for family function, behavioral difficulties, and other mental health problems.
Computer-aided Screening and Assessment
In this information age, there is increasing interest in using technology to assist in providing preventive services to adolescents. Computer-aided screening, information kiosks, and Internet-based health information are all being investigated as tools to increase access to information and resources, as well as to deliver preventive services in the most cost-effective manner possible. For example, Paperny and Hedberg (1999) tested a low-cost strategy to provide preventive services to adolescents with the use of computerized health assessments, individualized educational videos, trained health counselors, and nurses. They found that most adolescents preferred the computer-assisted visits to standard office visits, and that preventive services could be delivered at a very modest cost. Further work will be required to assess the utility of this strategy in affecting health outcomes.
A comprehensive history is the most important aspect of the preventive services evaluation. As with any history, essential domains include past medical history, family
history, psychosocial history, and an age-appropriate review of systems. Any current health concerns should also be sought. When preventive services are delivered in the setting of a visit made with another specific agenda (e.g., sports physical, acute medical problem), the patient's agenda should be fully addressed before preventive services are offered.
FIGURE 4.4 Brief periodic preventive services questionnaire for adolescents. (From American Medical Association. Guidelines for adolescent preventive services[Recommendations monograph]. Chicago: American Medical Association, 1995.)
FIGURE 4.4 (Continued)
FIGURE 4.5 Brief periodic preventive services questionnaire for parents/guardians. (From American Medical Association. Guidelines for adolescent preventive services[Recommendations monograph]. Chicago: American Medical Association, 1995.)
FIGURE 4.5 (Continued)
Past Medical History
Past medical history is best obtained from both the adolescent and the parents and should include the following:
Most information about family history is most accurately obtained from the parents. It should include the following:
The psychosocial history is obtained primarily from the adolescent while he or she is interviewed alone. Some material will also be gathered from the parents or from interviews with the family together. Obtaining much of this information is dependent on successfully establishing trust and rapport between the practitioner and the adolescent. Many clinicians rely on the HEADSS acronym to guide their psychosocial history. The original acronym included home, education, activities (including information about peers), drugs, sexuality, andsuicide (mental health). A more upto-date incarnation of the acronym—HEEADSSS—includes additional questions covering eating and safety (see Chapter 3). A complete psychosocial history includes the following areas:
Review of Systems
The review of systems covers the following areas:
The physical examination is another important component of the screening evaluation of the adolescent. The examination allows the clinician to assess growth and pubertal development and to instruct the adolescent in methods of self-examination and other means of health promotion. The physical examination also affords the adolescent an opportunity to ask about any specific health concerns, and it provides the clinician with the opportunity to detect unnoticed diseases. The examination should be performed in such a way as to preserve the adolescent's modesty. Main elements of the physical examination (Fig. 4.6) include the following topics.
Height, Weight, and Vital Signs
Height, weight, blood pressure, and pulse should be measured. The serial measurement of height and weight allows for monitoring of the adolescent's growth and for the earlier detection of risk factors for obesity. Body mass index (BMI) should be calculated and tracked. Gender-specific age-based BMI norms
are available and are used in assessing risk for obesity (Figs. 4.7, 4.8, 4.9). Blood pressure should be recorded with an appropriately sized cuff. If blood pressure is elevated, it should be rechecked at least three separate visits before a diagnosis of hypertension is considered (Figs. 4.10, 4.11, 4.12).
FIGURE 4.6 Adolescent physical examination form. (From American Medical Association. Guidelines for adolescent preventive services [Recommendations monograph]. Chicago: American Medical Association, 1995.)
Among 12- to 17-year-old adolescents, approximately 25% have visual acuity of 20/40 or less. This condition often develops during early adolescence. Adolescents should have a vision screening at the time of their initial evaluation and every 2 to 3 years thereafter. This can be done with a standard Snellen chart or a similar test. To pass a line the adolescent should view the chart with one eye covered and be able to read one half or more of the line correctly. Referral should be made for vision <20/30 in either or both eyes.
There is increasing concern about threats to hearing and every adolescent should have at least one test for hearing screening performed during the adolescent years. It is important that this test be performed in a quiet room to allow for detection of subtle defects that may be contributing to a learning problem. Screening examinations are usually conducted at frequencies of 1,000, 2,000, and 4,000 Hz at 20 dB. Referral for more comprehensive hearing testing is indicated if there is a failure to hear 1,000 or 2,000 Hz at 20 dB or 4,000 Hz at 25 dB. The more comprehensive threshold test evaluates for the lowest intensity of sound heard at frequencies of 250, 1,000, 2,000, and 4,000 Hz. Evaluation is indicated with a threshold of 25 dB at two or more frequencies or at 35 dB for any frequency.
Sexual Maturity Rating
The sexual maturity rating (SMR), discussed in Chapter 1, is the method by which pubertal development is evaluated and described. Because many “normal values” in adolescents depend more on SMR than on age, evaluation of SMR is important not only in describing pubertal milestones but also in adequately assessing many physical parameters (e.g., BMI), and laboratory values (e.g., hemoglobin).
Check for evidence of acne, warts, fungal infections, and other lesions. Carefully inspect moles, especially in patients who are at particular risk for melanoma.
Teeth and Gums
Teeth and gums frequently present problems in the adolescent age-group. Check for evidence of dental caries or gum infection. Look for signs of smokeless tobacco use. Enamel erosions are sometimes the first clue to the self-induced vomiting associated with some eating disorders. Regular checkups with a dentist should be encouraged.
Check for thyromegaly or adenopathy.
Check for heart murmurs or clicks.
Check for evidence of hepatosplenomegaly, tenderness, or masses.
The musculoskeletal examination is especially important in adolescent athletes, in whom instabilities or other evidence of previous injury is the best predictor of future injury. Check for signs of overuse syndromes or osteochondroses. Check for scoliosis, particularly in premenarchal females.
