health care maintenance in female adolescents

Mayo Clin Proc. • December 2005;80(12):1641-1650 • www.mayoclinicproceedings.com 1641

ADOLESCENT HEALTHCONCISE REVIEW FOR CLINICIANS

From the Division of Women’s Health Internal Medicine (E.A.B., B.S.T., D.P.V.,J.A.F.), Division of Infectious Diseases (J.E.B.), and Division of CommunityInternal Medicine (A.P.M.), Mayo Clinic College of Medicine, Scottsdale, Ariz.

A question-and-answer section appears at the end of this article.

Address reprint requests and correspondence to Elizabeth A. Boatwright, MD,Division of Women’s Health Internal Medicine, Mayo Clinic College of Medi-cine, 13400 E Shea Blvd, Scottsdale, AZ 85259 (e-mail: [email protected]).

© 2005 Mayo Foundation for Medical Education and Research

Health Care Maintenance in Female Adolescents

ELIZABETH A. BOATWRIGHT, MD; BEVERLY S. TOZER, MD; DEEPA P. VERMA, MD; JANIS E. BLAIR, MD;ANITA P. MAYER, MD; AND JULIA A. FILES, MD

The assessment and care of female adolescents by primary carephysicians can be facilitated with increased knowledge about thisstage of development, the health care risks faced by these pa-tients, and the resources available to aid in their care. With afocus on preventive health maintenance, this concise reviewaddresses these areas as well as how to build relationships withfemale adolescent patients, conduct age-appropriate interviewsand tests, and maintain patient confidentiality.

Mayo Clin Proc. 2005;80(12):1641-1650

AAP = American Academy of Pediatrics; AMA = American MedicalAssociation; BMI = body mass index; GAPS = Guidelines for AdolescentPreventive Services; HIPAA = Health Insurance Portability and Account-ability Act; HIV = human immunodeficiency virus; LDL = low-densitylipoprotein; MMR = measles-mumps-rubella; STI = sexually transmittedinfection; Td = tetanus-diphtheria; Tdap = tetanus-diphtheria-pertussis

Female adolescents have unique health care needs.Many internists may be uncomfortable about meeting

those needs because of a lack of specific training focusedon this age group. Published recommendations by profes-sional health organizations can guide health care practi-tioners in their approach to adolescent health care (Tables 1and 2).1,2 With slight variations, these recommendationsconsist of 4 major categories of preventive services: (1)screening for behavioral and physical conditions, (2) coun-seling to reduce risks, (3) providing immunizations, and (4)offering anticipatory guidance or general health guidance.In this review, we aim to highlight important health risks offemale adolescents and provide internists with practicaltools for assessment and care of these patients, using as aframework the Guidelines for Adolescent Preventive Ser-vices (GAPS) recommendations of the American MedicalAssociation (AMA),3 modified by more recent screen-ing recommendations from the American Academy of Pe-diatrics (AAP),2 the Bright Futures program,4 and otherhealth organizations. Currently, a task force of membersfrom the AMA, AAP, and the Bright Futures program is

revising recommendations for adolescent screening andhealth maintenance. Published recommendations fromthis joint committee are anticipated in 2006 and 2007, andearly recommendations have been incorporated into thisreview.

OVERVIEW OF ADOLESCENCE

Adolescence is a time of great physical, emotional, andsocial change. It encompasses the ages between 11 and 21years, although puberty can begin as early as age 7 or 8years in some girls.

Physical pubertal changes occur in a predictable patternthat can be anticipated and monitored.5 On average, pu-berty lasts 3 to 4 years. Breast budding is the first sign ofpuberty in girls, beginning between ages 7 and 13 years.Growth of pubic hair follows, although in as many as 15%of girls, pubic hair may start growing before breast budsdevelop. The growth spurt in female adolescents startsduring Tanner stage 2, usually 1 year after the onset ofpuberty, and peaks in Tanner stage 3. Peak height velocityoccurs 18 to 24 months earlier in girls than in boys, and thegrowth spurt lasts as long as 36 months. Growth is com-pleted primarily by the time of menarche, which followsdevelopment of breast buds by 2 to 3 years.

While major physical changes are occurring, cognitivechanges transform a concrete-thinking adolescent into ayoung adult with the ability to reason abstractly, to antici-pate future consequences, and to empathize with others.Cognitive development does not mirror physical matu-rity, and adolescents may regress during times of stressor illness. As adolescents mature cognitively, they arebetter able to participate actively in their own healthmaintenance.

Adolescent psychosocial development entails the estab-lishment of a personal identity and self-image, autonomyfrom parents, and ability to form mature relationships. Thispsychosocial development has commonly referencedstages (Table 3).

