Adolescent Wellness Exam Time Tool

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ADOLESCENT WELLNESS EXAM:
Overcoming Reluctance on Both Sides by Building Rapport Using Every Opportunity to Promote Healthy Choices
A Resource from the American College of Preventive Medicine

A TIME TOOL FOR CLINICIANS

ACPM's Time Tools provide an executive summary of the most up-to-date information on delivering preventive services to patients in the context of a clinical visit. Information presented is based on evidence presented in peer-reviewed journals. Please refer to the Adolescent Wellness Exam Clinical Reference for more information.

Adolescent Wellness Exam
Adolescence is thought of as the healthiest stage of life. Most infectious disease and developmental issues of childhood are left behind and the chronic illnesses of adulthood have yet to appear.

But adolescents face many challenges that are unique to their stage of life.

Rapid physical growth, changing hormones, and sexual maturity.
Social and behavioral factors that lead to morbidity and mortality.
Over 70% of adolescent deaths are the result of injuries from four causes: motor vehicle crashes and other unintentional injuries, homicide, and suicide.

Three out of four adolescents engage in at least one risk behavior, yet these behaviors all too often remain unidentified until problems develop. They are seldom discussed with health care providers.

Substance abuse, pregnancy, sexually transmitted disease, depression, eating disorders, suicide, and violence, are common issues that can cause health crises for today's adolescents.

These challenges mandatea fundamental change in adolescent health care services—a greater emphasis on addressing psychosocial issues in clinical practice.

The annual wellness exam is the foundation

Both the Guidelines for Adolescent Preventive Services (GAPS) (American Medical Association, 1997) and Bright Futures (American Academy of Pediatrics, 2008) agree:

An annual confidential wellness exam is one vital key to improving adolescent health.
It is needed to keep up with the changing needs of adolescents, but even more importantly, to develop a trusting relationship that fosters the discussion of sensitive issues.

In fact, every visit should be viewed as an opportunity to ask about risky behaviors and provide brief counseling. It's about taking advantage of teachable moments.

Adolescents are not getting preventive health care

Despite the fact that authoritative recommendations have been in place since the early 1990s, implementation of clinical preventive services remains far belowrecommended levels.

About two out of three adolescents visit a health care provideronce a year, but only 1 in 15 visits are for preventive care, and the proportion gets smaller with increasing age.
Only about 1 in 6 visits overall includes any preventive guidance.

Reasons for this trend:

Adolescents are increasingly resistant to health care visits as they age and think they’re not necessary.
Parents become less involved in their children's lives—less likely to prompt them to seek health care.
Adolescents are unwilling to discuss risky behaviors with health care providers; they lack trust in the confidentiality of information they would share.
Providers lack training and confidence to deal with sensitive issues.
Health care providers do not always recognize adolescent health risks -- some believe that these issues are not the responsibility of primary care.

The result: many health care providers are not pushing the major adolescent wellness issues, so they are not consistently addressed.

Psychosocial issues take center stage
Change occurs rapidly in adolescence; new challenges develop with each school year:

Adolescents face the need to fit in, to be accepted; the pressure to experiment, to take risks; challenges to self esteem, body image, and coping with sexuality; violence, depression, the extremes of emotions; and being torn between dependence and independence.
Self esteem may be fragile. Some adolescents may be easily overwhelmed.
Difficulties in one area may enhance the chances of difficulties with other issues (e.g., adolescents who are not doing well academically are also more likely to engage in risky behaviors).

Enhancing communication - openness and confidentiality are the keys

A casual and confidential discussion of health issues is often the best approach with adolescents. To make the most of this conversation:

Confirm your role as health advisor and advocate, and your commitment to keeping information confidential.
Affirm positive behaviors.
Stimulate conversation with non-threatening, open-ended or general questions such as, "Many teenagers feel pressure from their friends to use drugs or alcohol. Have you experienced this?"
Speak openly about sensitive issues. Tell the teen that it's okay to discuss these issues.
Look for hidden agendas. The real reason for the visit may not be apparent at first. Be prepared to draw it out.
Ask about functioning at home, school performance, peer relationships, and sleep patterns. These can give clues to emotional issues.
Repeat back your understanding of the issues. This helps ensure clear communication.
Grasp "teachable moments" to address any issue.
Promote the doctor/adolescent/family partnership—the compatible or shared goals.
Develop joint action plans: simple, achievable, measurable goals.

So … what to cover in the adolescent wellness exam?