Examine for symmetry and developmental variations; in girls, assess SMR. Examine for masses or discharge; in boys, identify gynecomastia (present in approximately one third of pubertal males). The value of breast self-examination is unclear, especially in adolescent females in whom the risk of breast cancer is extremely low. If breast self-examination is to be taught and encouraged, it should be done only when developmentally appropriate.
Test strength, reflexes, and coordination.
Examine the penis and testicles. Assess SMR. Look for signs of STDs. Retract the foreskin in uncircumcised patients. Check for hernia.
Pelvic Examination (Female)
A pelvic examination is indicated for female adolescents who have ever been sexually active and for any female adolescent who requests an examination. In addition, pelvic examination is indicated for female adolescents with pelvic pain, an atypical or changing vaginal discharge, or an undiagnosed menstrual disorder. “Annual” pelvic examination and Pap screening, which had previously been recommended for all women beginning at approximately 18 years of age, are now recommended beginning 3 years after coitarche or age 21, whichever comes earlier. Annual screening for STDs (which may or may not require a pelvic examination) is clearly recommended for sexually active female patients (see Chapter 48).
Rectal examination is not routinely indicated as a screening procedure in the male adolescent. It is sometimes, but not always, part of the female pelvic examination.
Laboratory tests should be kept to a minimum in the asymptomatic adolescent. Suggested screening tests are discussed in the following sections.
Hemoglobin or Hematocrit
During adolescence there is a significant prevalence of iron deficiency anemia due to rapid growth, poor nutritional habits, exercise, and menstrual losses. A screening hemoglobin or hematocrit is recommended at the first encounter with the adolescent or at the end of puberty, or both. Although the normal levels remain stable for females throughout adolescence, the normal levels in males are dependent on age and, more importantly, on SMR. Lower levels of the normal hematocrit in white male adolescents range from 35.6% at SMR 1 to 40.6% at SMR 5; in African-American male adolescents this range is slightly lower, from 34.9% (SMR 1) to 39.3% (SMR 5).
A routine urinalysis, including a dipstick test for glucose and protein and a microscopical evaluation, is recommended at the first encounter with the adolescent or at the end of puberty, or both. However, up to one third of healthy adolescents have small amounts of proteinuria that is nonpathological and requires no treatment (see Chapter 27). Abnormal pyuria requires further investigation for urinary tract infection and, in males, for Chlamydia infection.
Sickle Cell Screening
Screening for sickle cell anemia is recommended at the first visit with an African-American adolescent if it has not been documented already.
FIGURE 4.7 Body mass index calculation for selected weight and stature. (From American Medical Association. Guidelines for adolescent preventive services [Recommendations monograph]. Chicago: American Medical Association, 1995.)
FIGURE 4.8 Tracking of height, weight, and body mass index by age: girls. (From American Medical Association. Guidelines for adolescent preventive services[Recommendations monograph]. Chicago: American Medical Association, 1995.)
FIGURE 4.9 Tracking of height, weight, and body mass index by age: boys. (From American Medical Association. Guidelines for adolescent preventive services[Recommendations monograph]. Chicago: American Medical Association, 1995.)
FIGURE 4.10 The 90th and 95th percentiles for blood pressure by age and gender. (From American Medical Association. Guidelines for adolescent preventive services[Recommendations monograph]. Chicago: American Medical Association, 1995.)
Sexually Active Adolescents
Suggested tests for sexually active adolescents are discussed in the following sections.
Cervical gonorrhea and chlamydia culture or nonculture test, and vaginal wet mount are recommended. Syphilis serology should be considered in high-risk populations or where syphilis is prevalent. Screening for the HIV should be offered to all sexually active adolescents and should be encouraged for adolescents with any history of STD. Begin annual Pap smears 3 years after coitarche or at age 21.
A leukocyte esterase test on the first 15 mL of a random urine sample is recommended to screen for Chlamydia infection. However, there is concern about the sensitivity and specificity of this test. In high-risk populations, annual urethral screening for gonorrhea and chlamydia by culture or nonculture test can be encouraged. Syphilis serology should be considered in high-risk populations or where syphilis is prevalent. Screening for the HIV virus should be offered to all sexually active adolescents and should be encouraged for adolescents with any history of STD.
Men who have sex with men
Annual syphilis serology, gonorrhea cultures (urethral, rectal, and pharyngeal), Chlamydia screening, and HIV screening are recommended. Homosexual males who are not already immunized should be screened for hepatitis B as well. Those with negative surface antigen and antibody tests should receive hepatitis B vaccine.
Liver Function Tests
Liver function tests are not a routine screening test but should be obtained as indicated by the drug or alcohol history.
Cholesterol and Fasting Triglyceride Testing
Targeted cholesterol and fasting triglyceride testing is indicated in adolescents with heart disease, hypertension, diabetes mellitus, or a family history of heart disease or hyperlipidemia. Intervention is indicated for individuals with a total cholesterol level >180 to 200 mg/dL on repeated testing (see Chapter 12). Some authorities advocate at least one screening cholesterol test during adolescence. Targeted screening in adolescents misses one third to one half of those teens with elevated cholesterol concentrations. However, the recommended intervention for most adolescents with mild to moderate hyperlipidemia is a prudent low-fat diet, which can be taught to all adolescents.
Human Immunodeficiency Virus Antibody Testing
Routine screening for antibody to HIV is a controversial matter. Individuals at risk should be encouraged to receive HIV testing after a discussion regarding the benefits and possible negative consequences of the results (see Chapter 31). Individuals with any STD should be screened for others, including HIV infection.
A purified protein derivative (PPD) tuberculin skin test should be considered at the first encounter with the adolescent based on an assessment of individual risk factors and recommendations of the local health department (in high-risk areas, screening is usually recommended yearly).
FIGURE 4.11 Tracking of blood pressure by age: girls. (From American Medical Association. Guidelines for adolescent preventive services [Recommendations monograph]. Chicago: American Medical Association, 1995.)