During the potentially tumultuous period of adoles-cence, individuals must develop an ideology and a set ofvalues to guide them into adulthood. These values willhave strong implications for their overall health far into thefuture. Physicians are in a unique position to provide non-judgmental purposeful guidance to adolescents, thus help-

For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.

Mayo Clin Proc. • December 2005;80(12):1641-1650 • www.mayoclinicproceedings.com1642

ADOLESCENT HEALTH

ing them to make healthy choices and establish a lifestylefor a successful transition into adulthood.

RISK-TAKING BEHAVIOR

Risk-taking behavior is common in adolescence. Experi-mentation allows adolescents to try out newly developedskills or physical prowess and to test limits and valuesystems in order to establish their own. Some risk taking isbeneficial because it builds confidence and competence.However, other obviously dangerous risk taking contrib-utes to adolescent mortality and morbidity (Table 4), withapproximately 25% of all adolescents being at significantrisk of school failure, serious injury, or death.9

Most deaths in the United States among persons aged 10to 24 years can be attributed to 4 major causes: motorvehicle accidents (32%), other unintentional injuries (12%),homicide (15%), or suicide (12%).7 Adolescent male mor-tality is 2.6 times that of female mortality (Figure 1),10 withmotor vehicle accidents the leading cause of death forboth.11

As reflected in Table 4, female and male adolescentsengage in tobacco use and alcohol use in equal numbers.Female adolescents are less likely than male adolescents tocarry a weapon or drive after drinking alcohol but are morelikely to be a passenger in an automobile with a driver whohas been drinking alcohol. Female adolescents are at higherrisk of depression and suicide attempts, although their male

counterparts have higher numbers of successful suicides(Table 4; Figure 1). Female adolescents are also morelikely than male adolescents to have an eating disorder(Table 4).

Substantial morbidity among female adolescents resultsfrom sexual activity. This morbidity includes unintendedpregnancies and sexually transmitted infections (STIs), in-cluding infection with the human immunodeficiency virus(HIV). Female adolescents have the highest prevalence ofSTIs nationally (except for HIV infection).12 As reflected inTable 4, female adolescents are more likely than maleadolescents to have negative or mixed feelings about initi-ating sexual activity8 and they are more likely to experienceabuse or victimization.

Rates of sexual activity among adolescents have de-clined during the past decade; nationally, 46.7% of highschool students reported ever having sexual intercoursewhen surveyed in 2003, compared with 53% in 1993.13

This trend is encouraging, and ongoing investigations ofthe reasons for the trend will likely influence future adoles-cent practice guidelines.

In contrast to adolescent mortality, two thirds of alldeaths among adults older than 25 years of age result fromcardiovascular disease (39%) or cancer (24%).7,11 Strik-ingly, the behaviors considered risk factors for these con-ditions (eg, tobacco use, unhealthy eating, and lack ofexercise) often begin during adolescence (Table 4).

Awareness of these prevalent high-risk behaviors canenable physicians to more easily tailor the patient interviewto include important psychosocial questions. The impor-tance of asking focused questions aimed at screening forbehavioral health risks has been stressed by many profes-sional organizations.2-4,14 The AMA’s GAPS3 are detailedin Table 2.

THE ADOLESCENT INTERVIEW

One of the most challenging aspects of providing care toadolescents is effectively conducting the adolescent inter-view. Various resources exist to help the internist with thistask (Table 1).

Questionnaires have been created by many professionalorganizations to aid in the initial task of collecting informa-tion from both the adolescent and the parent. Acronyms canserve as helpful interview prompts, the most common ofwhich addresses the areas of home, education/employment,activities, drugs, sex, and suicide (HEADSS) (Table 5).The use of acronyms makes it easier to remember impor-tant adolescent issues to discuss at each office encounter;even an office visit for a minor complaint should be viewedas an opportunity for the physician to uncover risk-takingbehavior.

TABLE 1. Resources for Adolescent Services

Guidelines for Adolescent Preventive Services (GAPS),American Medical Association

www.ama-assn.org/ama/pub/category/1980.htmlAccessed October 3, 2005 (monograph and adolescent and parentquestionnaires can be downloaded free of charge)

American Academy of Pediatricswww.aap.org/policy/re9939.html

Accessed October 3, 2005Bright Futures Guidelines, Maternal and Child Health Bureau,

US Public Health Serviceswww.brightfutures.org/bf2/pdf/index.html

Accessed October 3, 2005 (book, pocket guides, anticipatoryguidance cards, and family forms can be ordered)