Prior to consult: Make the most of the limited time

Delegate some services to office personnel. Take time to train them.
Instruct patient/family to complete medical/behavioral history forms in waiting room. Some providers and practices use computers or small audio devices with interactive software to help engage adolescents and maintain confidentiality.
Arrange for nurse to review forms, identify and chart screening needs.
Instruct nurse to also review immunization status, identify and chart immunizations due.

For recommended immunizations, visit:

Nurse:

Obtain height and weight; calculate body mass index (BMI); determine BMI percentile for age/gender. http://apps.nccd.cdc.gov/dnpabmi/Calculator.aspx

Measure blood pressure; use blood pressure age/gender tables to determine percentile (from The Fourth Report on High Blood Pressure in Children and Adolescents: http://www.nhlbi.nih.gov/health/prof/heart/hbp/hbp_ped.pdf)
Identify issues that adolescent and/or parents would like to discuss with health care provider.

Provider preparation: Scan chart before meeting adolescent/family.

Goal is to maximize time for guidance and counseling.

Greeting and introduction:

Greet each family member, introduce self, and use their names.
Establish rapport.
Review role as adolescent's health adviser and advocate.
Emphasize commitment to a trusting, confidential and unconditional relationship.
- "I am your doctor, not your parent's doctor. You can talk to me about anything in your life because it all affects your health. I will respect your privacy, and will only discuss issues with your parents if you give me permission, or if we are concerned that someone is in danger."

What to include in the consult:

Address needs and concerns of adolescent and parents. Use open-ended questions to clarify issues.
1. Assess concerns; present plan to address them—include when and how
Review forms and chart with adolescent/parent.
1. Observe patient’s interaction with parent(s), if present.
2. Identify needs.
3. Work with adolescent and family to prioritize goals for visit.
Perform a comprehensive physical exam.
1. Take this opportunity to ask parent(s) to leave the room; adolescents usually prefer privacy from parents.
2. Use this time to ask about issues teens are uncomfortable discussing in front of parents (i.e., risk behaviors: sex, substance experimentation, etc.).
3. Exam components that are especially relevant during adolescence include:
  - Blood pressure status (percentile for age/gender)
  - Height, weight and BMI status (percentile for age/gender)
  - Skin
  - Breast: sexual maturity (females), gynecomastia (males)
  - Genitalia: sexual maturity, structural abnormalities (males), sexually transmitted diseases (STDs)

Discuss needed screening based on risk assessment forms.
Discuss needed immunizations.
Provide anticipatory guidance counseling. Five areas to address over the course of annual visits: Table 2
1. Physical growth and development
  - Physical and oral health, body image, healthy eating, physical activity
2. Social and academic competence
  - Connectedness with family, peers and community, relationships, school performance
3. Emotional well-being
  - Coping, mood regulation, mental health, sexuality
4. Risk reduction
  - Tobacco, alcohol, drugs, pregnancy, sexually transmitted diseases (STDs)
5. Injury and violence prevention
  - Seat belt and helmet use, passenger and driver safety, firearms, interpersonal violence (fighting), bullying
Suggest options for addressing unmet needs, additional resources for complex issues.
1. Acknowledge importance of issue.
2. Offer resources (handouts, CD, DVD, websites).
3. Suggest a follow-up visit or phone call.
4. Provide a referral to a specialist, program, community organization, etc.

Final Thoughts

Adolescence can be a challenging time, not only for the adolescent but also for his or her health care provider. The challenge for providers is to become proficient at assessing and providing guidance for the unique psychosocial issues of adolescence, and learning how to relate to adolescents in a way that builds a trusting, open relationship. An annual wellness visit should be promoted, but every visit can be used to encourage healthy choices.

Supporting references and additional information:

Download printable versions of these resources:

For other information and useful links, visit the American College of Preventive Medicine Adolescent Health Initiative or the ACPM website at www.acpm.org.

TABLE 1
BRIGHT FUTURES -- RECOMMENDED SCREENING
	Test	Indication (for selective)
Universal:
Vision (once during each stage)	Snellen test
Dyslipidemia (once during late adol)	Lipid screen

Selective:
Vision (between universal screening)	Snellen test	Positive on risk questions
Hearing	Audiometry	Positive on risk questions
Anemia	Hemoglobin or hematocrit	Positive on risk questions
Tuberculosis	Tuberculin skin test	Positive on risk questions
Dyslipidemia	Lipid screen	Positive on risk questions, and not previously screened with normal results
STIs	Chlamydia and gonorrhea screen	Sexually active
STIs	Syphilis blood test HIV	Sexually active and positive on risk screening
Pregnancy	Urine hCG	Sexually active without contraception; late menses, amenorrhea, heavy or irregular bleeding
Cervical dysplasia	Pap smear	Sexually active or no later than age 21
Alcohol or drug use	Alcohol, drug screening tools	Positive on risk questions