FIGURE 4.12 Tracking of blood pressure by age: boys. (From American Medical Association. Guidelines for adolescent preventive services [Recommendations monograph]. Chicago: American Medical Association, 1995.)
Recommendations from the Centers for Disease Control and Prevention (CDC) on interpretation of the PPD results include the following points:
Obtaining the immunization history and completing the immunizations properly is increasingly important in the care of adolescents, because a variety of common childhood diseases appear during adolescence and the young adult years. This is a group that still has significant rates for nonimmunization. During 2001 to 2004, persons aged 20 years or older accounted for 50% of reported measles cases, and adolescents (age 10 to 19 years) accounted for 18.6% of cases. The rate of rubella susceptibility and risk for rubella infection are highest among young adults. The number of cases of varicella is falling in all ages with increasing immunization rates in infants and children; however, many adolescents and young adults remain susceptible. With increasing immunization rates, especially among the young, there is a corresponding decrease in the incidence of vaccine-preventable disease, with fewer opportunities for the nonimmunized population to be exposed to these diseases at a young age. As a result, there is an expansion of the nonimmunized, susceptible adolescentpopulation.
With the advent of ever-newer vaccines, adolescents previously considered to be fully vaccinated suddenly find themselves “behind.” The challenge of ensuring that adolescents' immunizations are up-to-date is compounded by the substantial number of adolescents who have received their immunizations in more than one place; inadequate documentation of prior vaccination remains a significant issue in the adolescent population. The issue of documentation may be resolved over time with the increasing use of vaccine registries. Because vaccination schedules remain a moving target, clinicians are well advised to keep abreast of the latest vaccine recommendations of the ACIP of the CDC. The current immunization schedule is available at http://www.cdc.gov. In addition, international travel information is available at http://www.cdc.gov/travel.
General Vaccination Information
Vaccination of adolescents is safe and should be seen as a high priority for adolescents whose previous immunization is lacking or incomplete. Adolescents who have been partially vaccinated can have their vaccination completed without restarting the series. Likewise, adolescents who begin vaccination can complete it at any time after the vaccination process is interrupted, even if there has been a substantial delay between doses. Vaccines should not be given more frequently than the recommended intervals. Although not every possible combination of vaccines has been explicitly tested, there are no contraindications to giving any or all of these vaccines simultaneously, so long as they are given at separate and appropriate anatomical
sites. Nevertheless, many clinicians faced with having to give four or five vaccines choose to offer the patient a return visit to limit the number of simultaneous injections.
Since 1994, all health care providers who administer measles-mumps-rubella (MMR), polio, diphtheria and tetanus toxoids and pertussis (DTP), and Td vaccines have been required to distribute vaccine information sheets each time a patient is vaccinated. The clinic or office should obtain a signature of either the patient, parent, or guardian to acknowledge having been provided with vaccine information. This should also be noted in the medical record. Appropriate documentation of vaccination includes consent for vaccination, immunization type, date of administration, injection site manufacturer and lot number of vaccine, and name and address of the health care provider administering the vaccine. Helping patients and their families to maintain their own immunization records facilitates proper vaccination of adolescents who may go on to receive immunizations in more than one location. Vaccination registries, which are available online in many states, will also improve this process.
Erroneous Contraindications against Vaccination
In an effort to improve vaccination rates, the ACIP has specifically addressed a variety of situations in which many practitioners have deferred or delayed vaccination. Situations that specifically do not represent contraindications to vaccination include the following:
Furthermore, “minor illnesses” such as mild upper respiratory tract infections, with or without low-grade fever, are not contraindications for vaccination. Inappropriate avoidance of vaccination because of a mild acute illness has contributed to many missed opportunities for vaccinating children and adolescents.
Vaccination during Pregnancy
Because of theoretical risks to the developing fetus, live attenuated virus vaccines are not routinely given to pregnant women or to those who are likely to become pregnant within 3 months of receiving the vaccine. There is no convincing evidence of risk to the fetus after immunization of pregnant women with inactivated virus vaccines, bacterial vaccines, or toxoids. This includes tetanus and diphtheria toxoid. There is also no risk to the fetus from passive immunization of pregnant women with immune globulin. Because MMR vaccine viruses are not transmitted from individuals receiving them, children of pregnant women may receive these vaccines.
Sample Schedule for Nonimmunized Adolescents
Most adolescents seeking preventive health services are either fully or partially immunized. For adolescents who have received no immunizations, a sample immunization schedule is provided in Table 4.3. Immunization recommendations are updated annually by the CDC and can be found at http://www.immunize.org/cdc/child-schedule.pdf.
Adolescents with Human Immunodeficiency Virus Infection
Vaccine recommendations for HIV-infected adolescents are described in the text for individual vaccines and are summarized in Table 4.4.
Diphtheria, Tetanus, Pertussis
It is now well known that adolescents and adults have a higher incidence and prevalence of pertussis than children. In recent years, the highest increase in cases has been in the 10 to 19 years age-group. In adolescents, pertussis infection typically presents clinically as a mild respiratory infection that goes on to produce a protracted (3 or more
weeks) cough. Adolescents with pertussis make frequent health care visits and miss considerable school days. In one study, 83% of adolescents with pertussis missed an average of 5.5 days of school. Moreover, in nearly half of households with an ill adolescent, a parent missed days of work.