US Preventive Services Task Forcewww.ahrq.gov/clinic/prevenix.htm

Accessed October 3, 2005American Academy of Family Physicians

www.aafp.orgAccessed October 3, 2005

Society for Adolescent Medicine, Blue Springs, Mowww.adolescenthealth.org

Accessed October 3, 2005Centers for Disease Control and Prevention

www.cdc.gov. Accessed October 3, 2005North American Society for Pediatric and Adolescent Gynecology

www.naspag.orgAccessed October 3, 2005



ADOLESCENT HEALTH

TABLE 2. Recommendations for Preventive Health Services for Female Adolescents*

Age (y) of adolescent

Early Middle Late

11 12 13 14 15 16 17 18 19 20 21

Health guidanceParenting -----------• ----------- --------• --------Development • • • • • • • • • • •Diet and physical activity • • • • • • • • • • •Healthy lifestyles • • • • • • • • • • •Injury prevention • • • • • • • • • • •

Screening historyEating disorders • • • • • • • • • • •Sexual activity • • • • • • • • • • •Alcohol and other drug use • • • • • • • • • • •Abuse • • • • • • • • • • •School performance • • • • • • • • • • •Depression • • • • • • • • • • •Risk for suicide • • • • • • • • • • •

Physical assessmentBlood pressure • • • • • • • • • • •Body mass index • • • • • • • • • • •Comprehensive examination -----------• ----------- --------• -------- -----------• -----------

Sensory screeningVision S O S S O S S O S S SHearing S O S S O S S O S S S

TestsCholesterol -----------1----------- --------1-------- -----------1-----------Tuberculosis -----------2----------- --------2-------- -----------2-----------Gonorrhea, chlamydia, and HPV -----------3----------- --------3-------- -----------3-----------Syphilis -----------4----------- --------4-------- -----------4-----------HIV -----------4----------- --------4-------- -----------4-----------Papanicolaou smear -----------5----------- --------5-------- -----------5-----------Hematocrit/hemoglobin†Urinalysis‡

Fasting serum glucose§Immunization

MMR -----------• -----------Td booster or Tdap booster -----------6----------- --------6--------Hepatitis B -----------7----------- --------7-------- -----------7-----------Hepatitis A -----------8----------- --------8-------- -----------8-----------Varicella-zoster -----------9----------- --------9-------- -----------9-----------Meningococcus ----------10----------- -------10-------- ----------10-----------

1. Screen once if family history is positive for early cardiovascular disease or hyperlipidemia.2. Screen if positive for exposure to active tuberculosis or lives or works in high-risk situation (eg, homeless shelter or health care facility).3. Screen at least annually if sexually active. HPV screening is by visual inspection and Papanicolaou smear; HPV typing in adolescents is controversial,

given the high likelihood of regression over time.4. Screen if at high risk for infection.5. Screen annually if sexually active or if 21 years or older.6. Tdap is recommended as a single booster at the 11- to 12-year visit or at 13 to 18 years of age if not previously given; it can be given as a booster for

pertussis if Td was given previously.7. Vaccinate against hepatitis B virus if not yet vaccinated; catch-up vaccination for incompletely immunized adolescents can be given independent of

timing of previous dose(s).8. Vaccinate if at risk for hepatitis A infection.9. Vaccinate if no reliable history of chicken pox or previous vaccination. One shot is required for children ≤12 years; adolescents ≥13 years require

2 shots, 1 month apart.10. Vaccinate with MCV4 at age 11 to 12 years or after age 15.*Closed circles indicate service to be performed at that age. Dotted lines indicate service to be performed at some time during that stage of development.

Body mass index = weight in kilograms divided by height in meters squared (kg/m2); HIV = human immunodeficiency virus; HPV = humanpapillomavirus; MCV4 = meningococcal conjugate vaccine; MMR = measles-mumps-rubella; O = objective by standard testing; S = subjective by history;Td = tetanus-diphtheria; Tdap = tetanus-diphtheria-pertussis.

†All menstruating adolescents should be screened periodically, with frequency of laboratory work at the discretion of the clinician, depending on risk factorsfor anemia (eg, heavy menses).