TABLE 2
BRIGHT FUTURES -- ANTICIPATORY GUIDANCE RECOMMENDATIONS
Physical Growth and Development
Early	Middle	Late
Brush teeth twice daily; floss once	Brush teeth twice daily; floss once	Brush teeth twice daily; floss once
Physically active 60 min/day	Physically active 60 min/day	Physically active 60 min/day
Limit non-academic screen time £ 2 hrs/day	Limit non-academic screen time £ 2 hrs/day	Limit non-academic screen time £ 2 hrs/day
3+ servings low fat milk/other dairy per day	3+ servings low fat milk/other dairy per day	3+ servings low fat milk/other dairy per day
Eat with family	Eat with family	Eat with family
	3 meals/day, esp breakfast; healthy food choices	3 meals/day, esp breakfast; healthy food choices
	Protect hearing	Protect hearing

Social and Academic Competence
Early	Middle	Late
Stay connected with family	Stay connected with family	Stay connected with family, friends
Follow family rules, curfews	Follow family rules, curfews	Recognize that some friendships change
Explore new interests, activities, including helping others	Explore new interests, activities, including helping others	Get involved with the community
Take responsibility for school work	Take responsibility for school work	Take responsibility for getting to school/work on time
Talk to parent/trusted adult about problems at school	Talk to parent/trusted adult about problems at school	Consider future education/work plans

Emotional Well-Being
Early	Middle	Late
Find ways to deal with stress	Find ways to deal with stress	Find ways to deal with stress
Everyone has hard times and disappointments; usually temporary; talk with parent/trusted adult if causing problems	Everyone has hard times and disappointments; usually temporary; talk with parent/trusted adult if causing problems	Everyone has hard times and disappointments; usually temporary; talk with parent/trusted adult or me if can't get back on track
Get accurate info about physical development, sexual feelings, sexuality; talk to parent/trusted adult or me	Get accurate info about physical development, sexual feelings, sexuality; talk to parent/trusted adult or me; do you have any questions?	Practice problem solving and responsible decision-making
		Sexuality is important to normal development; do you have any questions?

Risk Reduction
Early	Middle	Late
Don't smoke, drink or use drugs	Don't smoke, drink or use drugs	Don't smoke, drink or use drugs/steroids/diet pills
Avoid situations with drugs/alcohol	Avoid situations with drugs/alcohol	Avoid situations with drugs/alcohol
Support friends who don't use	Support friends who don't use	Support friends who don't use
Talk with me if concerned about your own or family member's use	Talk with me if concerned about your own or family member's use	Think through decisions about sex; consider role of alcohol/drug use and avoid risky places and relationships
The safest way to prevent pregnancy and STIs is to not have sex, including oral sex	Abstaining from sexual intercourse, including oral sex, is safest way to prevent pregnancy and STIs; plan for how to avoid sex in risky situations	If sexually active, protect against STIs/pregnancy; have a plan for decisions about sex in risky situations
Have a plan for avoiding risky situations; if sexually active, protect against STIs/pregnancy	If sexually active, protect against STIs/pregnancy

Violence and Injury Protection
Early	Middle	Late
Wear seat belts, helmets, protective gear, life jacket	Wear seat belts, helmets, protective gear, life jacket	Wear seat belts, helmets, protective gear, life jacket
Don't ride in a car with someone who has been drinking/using drugs; call parent/trusted adult for help	Don't ride in a car with someone who has been drinking/using drugs; call parent/trusted adult for help	Don't ride in a car with someone who has been drinking/using drugs; call parent/trusted adult for help
Healthy dating relationships are built on respect; saying No is ok	Limit night driving; driving with teen passengers	Don't use alcohol or drugs and drive
Manage conflict nonviolently; talk to parent/trusted adult if bullied or stalked	Fighting, carrying weapons can be dangerous	Remove guns from the home; if not possible, store unloaded and locked; keep key away from children
	Manage conflict nonviolently; avoid risky situations; healthy relationships are built on respect and mutual interests; saying No is ok	Manage conflict nonviolently; avoid risky situations; leave violent relationships; healthy relationships are built on respect; saying No is ok

Supporting references and additional information:

Download printable versions of these resources:

For other information and useful links, visit the American College of Preventive Medicine website at www.acpm.org.

For other information and useful links, visit the American College of Preventive Medicine Adolescent Health Initiative or the ACPM website at www.acpm.org.

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