Two new tetanus toxoid, diphtheria toxoid, and acellular pertussis (Tdap) vaccines created for use in adolescents and adults have recently been approved for use in the United States. Boostrix is a product of GlaxoSmithKline and is licensed for use in adolescents aged 10 to 18 years. Adacel is a product of Sanofi Pasteur and is licensed for use in adolescents and adults aged 11 to 64 years. Both of these vaccines have been demonstrated to be safe and effective when administered as a single booster dose to adolescents. The ACIP now recommends that adolescents aged 11 to 18 who have completed their primary vaccination series against diphtheria, pertussis, and tetanus now receive a single dose of Tdap instead of the Td. The preferred age for Tdap vaccination is 11 to 12 years; ideally, Tdap should be given concurrently with the new tetravalent meningococcal conjugate vaccine (Menactra; see subsequent text). Tdap can be administered concurrently with other vaccines as well using a separate syringe at a different anatomic site. Adolescents who have already received a single dose of Td should still receive a single dose of Tdap between the ages of 11 and 18 years. An interval of at least 5 years is recommended (but not required) between Td and Tdap to reduce the risk of reactions. After Tdap vaccination, Td boosters continue to be recommended every 10 years throughout life. The dose of Tdap is 0.5 mL administered intramuscularly in the deltoid muscle.
Tdap is contraindicated in those who have had serious allergic reactions to any of its components and in those who have developed encephalopathy associated with previous pertussis vaccination. Tdap should be deferred in patients who developed Guillain-Barré syndrome (GBS) associated with previous tetanus toxoid vaccination and in those with progressive encephalopathies or uncontrolled epilepsy. Vaccination should be postponed in patients who are acutely ill with moderate–serious illnesses until the illness has resolved. Reactions to previous DTP/Tdap vaccination (except those noted earlier) are generally not contraindications to vaccination. Neither are breast-feeding, immunosuppression, or intercurrent minor illnesses. Because pregnant women have been excluded from prelicensure trials, neither Tdap vaccines are approved for use in pregnancy (Pregnancy Category C). However, Td vaccine, also Pregnancy Category C, has been used extensively during pregnancy without any evidence of teratogenicity and pregnancy is not considered a contraindication to Tdap vaccination.
The most common side effect of either Tdap vaccine was pain at the injection site. No serious adverse effects related to vaccination have been observed in the first 6 months of postvaccination monitoring with either Boostrix or ADACEL.
Pertussis infection in adolescents is discussed in detail in Chapter 29.
The hepatitis A vaccination now offers effective, long-lasting protection against this virus. Two vaccines are available: Havrix (SmithKline Beecham Biologicals) and Vaqta (Merck & Co.). The vaccines are inactivated and come in adult and pediatric formulations, with different dosages and administration schedules. Almost 100% of children, adolescents, and adults develop protective levels of antibody to hepatitis A virus after completing the vaccine series. The vaccine can be administered simultaneously with other vaccines and toxoids, including hepatitis B, diphtheria, and tetanus, without altering immunogenicity or adverse effects. However, other vaccines should be given at separate injection sites. The recommended dosing is described in Table 4.5.
Twinrix (GlaxoSmithKline) is also available containing both vaccines for hepatitis A and hepatitis B. Hepatitis A, including others for whom the vaccine is recommended, is discussed in detail in Chapter 30.
Two recombinant hepatitis B vaccines (Recombivax HB and Engerix-B) are used currently in the United States. Universal vaccination is now recommended in the United States, and the ACIP recommends the three-dose hepatitis B vaccine series for adolescents at age 11 to 12 years who have not previously been immunized. Vaccination should be a special priority for the following persons:
Persons in casual contact with carriers in settings such as schools and offices are at minimal risk of hepatitis B infection, and vaccine is not routinely recommended.
Hepatitis B is discussed in detail in Chapter 30.
Hepatitis B vaccine is given in a three-dose series. The second dose is given 1 to 2 months after the first, and the third dose is given 4 to 6 months after the first. The series does notneed to be restarted if it is interrupted. The three-dose hepatitis B vaccine induces protective antibodies (anti-HBs) in >90% of healthy adults and >95% of infants, children, and adolescents through 19 years of age. Protective effects appear to be quite durable and long lasting. Hepatitis B vaccine can be given simultaneously with other vaccines.
Adverse reactions to hepatitis B immunization are unusual. Pain at the injection site and fever are the most commonly reported adverse effects. Anaphylaxis is rare. Anecdotal cases of autoimmune disease, chronic fatigue syndrome, GBS, and CNS diseases associated with hepatitis B vaccination have not been causally linked to immunization.
Haemophilus Influenzae Type B
Haemophilus influenzae type B vaccine is indicated for those adolescents not previously immunized who are at risk because of splenic dysfunction or other conditions. A single dose of 0.5 mL is recommended.
Two vaccines for prophylaxis against human papillomavirus (HPV) have been developed, a quadrivalent vaccine (Gardasil, Merck & Co.) and a bivalent vaccine (see Chapter 66). The quadrivalent vaccine was licensed in June 2006 by the FDA and the ACIP has recommended that it be routinely given to girls aged 11 to 12 years. The quadrivalent vaccine targets HPV types 16 and 18 (the most common HPV types implicated in cervical cancer) as well as HPV types 6 and 11 (the most common HPV types associated with genital warts). So far, both vaccines have been shown to be safe, highly immunogenic, and to prevent infections with HPV types 16 and/or 18 in randomized, double-blind, placebo-controlled trials. Approximately 70% of cervical cancer is related to HPV types 16 and 18 and 90% of genital warts are related to types 6 and 11. Therefore, the potential is very high to prevent a significant number of both genital warts and cervical cancer. Vaccine-related adverse effects were rare and no serious adverse effects have been reported.