‡Urinalysis dipstick for leukocytes suggested yearly in sexually active adolescents.¶Fasting serum glucose recommended every 2 years, starting at age 10 years or with onset of puberty (if earlier than 10 years) for adolescents who are

overweight or from high-risk families or ethnic groups.Modified from Guidelines for Adolescent Preventive Services (GAPS): Recommendations Monograph, copyright 1997, American Medical Association,with permission.1 Sensory screening data from American Academy of Pediatrics.2



ADOLESCENT HEALTH

Paper questionnaires and acronyms are useful tools forobtaining information. However, they are limited in scopeand lack the crucial relational aspect of the interview thatengenders trust in an adolescent and elicits honest re-sponses. Thus, physicians must develop an “adolescent-friendly” approach to build rapport and encourage openand honest communication. An accepting atmosphere iscreated initially in the waiting room, with the display ofage-appropriate literature and a reception staff that treatsadolescents with respect. Also, a longer appointment timefor the first visit will facilitate interaction with both theadolescent and the parent. The first few minutes with theadolescent often determine whether a trusting relationshipcan be established; these minutes are well spent in showinggenuine interest in the adolescent and by conversing in arelaxed informal manner.

The dual relationship forged by the physician withboth the adolescent and the parent will provide an under-standing of family dynamics, and it will also help enlistthe parent as an ally to promote the adolescent’s health.The physician should initially interview the parent andadolescent together and then meet with the adolescentalone. Periodic group meetings can then be scheduled asneeded.

By including the parent initially, the clinician can dis-cuss issues of confidentiality and the expected transitionfrom parental oversight to adolescent responsibility forhealth maintenance. The parent can provide essential de-tails about the patient’s personal and family medical his-tory and can voice any concerns before being dismissed sothat the adolescent can talk with the physician alone.

Allowing the adolescent to express herself openly en-ables the physician to gain important information about thepatient’s concerns and her understanding of health issues.The adolescent’s primary concern may be different fromthe physician’s, and she will feel more respected by aphysician who actively listens. The physician should bealert for any hidden agenda. For example, a patient maycomplain of a sore throat but actually be worried abouthaving an STI.

A primary goal of adolescent medicine is to instill asense of responsibility in adolescents for their own healthmaintenance. This approach differs from the pediatricmodel, in which the child experiences health care throughthe mediation of a parent. Ideally, adolescent patients willestablish a direct relationship with their physician, whichwill give them a sense of having their “own” physician.

Keeping this goal in mind can help physicians clarifytheir role. The female adolescent’s physician is neither asurrogate parent nor “one of the gang.” Instead, physiciansof adolescents are in a unique position as adults with au-thority who serve as advocates for adolescents while en-couraging them to make healthy choices. Describing thephysician’s role can be an effective way to begin askingsensitive questions and counseling adolescents about de-veloping a healthy lifestyle.

CONFIDENTIALITY

A crucial aspect of gaining the trust of any adolescent is anassurance of confidentiality, which should be discussedopenly during the initial interview. In general, health caredelivery to a minor (<18 years) requires parental consent.

TABLE 3. Developmental Stages of Adolescents

Characteristic

Stage Psychosocial Psychological

Early adolescence Begin separation from parents Focus on body changes: “Am I normal?”(11-13 y) Peer group influence begins Early formal operation thinking

Same-group activities Poor futurity orientationComparison of body changes with same-sex peers Beginning of increase in sexual driveIntense same-sex friendships Imaginary audience behavior, narcissism, egocentrismCrushes

Middle adolescence Peak of conflict with parents; test limits Focus on personal and sexual identity: “Who am I?”(14-17 y) Peer influence and conformity at highest level Autonomy is chief concern

Sexual behaviors (both same and opposite sex) More future orientedincrease; experimentation without commitment Formal operational thinking established

Risk-taking behaviors increase (may regress under stress)Acceptance of body changes

Late adolescence to Close friendships Focus on identity in relation to society: “What is myyoung adulthood Intimacy issues of increasing importance role in relation to society?”(18-21 y) Reconnection with parents Formal operational thinking well established

Career goals defined Future-oriented realistic goalsMultiple peer groupsPeer group influence wanes

Modified from Joffe,6 with permission from Lippincott Williams & Wilkins.



ADOLESCENT HEALTH

TABLE 4. Prevalence of Risk-taking Behaviors Among US High School Students in 2003*

Female MaleBehavior (%) (%)

Never or rarely use seatbelt† 14.6 21.5Never or rarely use bike helmet† 84.2 87.2Rode with driver who had been drinking alcohol† 31.1 29.2Drove after drinking alcohol† 8.9 15.0Carried a weapon (gun, knife, club)† 6.7 26.9Got into a physical fight‡ 25.1 40.5Experienced dating violence (hit, slapped,

physically hurt by partner)‡ 8.8 8.9Forced to have sexual intercourse‡ 11.9 6.1Felt sad or hopeless every day ≥2 weeks in a row‡ 35.5 21.9Seriously considered suicide‡ 21.3 12.8Made plan for suicide‡ 18.9 14.1Attempted suicide‡ 11.5 5.4Tobacco use

Ever 58.1 58.7Daily for ≥30 days 15.8 15.7Currently (≥1 within previous 30 days) 21.9 21.8Before age 13 y 16.4 20.0

Alcohol useEver 76.1 73.7Current (≥1 in past 30 days) 45.8 43.8Episodic heavy drinking§ 27.5 29.0Before age 13 y 23.3 32.0

Marijuana useEver 37.6 42.7Current 19.3 25.1Before age 13 y 6.9 12.6

Cocaine (any form) useEver or current 7.7/3.5 9.5/4.6

Ecstasy (any use ever) 10.4 11.6Methamphetamines (any use ever) 6.8 8.3Inhalant (any use ever) 11.4/3.4 12.6/4.3Illegal corticosteroid (any use ever) 5.3 6.8Injected drug (any use ever) 2.5 3.8Sexual intercourse

Ever 45.3 48.0Before age 13 y 4.2 10.4≥4 sex partners 11.2 17.5Currently sexually active (in past 3 months) 34.6 33.8

Condom used during last intercourse 57.4 68.8

Alcohol or drug use before last intercourse 21.0 29.8Ever pregnant or fathered child 4.9 3.5Voluntary or involuntary first sexual intercourse

Did not want to at that time 13.0 6.0Mixed feelings 52.0 31.0Really wanted it to happen at that time 33.0 60.0

Dietary behavior≥5 servings per day of fruit and vegetables

in past 7 days 20.3 23.6≥3 glasses milk per day in past 7 days 11.2 22.7

Physical activityExercises vigorously or sufficiently (sweats,

breathes hard ≥20 minutes on ≥3 of 7 days) 55.0 70.0Exercises insufficiently

(<3 of 7 days or <20 min/session) 40.1 26.9Participates on ≥1 sports team 51.0 64.0Watches television ≥3 hours per day on

average school day 37.0 39.3Weight

Overweight (>95th percentile BMI) 9.4 17.4At risk for being overweight

(>85th, <95th percentile BMI) 15.3 15.5Describes self as overweight 36.1 23.5Trying to lose weight 59.3 29.1

Has tried to lose or control weightAte less food 56.2 28.9Exercised 65.7 49.0Went without eating for 24 hours 18.3 8.5Used diet pills, powders, or liquids 11.3 7.1Vomited or used laxatives 8.4 3.7

However, in some situations, obtaining parental consentmay represent a barrier to care.15-17 Thus, federal and statelaws, as well as many professional organizations, recog-nize exceptions.

Sources of legal requirements in adolescent health careinclude the US Constitution and state constitutions, federalstatutes and regulations (eg, the HIPAA [Health InsurancePortability and Accountability Act] privacy rule, the TitleX family planning program, federal drug and alcoholprograms, protection of human subjects in research), andstate statutes and regulations.18 State statutes and regula-tions determine issues of rights and duties of parents, legal

status of children, guardianship of minors, consent forhealth care, privacy and confidentiality, child abuse re-porting, and public health reporting. Because state lawsvary, physicians should become familiar with the laws intheir own state that govern confidential health care foradolescents. Helpful Web sites to access state laws in-clude (1) www.guttmacher.org/statecenter/youth.html, (2)www.healthprivacy.org, and (3) www.cahl.org.

In general, exceptions to parental consent are based oneither the status of the adolescent or specific situationsinvolving the adolescent. Parental consent is not requiredfor adolescents who are emancipated, married, homeless,

*BMI = body mass index, weight in kilograms divided by height in meters squared (kg/m2).†In the 30 days before the survey.‡In the 12 months before the survey.§Five or more drinks of alcohol on ≥1 occasion within the previous 30 days.Data from the Centers for Disease Control and Prevention.7 Voluntary or involuntary first sexual intercourse data from Abma et al.8

Female MaleBehavior (%) (%)



ADOLESCENT HEALTH

TABLE 5. Adolescent Interview: HEADSS*

HomeComposition of household; family dynamics, relationships with

adolescent; living situation; guns in the homeEducation/Employment

School attendance; absences; attitude toward school; ever failed orskipped a grade; suspension; favorite and most difficult subjects;goals: vocational/technical school, college, career

ActivitiesHow time is spent when not in school; sports, exercise, clubs, hobbies;

television viewing; job; friendships; driving; weapon carrying andfighting

DrugsCigarettes or smokeless tobacco (age at first use, packs per day);

alcohol or drugs (use at school or parties, use by friends and self,type and quantity)

SexDating; sexual feelings (opposite or same sex); sexual intercourse (age

at first intercourse, number of lifetime partners, recent change inpartners, type of contraception and frequency of use); history ofsexually transmitted disease; prior pregnancies, abortions; history ofnonconsensual intimate physical contact or sex; history of tradingsex for money or drugs