The current recommendation is that the quadrivalent vaccine (Gardasil) be given to girls aged 11 to 12, but the vaccination series of three vaccines can be started as early as age 9 at the discretion of the health care provider. Ideally, vaccination should occur before the onset of sexual activity as the vaccine will not be effective against any HPV subtypes that may have been already acquired. However, women aged 13 to 26, even if they are already sexually active, are thought to benefit from the vaccine as well, acquiring protection from any HPV subtypes to which they have not already been exposed. “Catch-up” vaccination has also been recommended by the ACIP. The vaccine is not currently recommended for males. Time and experience will establish how vigorously the vaccine will be endorsed by health care providers, or how the vaccine will be accepted by patients and families. The longerterm effects of vaccination on cervical cancer are unclear and less is known even about the effect of vaccination on other cancers (e.g., vulvar, penile, anal). Although some individuals have raised concerns that increased or riskier sexual behavior will be an unintended consequence of the vaccine, there is no evidence to support these claims. Finally, widespread deployment of HPV vaccines will likely have an eventual effect of the recommendations for cervical cancer screening. However, the current vaccine offers no protection against 30% of the HPV subtypes currently causing cervical cancer, so some strategy for cancer screening will continue to be required. Despite these unanswered questions, it seems likely that these new vaccines have the potential to dramatically reduce rates of genital warts and cervical and other cancers.
Influenza continues to cause major outbreaks of illness, usually beginning in December or January each year. If vaccine is administered, it ought to be given in the fall. Two types of vaccine are available, an inactivated vaccine and a live attenuated vaccine. Both vaccine types contain three virus strains (two type A and one type B), representing the strains most commonly found worldwide and predicted to be most likely to cause infections in the coming year. Vaccines are updated annually. Influenza in adolescents is discussed in detail inChapter 29.
Vaccination with inactivated influenza vaccine is recommended for the following adolescents because of their increased risk for complications from influenza:
In addition, the vaccine should be administered to any person who wishes to reduce the likelihood of becoming ill with influenza or transmitting influenza to others. Students or other persons in institutional settings (e.g., those who reside in dormitories) should be encouraged to receive the vaccine to minimize disruption to their routine activities during epidemics.
Inactivated influenza vaccine is administered intramuscularly in the deltoid muscle. Only a single dose is required for those older than 9 years. It is contraindicated in persons with anaphylactic reactions to eggs and it should be delayed in those with significant febrile illnesses (but not in those with minor upper respiratory infections).
Live, attenuated influenza vaccine (LAIV) is marketed in the United States as Flumist. It is administered intranasally and is indicated for healthy persons aged 5 to 49 years, including those who may have contact with high-risk groups. It is contraindicated in adolescents with asthma, reactive airways disease, or other chronic condition; in adolescents receiving aspirin or other salicylates (because of the association of Reye syndrome with wild-type influenza infection); in adolescents with a history of GBS; in pregnant women; or in adolescents with a history of hypersensitivity, including anaphylaxis, to eggs. LAIV should not be used in those who will have close contact with severely immunocompromised persons within 7 days of vaccination. LAIV is administered only through the intranasal route, 0.25 mL in each nostril. Only a single dose is required for those older than 9 years. A refrigerator stable version with broader age indications for both healthy and at-risk individuals may be available by the 2008 influenza season.
The most common adverse effects of LAIV include runny nose, nasal congestion, and sore throat. Serious adverse effects are rare (rates <1%).
Chemoprophylaxis drugs are also available to help prevent influenza. Chemoprophylaxis is appropriate for individuals who are at high risk and who either have not been immunized or are exposed to influenza before a vaccine response has occurred (2 weeks). It is also useful for immunosuppressed adolescents who may not respond to the vaccine and for adolescents for whom vaccination is contraindicated. Chemoprophylaxis for influenza is discussed in Chapter 29.
Measles has been decreasing dramatically in the United States, with 441,703 cases in 1960; 47,351 in 1970; 13,506 in 1980; 2,933 in 1988; and 312 in 1993. There was an increase to 963 in 1994, but the number dropped to 288 in 1995, and case numbers in 1997, 1998, and 1999 reached all-time lows. In 2004, only 37 confirmed measles cases were reported to the CDC. Measles is not considered endemic in the United States at this time; the incidence is <0.02 cases per 100,000 population.
Although the potential still exists for measles epidemics on college campuses, reported case numbers are low at present because of cyclical changes in measles incidence, improvement in measles vaccination coverage among preschool-aged children, and increased use of a second dose of vaccine among school- and college-aged youth. Because of the low incidence of measles, suspected cases should be confirmed by serology. Because of the problem of waning immunity, it is now universally recommended that children and adolescents receive a second vaccination either at primary school level or on entry to junior high school. If these opportunities are missed, the vaccine should be caught up whenever the teen presents for health care. Likewise, all young adults who enter college or other institutions of postsecondary education should have documentation of receiving two doses of measles vaccine, and those who do not have such documentation should receive a second dose of vaccine. In practice, measles vaccine is usually administered as MMR vaccine.
Adolescents should be vaccinated if there is no evidence of prior live measles virus immunization received after 1 year of age, unless the adolescent has had physician-diagnosed measles or has laboratory-confirmed immunity. Routine serological testing for immunity to measles is not indicated before immunization.
Exposed Susceptible Adolescents
Unvaccinated adolescents exposed to measles should receive measles vaccine. If more than 5 days has elapsed since exposure, immune serum globulin (IVIG), 0.25 mL/kg, is also given.
Vaccination with live measles virus, or any other live virus, is contraindicated in immunosuppressed patients and in those receiving immunosuppressive therapy. At present, information available on MMR vaccination among asymptomatic and symptomatic HIV-infected individuals has not demonstrated serious or unusually adverse events. Therefore, HIV-infected patients can be immunized so long as they are not actively immunocompromised. Adolescents with leukemia in remission can also be vaccinated, as can those who have had short-term (<2 weeks), low- to moderate-dose systemic corticosteroid therapy, topical steroid therapy, or intraarticular steroid injections.
Adverse effects of measles vaccine include fever, rash, and, rarely, transient thrombocytopenia. There is no causal link between measles vaccination and seizures, encephalitis, or encephalopathy.