Suicide or depressionFeelings about self; history of depression or feeling blue; sleep

pattern; thoughts of hurting self; prior suicide attempts; history ofother mental illness

*An approach to the psychosocial interview that allows the practitioner tomove from less to more sensitive or intimate subjects.

or in the military. In most states, pregnant adolescents maylegally consent for all care or for pregnancy-related care.Parents of minors are who are authorized to give consentfor their child’s health care (unless they are deemed incom-petent), and such parents are explicitly authorized to con-

sent for their own care in most states. The “mature minorrule” is accepted in many, but not all, states.

Situations in which adolescents with the status of aminor do not require legal consent include emergencytreatment when a parent is unavailable, STI-related care,care after a rape or an assault when the minor is aged 12years or older, abortion-related care (in some states only),care related to alcoholism or substance abuse when theminor is aged 12 years or older, HIV testing, and outpatientmental health care.18-20

Although guidelines exist for the provision of confi-dential care, patient confidentiality also includes corol-lary concerns such as access to medical records and cov-erage of its cost. Legal access to the medical record by aparent or legal guardian varies by state and, in general, theprivacy rule of the federal HIPAA of 1996 defers to statelaw in this area. HIPAA considers an adolescent’s medi-cal records to be confidential in those situations in which(1) she can and does consent to her own care, (2) shecan receive care and a court has approved the treatment,and (3) the parent has assented to confidentiality (in thiscase, the discussion should be documented and eachpractice should have its own confidentiality policy anddocumentation).21 Managed care companies seldom havea confidentiality policy; thus, any explanations of bene-fits forms are typically released to the parent as thepolicy holder. This fact should be reviewed with the ado-lescent, who may opt to obtain some of her care at a TitleX family planning facility such as Planned Parenthood

10

6

4

2

0

8

Otherunintentional

injuries

Motor vehicle

accidents

Suicide Homicide

Male

Male

Female

Female

Dea

ths

(in t

hous

ands

)

Malignancy Allother

35558427

8743860 3612

6424595

8161260 4781

3214907

FIGURE 1. Leading causes of death in 2002 in the United States for female adolescents andmale adolescents. Data from the Centers for Disease Control and Prevention.10



ADOLESCENT HEALTH

or who may decide to pay out of pocket for servicesrendered.16,20,22

Numerous medical associations have established formalpolicies addressing confidentiality in the care of adoles-cents.16,18,23,24 In general, they all recommend confidentialmedical care for adolescents, parental involvement whenappropriate, and conditional assurance of confidentiality.

Occasionally, it is appropriate to break confidentiality,and these instances should be outlined during the initialinterview. Examples include behaviors harmful to the pa-tient or someone else, situations of abuse, reportable infec-tious diseases, illegal behavior, or any issue that the clini-cian believes should be shared with the parent in the ado-lescent patient’s best interest. Whenever a clinician decidesto break confidentiality, doing so should ideally be dis-cussed with the adolescent and an offer should be made todiscuss the issue in the presence of both the parent and theadolescent.16,19

THE PHYSICAL EXAMINATION

In the absence of specific physical complaints, a compre-hensive physical examination is recommended roughly ev-ery 3 years for adolescents. The important physical screensthat should be performed yearly are highlighted subse-quently and in Table 2. Any abnormal findings should thenprompt a more thorough medical evaluation.

BLOOD PRESSURE

Blood pressure should be screened yearly. Age and sex-specific blood pressure norms were updated in 2004 andare available at www.nhlbi.nih.gov/health/prof/heart/hbp/hbp_ped.pdf. Patients with systolic or diastolic pressure ator above the 90th percentile should have blood pressuremeasurements repeated 3 different times in 1 month, insimilar clinical conditions, to confirm baseline blood pres-sure. Adolescents with blood pressure values greater thanthe 95th percentile should have a complete biomedicalevaluation to determine treatment options. When bloodpressure values are between the 90th and 95th percentiles,an obesity assessment should be conducted, and bloodpressure should be checked again in 6 months.

BODY MASS INDEX

The body mass index (BMI) is a simple screening tool forobesity or underweight conditions (Figure 2). Patientsshould be screened for organic disease or an eating disorderif their BMI is below the fifth percentile or if they have hada weight loss of more than 10% of their previous weight.Dieting when not overweight or use of self-induced emesis,laxatives, diuretics, or starvation should also prompt fur-ther evaluation. Adolescents with a BMI greater than the

95th percentile are overweight and should be assessed forpsychological morbidity and cardiovascular risk. Adoles-cents with a BMI between the 85th and 94th percentiles areat risk of becoming overweight. They should undergo anin-depth health assessment and receive counseling on diet,exercise, and risk reduction.

PELVIC EXAMINATION

Sexually active female patients and all female patients aged21 years or older should undergo a Papanicolaou (Pap)smear annually to screen for cervical cancer.26,27 Sexuallyactive patients should also be screened for STIs by obtain-ing cervical samples to check for gonorrhea and chlamydiaby DNA probe and by evaluating for evidence of the hu-man papillomavirus by visual inspection and Pap smear.(Because most human papillomavirus–induced abnormalPap smears will regress over time, no current recommenda-tion supports routine testing with polymerase chain reac-tion in adolescents; however, it can be helpful in evaluatingabnormal Pap smears.) Urine tests for gonorrhea, chlamy-dia, and Trichomonas are options for screening asymptom-atic patients, although their specificity and sensitivity vary.Serologic testing for syphilis should be performed in ado-

FIGURE 2. Body mass index-by-age percentiles for girls 2 to 20years. From the National Center for Health Statistics.25



ADOLESCENT HEALTH

lescents who have lived in an area with a high incidence ofsyphilis, who have had other STIs or more than 1 sexualpartner within the past 6 months, or who have ever ex-changed sex for money or drugs. Every sexually activeadolescent should be offered HIV testing. The frequency ofscreening for STIs depends on risk factors.

LABORATORY WORK-UP

Cholesterol screening with a total serum cholesterol level isappropriate for obese adolescents or for those who haveother cardiovascular risk factors, parents with elevatedcholesterol levels, or an unknown family medical history.Adolescents with a total serum cholesterol level lower than170 mg/dL should be retested within 5 years. A fastinglipoprotein analysis should be performed in adolescentswith a total serum cholesterol level of more than 170 mg/dLor in adolescents with a family history of premature coro-nary artery disease.

The Expert Panel on Blood Cholesterol Levels in Chil-dren and Adolescents28 has recommended a goal low-den-sity lipoprotein (LDL) level lower than 110 mg/dL. Pa-tients with an LDL level of 100 to 129 mg/dL should becounseled about appropriate diet and exercise habits, thenretested in 1 year. Adolescents with an LDL level of 130mg/dL or more should undergo further medical evaluationand treatment.

A complete blood cell count with indices is recom-mended for female adolescents after menarche, with a fol-low-up complete blood cell count for those with any signsor symptoms of anemia.29 Urinalysis is suggested yearly forsexually active females.29 A fasting glucose level every 2years is recommended by the American Diabetes Associa-tion for adolescents who are overweight or from high-riskfamilies or ethnic groups.30 Finally, any adolescent at riskfor exposure to active tuberculosis should have a purifiedprotein derivative skin test for tuberculosis.

HEARING AND VISION SCREENING

The AAP recommends objective hearing and visionscreening at each stage of adolescence (at approximately12, 15, and 18 years of age). Subjective screening withspecific questions should be performed yearly.2,29

IMMUNIZATIONS

During adolescence, immunizations should be updated.The second measles-mumps-rubella (MMR) vaccineshould be administered to patients who are 11 or 12 yearsold, if they have not yet received 2 MMR vaccines aftertheir first birthday. Adolescents who have not received the2 MMR vaccines during childhood should complete the 2-dose series during adolescence (at a 4-week interval).

The tetanus-diphtheria (Td) booster is required every 8to 10 years. Because of the rising incidence of pertussis inthe United States, particularly among adolescents, 2 newtetanus-diphtheria-pertussis (Tdap) boosters have been ap-proved by the Food and Drug Administration (Adacel,approved for ages 11-64 years; Boostrix, approved for ages10-18 years). The Advisory Committee on ImmunizationPractices of the Centers for Disease Control and Preventionhas recommended a single booster dose of Tdap in adoles-cents.31 Tdap can be given instead of the Td booster at the11- to 12-year visit or when the adolescent is 13 to 18 yearsof age, if not given earlier. For pertussis protection, anyadolescent who received the Td booster may also receivethe Tdap booster at a later time, even if the time elapsed isless than 5 years (there is some chance of an increased localreaction). Parallel recommendations are being evaluated bythe AAP and, if approved, will become part of the 2006Recommended Childhood Immunization Schedule.

The hepatitis B series is required for all adolescents, andthe hepatitis A series is recommended for high-risk patients(eg, international travelers, persons with chronic liver dis-ease, or persons living in states with a high prevalence ofhepatitis A). Varicella vaccine should be given if the ado-lescent has no history of infection with the varicella-zostervirus or no history of previous vaccination; 2 shots at least1 month apart are required for immunization of adolescentsaged 13 years or older.