Routine vaccination against meningococcal disease became the recommendation of the ACIP beginning in 2005, coinciding with the availability of a new tetravalent meningococcal polysaccharide-protein conjugate vaccine (MCV4) marketed as Menactra by Sanofi Pasteur. Subsequently, the AAP has also recommended routine vaccination with the new MCV4 vaccine. Like the meningococcal vaccine that preceded it, MCV4 provides immunity against serotypes A, C, Y, and W135. However, unlike the previous meningococcal vaccine, the new vaccine is likely to provide protection that is substantially longer lasting. The current recommendation is for adolescents to be immunized as part of a preadolescent health supervision visit at age 11 to 12 years. For those not receiving the vaccine at age 11 to 12 years, immunization before high school entry is recommended. Routine vaccination for college students living in dormitories, military recruits, and others at high risk continues to be recommended. Because their risk is low, routine vaccination of adults who are not members of high-risk groups is not recommended. However, the vaccine is licensed for use for those aged 11 to 55 years; therefore, adults who wish to reduce their risk of meningococcal disease may elect to be vaccinated. The vaccine is given as a single 0.5 mL dose, administered intramuscularly.
Vaccination with MCV4 is contraindicated in those who have severe allergic reactions to any of its components (which include diphtheria toxoid and natural latex). Vaccination should be postponed in cases of moderate to severe illness; minor acute illnesses are not a contraindication to vaccination. Because MCV4 is inactivated, immunosuppression is not a contraindication (although the protection in immunocompromised patients may be reduced). No data is available on vaccination with MCV4 during pregnancy.
Local redness, pain, and swelling were the most common adverse effects. Serious adverse effects have not occurred at rates higher than would be expected in the adolescent population. Concern about a possible association between vaccination with MCV4 and GBS have been raised after seven cases of GBS were identified occurring 11 to 31 days after vaccination. However, the number of cases of GBS is not higher than would be expected in the unvaccinated population. At this time, the CDC is investigating further but has made no changes in the recommendations for vaccination.
The number of cases of mumps has declined dramatically in the United States, from 59,647 cases in 1975 to 8,576 in 1980; 2,982 in 1985; 1,537 in 1994; 338 cases in 2000; and 258 cases in 2003. However, a recent mumps outbreak in 2006 highlights the importance of continued vigilance. Many of the involved individuals in this outbreak were college students, indicating the importance of this age-group as susceptible individuals. Approximately 65% of mumps cases now occur in patients between 10 and 19 years of age, with approximately 20% or more of such adolescents developing orchitis. A live mumps virus vaccine was developed in 1967. The vaccine has few side effects, and >90% of susceptible patients develop protective, long-lasting antibodies. Mumps vaccine is usually administered as MMR. Susceptible adolescents should receive a single dose of mumps vaccine alone or as MMR. Susceptible adolescents are those without documented live mumps vaccination beyond the age of 1 year, unless they have had physician-diagnosed mumps or have laboratory evidence of mumps immunity. Tests for immunity are unnecessary, because revaccination is safe.
Exposed Susceptible Adolescents
Nonvaccinated adolescents who are exposed to mumps should be immunized with the vaccine; vaccination has not been shown to prevent disease in such cases, but it will help prevent future infection. There is no evidence of efficacy of immune globulin.
Vaccination should be avoided in adolescents who are pregnant, have a serious febrile illness, have an immunodeficiency, are receiving immunosuppressive therapy, or have leukemia or lymphoma. HIV infection, unless the adolescent is severely immunocompromised, is not a contraindication to mumps vaccination.
Adverse reactions to mumps vaccine, including allergic reactions, are extremely rare. Purported reactions to mumps vaccine, including seizures and other CNS events, have not been causally linked to immunization.
Pneumococcal vaccine is indicated for individuals with a chronic illness, particularly of the cardiovascular or pulmonary system. It is also indicated for those who are at increased risk of pneumococcal disease, including patients with nephrotic syndrome, sickle cell disease, asplenia or functional asplenia, HIV infection, or B-cell immune deficiency, as well as patients at risk for meningitis. The duration of immunity is unclear and revaccination is not currently recommended by the CDC; however, some centers recommend reimmunization with pneumococcal
vaccine (Pneumovax 23) 3 to 5 years after primary immunization in patients who are at especially high risk.
The last reported case of poliomyelitis caused by locally acquired wild-type virus in the United States occurred more than 20 years ago. Killed-virus inactivated poliovirus vaccine (IPV) is now the vaccine of choice, and oral poliovirus vaccine (OPV) is no longer recommended for use in the United States. Routine vaccination of nonimmunized adults is not required unless they are at particularly high risk because of travel to endemic areas, exposure to wild poliovirus, or occupational exposure. The immunization schedule for nonimmunized adolescents consists of three doses of IPV—two doses with an interval of 4 to 8 weeks, and a third dose 6 to 12 months after the second dose. Persons exposed to wild poliovirus may receive an additional dose of IPV. Immunosuppression is not a contraindication to vaccination. There is a theoretical risk during pregnancy, so vaccination of pregnant women should be avoided. There is also a theoretical risk of anaphylaxis in patients with known allergies to streptomycin, polymyxin B, and neomycin. Adverse effects from the currently available IPV vaccine have not been described.
The number of cases of rubella in the United States has continued a marked decline, with 46,975 cases in 1966; 16,652 in 1975; 3,904 in 1980; 630 in 1985; 221 in 1988; 200 in 1995; and only 10 cases in 2004! Colleges have been high-risk settings for rubella transmission; cases of rubella have often occurred among nonimmunized adults in outbreaks in colleges and workplaces. Therefore, proof of rubella and measles immunity should continue to be required for attendance from both male and female students. All students who enter institutions of postsecondary education should have documentation of having received at least one dose of rubella vaccine or other evidence of rubella immunity. The diagnosis of acute rubella should be confirmed serologically with either the presence of immunoglobulin M (IgM) antibody or a significant rise in IgG titers. Rubella vaccination is usually administered as MMR.
Vaccination during Pregnancy
In 1979, a new rubella vaccine, RA 27/3 (Meruvax II), was introduced that leads to higher titers with fewer side effects. A review of rubella vaccination for the period 1971–1989, in which 321 known rubella-susceptible pregnant women vaccinated with live rubella vaccine within 3 months before or after conception were monitored, showed that none of the infants had malformations compatible with congenital rubella infection. The estimated risk with 95% confidence limits is from 0% to 1.2% with an observed risk of zero. The U.S. Public Health Service nevertheless recommends that women of childbearing age be asked whether they are pregnant. If they say no, they should be advised of the theoretical risk to a fetus from vaccination and instructed to avoid pregnancy for 3 months; they may then be vaccinated. Routine pregnancy testing before vaccination is not indicated. Certainly, if there is any question whether the adolescent might be pregnant, vaccination can be deferred until the question is resolved. When time and cost are not prohibitive, female adolescents can be tested serologically before vaccination. However, this should no longer be done routinely and should not interfere with immunization programs. Clinical diagnosis should not be relied on as evidence of rubella infection.
Males without evidence of prior vaccination should also be vaccinated to decrease the community prevalence of susceptible individuals and therefore the risk of exposure to susceptible pregnant females.
Replication of vaccine viruses can be enhanced in persons with immune deficiency diseases and in persons with immunosuppression, such as individuals with leukemia, lymphoma, or generalized malignancy and those receiving immunosuppressants or large doses of corticosteroids. Such persons should not receive live rubella virus vaccine. Asymptomatic HIV-infected persons in need of an MMR vaccination may receive it so long as severe immunocompromise is absent. Vaccinations should not be given to adolescents with serious febrile illnesses but should not be postponed because of a mild illness, such as an upper respiratory tract infection. Adverse effects from rubella vaccination include fever, rash, lymphadenopathy, and transient arthritis or arthralgias. Purported CNS events associated with immunization have not been causally linked to vaccination.
There were more than 151,000 reported cases of varicella in 1994, with an estimated 3.7 million cases in the United States each year. With widespread vaccination, fewer than 33,000 cases were reported in 2004. Still, varicella results in more than 9,000 hospitalizations annually, and in 2004, accounted for nine reported deaths. Whereas younger patients usually have uncomplicated chickenpox, older ones have more serious infections with higher rates of complications. The estimate from the CDC is that about $384 million could be saved annually with vaccine usage. A live attenuated varicella vaccination for chickenpox was approved in 1995 for use in children, adolescents, and adults. The vaccine is marketed under the name Varivax and is approximately 70% to 90% effective in preventing varicella. Varicella vaccination is now recommended for persons of all ages without documented chickenpox or measurable levels of protective antibody.
Children and young adolescents between 1 and 13 years of age without documented varicella infection should receive a single dose of varicella vaccine. Adolescents 13 years or older should receive two doses of varicella vaccine, 4 to 8 weeks apart. Immunization is also recommended for susceptible adults, particularly those at residential or occupational risk and those living or working with children. The vaccine can be co administered with MMR vaccine. Varivax is a live attenuated vaccine. It is not recommended for children younger than 1 year of age, pregnant women, people who are hypersensitive to gelatin or other vaccine components, those with a history of anaphylactoid reaction to neomycin, or those with active untreated TB. The vaccine should also be avoided in immunosuppressed patients (including those who are immunocompromised from HIV
infection) and those who are receiving immunosuppressive therapy. Approximately 5% to 10% of persons vaccinated develop a rash, which can be contagious. Other adverse reactions include redness, hardness, and swelling at the injection site; fatigue; malaise; and nausea.
Preventive Health Interventions
The practice of medicine is often more of an art than a science, and this is especially true in the care of adolescents. Only through experience do practitioners develop a style that “works” for them. Clinicians working with adolescent patients must feel comfortable in screening for psychosocial morbidity and assessing the level of risk in individual adolescent patients. This includes screening patients for risks associated with sensitive health issues such as sexual behavior, substance use, and mental health concerns. However, adequate screening is insufficient if it is not followed up with appropriate and effective intervention strategies when patients screen “positive” for serious health risks. The next steps—that is, how to deliver relevant health education and offer effective, brief office interventions—are not nearly as straightforward. Some precepts from behavioral medicine are important in designing practical office interventions:
Imagine a clinical encounter where a sexually active adolescent patient is asked about condom use. The patient responds that she uses condoms “sometimes.” At this point, a not infrequent clinician response is to wax eloquent for a few minutes on the importance and health benefits of condom use, with the patient usually listening respectfully and offering little. The clinician feels good about the “counseling” that has been offered, but the patient generally has gotten almost nothing of value from the interaction. In fact, the patient already understands the value of condoms—after all, she is using them sometimes. For this patient, the problem with condom use lies elsewhere—she can't afford them, her partner refuses to use them, someone is allergic to latex, or, most frequently, there never seems to be a condom available when one is required. None of these potential barriers is likely to emerge while the clinician sermonizes from atop a soapbox. Productive advice for this particular patient does not rest in a general treatise on the value of condoms but rather in addressing directly the specific barriers faced by the individual patient. This requires active listening, explicit questioning, specific strategies, and the willingness to go back and make sure that the intervention has been successful. Inherent in this approach is clinicians' willingness to go beyond screening and on to interventions and solutions, to engage with patients on difficult and sometimes sensitive issues, and, most importantly, to take the time to fully understand the context of health-risk behavior.
The G-A-P-S Algorithm
As part of the GAPS project, the AMA has attempted to develop a standardized method of assessment and intervention that embodies current health education principles but remains practical for office practice. The mnemonic G-A-P-S is used: gather information, assess further, problem identification, and specific solutions (Fig. 4.13). A publication from the AMA,GAPS: Clinical Evaluation and Management Handbook, includes fully developed algorithms for each of the GAPS recommendations (available at http://www.ama-assn.org/adolhlth).
FIGURE 4.13 Algorithm for providing health screening and guidance to adolescents. (From American Medical Association. Guidelines for adolescent preventive services[Recommendations monograph]. Chicago: American Medical Association, 1995.)
G: Gather Initial Information
Screen for problems using simple trigger questions, such as, “Have you been feeling down and blue?” or “Do you usually wear seat belts while riding in a car?” As has already been discussed,
this initial screening step may be facilitated by use of questionnaires, computers, or nonclinician personnel. If the screening result is negative and no increased risk is identified, basic information and positive reinforcement of the healthy behavior can and should be offered. If the result is positive, proceed to the next level.
A: Assess Further
Assess the level and nature of risk in the particular area. Identify the seriousness of the problem by assessing the patient's knowledge and involvement, predisposing and protective factors, the availability of family and other support, and the consequences for the patient's health and function (e.g., school, peer relationships). The intervention offered depends on the assessed risk. Often, low risk can be successfully managed with health information, a few targeted suggestions, and positive reinforcement about the issue. If the patient is at high risk, he or she probably needs an in-depth evaluation that may be beyond the bounds of a preventive services visit. A return visit for more intensive intervention, or referral, is warranted. Patients who are at intermediate risk also require an explicit intervention, such as that suggested in the next step. This can be begun within the context of the preventive services visit if the clinician feels comfortable with the particular issue.
P: Problem Identification
This step involves working with the patient toward an agreement on the problem, helping the patient decide to make a change, and working with the patient to develop a specific plan for that change. The goal is to be “patient-centered” in the approach—that is, to help the patient decide what is in his or her best interest, rather than forcing the patient to accept the physician's view of the problem or behavior. Problem identification is an attempt to define the problem in terms that the patient accepts. For example, questions such as, “You seem to be down and blue; is that something that is a problem for you right now?” or “Do you think it would be healthier for you if you used condoms?” may help the patient further acknowledge a problem. Once agreement on problem definition is reached, proceed to the next step. If the patient does not agree that there is a problem with a specified behavior, look for areas of agreement and common ground. An adolescent may not accept use of alcohol as being problematic but may acknowledge that binge drinking puts him or her at risk. Clinician perseveration on areas of obvious disagreement is unlikely to be productive and may negatively affect subsequent discussions. On the other hand, adolescent patients are often amenable to “agreeing to disagree,” will still accept factual risk information, and are willing to establish criteria that would elevate the issue to “problem” status and justify future discussion and intervention. For example, a question such as, “You clearly don't think that this is a problem area, but when would you consider it might become one?” would assist in setting boundaries that define the problem. Finally, any problem that poses an immediate threat to the adolescent's safety warrants an immediate intervention or referral whether the adolescent is fully prepared for change.
The clinician guides the adolescent to weigh the pros and cons of making a certain change. The adolescent may find several reasons to make (or not make) the change in behavior, and it is helpful to address these reasons explicitly. This technique helps prepare adolescents to deal with the ambivalence that they often feel toward changes in behavior. While beginning to develop a “plan,” find out what the adolescent is willing (or not willing) to do. Make sure the plan is concrete and fully detailed. Decisions should be framed as being in the adolescent's hands. If the adolescent is only willing to try using a condom once, that might become an initial plan. However, most adolescents are willing to make more substantive changes (e.g., always wearing seat belts, not drinking alcohol) at least for a specified period, usually a few weeks or months. Try to avoid sweeping changes that are unrealistic, such as avoiding alcohol use for the rest of their lives.
S: Specific Solutions: Self-efficacy, Support, Solving Problems, and “Shaking on a Contract”
Self-efficacy is assessed by asking whether the adolescent thinks he or she will be able to carry out the proposed plan. If the adolescent is ambivalent, revisit perceived barriers and attempt to redefine specific solutions. Plans should be achievable so that success becomes self-reinforcing. An overly ambitious plan may need to be modified.
Support is important, and adolescents should be encouraged to identify people who can help them carry out their plan. Hopefully, they will be able to call on resources such as trusted adults or close friends. At times, adolescents may want advice on how best to recruit their support system. At times, the clinician can also be helpful in helping adolescents to disclose information to parents or others.
Solving problems reminds us to assess the barriers that the adolescent foresees and to work with the adolescent in developing specific strategies to overcome them. For example, if an adolescent recognizes that he will have difficulty not drinking at an upcoming party, he must have a plan for how to deal with that situation. It is usually most helpful if adolescents come up with their own solutions, but they often can be helped to recognize solutions or options they might not have considered.
“Shaking on a contract” is a crucial step. It serves as a tangible reinforcement of the proposed plan and implies some commitment on the adolescent's part. Written contracts can also be used, especially for younger adolescents, but they are unwieldy as a general rule. It is important to specify the actions agreed to and the time frame in which the actions are to be taken. Make sure that the adolescent feels comfortable with the plan and understands it. If you are able to involve another party in the contract, such as a friend or parent, there is likely to be better compliance. Follow-up is critical and should be arranged in some form—either a visit, telephone contact, or e-mail—in the time frame agreed to in the contract.
http://odphp.osophs.dhhs.gov. Office of Disease Prevention and Health Promotion.
http://www.ama-assn.org/ama/pub/category/1947.html. Adolescent Health Online (AMA).
http://brightfutures.aap.org/web/. Bright Futures.
http://www.aap.org. American Academy of Pediatrics.
http://www.aafp.org. American Academy of Family Physicians.
http://www.adolescenthealth.org. Society for Adolescent Medicine.
http://www.nasbhc.org. National Association of School-based Health Centers.
http://www.cdc.gov/nccdphp/dash. CDC Department of Adolescent and School Health.
http://www.cdc.gov. Centers for Disease Control and Prevention.
http://www.acha.org. American College Health Association.
http://www.adolescenthealthlaw.org. Center for Adolescent Health and the Law.
http://www.ama-assn.org/ama/pub/category/1980.html. GAPS AMA site.
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