The meningococcal polysaccharide vaccine has beenrecommended for college freshmen living in a dormitorysetting. However, the new meningococcal conjugate vaccinegives longer-acting immunity and is now recommended as a1-time immunization to be given at one of the followingmilestones: 11 to 12 years, 15 years (entering high school),or 18 years (entering college).32 Influenza and pneumococcalvaccines are appropriate for high-risk patients.33

COUNSELING FOR RISK-TAKING BEHAVIORS

Mortality and morbidity due to risk-taking activities arepreventable through behavioral change. The physician canhave a positive effect on adolescents by identifying suchbehaviors as a health concern and working with adoles-cents to modify them. The hard work that follows theidentification of risk-taking behavior in a female adoles-cent not only entails building conviction in the patient thatshe does indeed want to change but also motivates her totake action. Recognizing the developmental stage of anadolescent is important in the process of motivating her tochange, and it may influence the ways in which the physi-cian interacts with the adolescent and her parent(s).

Ideally, the counseling process will instill responsibilityin the adolescent for her own health maintenance because



ADOLESCENT HEALTH

lasting change will occur only if the adolescent is inter-nally motivated. Motivational interviewing is an ap-proach that is both empathetic and directive. It seeks toelicit the patient’s ambivalence about her risk-taking be-haviors, as well as her own reasons for, and the perceivedadvantages of, change. This interview style has been stud-ied and shown to be effective even with short-term use,and it can be used with older adolescents. It is detailed inthe book Motivational Interviewing: Preparing Peoplefor Change.34

Brainstorming with the adolescent to set achievablegoals with measurable results for the next visit can helpinstill confidence and responsibility. Reinforcing positivebehaviors can also encourage adolescents to maintainhealthy patterns. Ongoing follow-up is crucial to maintain-ing accountability and gauging progress.

ANTICIPATORY GUIDANCE

A major component of preventive care for adolescents isanticipatory guidance: anticipating future health risks andgiving general health guidance on how to avoid them. Thistype of guidance includes education about healthy dietaryhabits (including safe weight management); regular exer-cise; responsible sexual behaviors (including abstinence);avoidance of tobacco, alcohol, other abusable substances,and anabolic steroids; injury prevention with helmet andseatbelt use; and avoidance of handguns.

Anticipating developmental changes can also help pre-pare adolescents and their parents for forthcoming physi-cal, emotional, social, and cognitive changes. GAPS3 sug-gests meeting with the adolescent’s parent periodically(generally once in each stage of adolescence; Tables 2 and3) to discuss (1) development, (2) adapting parenting prac-tices to meet the changing needs of the adolescent, (3)recognizing risk-taking behavior, (4) discussing sexuality,and (5) promoting family connectedness. By anticipatingupcoming challenges, and by giving adolescents and theirparents the tools for addressing those challenges, physi-cians will have a stronger influence on the health of adoles-cents as they enter adulthood.

RESOURCES

Physicians who provide care to adolescent patients cannotpractice in a vacuum. It is crucial to develop a network ofcommunity referrals to address issues identified throughscreening. Resources for physicians are listed in Table 1.Helpful educational literature specifically for patients andtheir families is also available through many of the sameorganizations, especially the AAP and the Bright Futures4

program.

REFERENCES1. American Medical Association. Guidelines for Adolescent Preventive

Services (GAPS): Recommendations Monograph. Chicago, Ill: AmericanMedical Association; 1997.

2. American Academy of Pediatrics. Guidelines for Health Supervision III.Elk Grove Village, Ill: American Academy of Pediatrics; 1997.

3. Elster AB, Kuznets NJ, eds. AMA Guidelines for Adolescent PreventiveServices (GAPS): Recommendations and Rationale. Baltimore, Md: Williams& Wilkins; 1994.

4. Green M, Palfrey JS. Bright Futures: Guidelines for Health Care Super-vision of Infants, Children, and Adolescents. 2nd ed, rev. Arlington, Va:National Center for Education in Maternal and Child Health; 2002:230-297.

5. Marshall WA, Tanner JM. Variations in pattern of pubertal changes ingirls. Arch Dis Child. 1969;44:291-303.

6. Joffe A. Adolescent medicine. In: Oski FA, DeAngelis CD, Feigin RD,McMillan JA, Warshaw JB, eds. Principles and Practice of Pediatrics. Phila-delphia, Pa: JB Lippincott Co; 1994:763-805.

7. Grunbaum JA, Kann L, Kinchen S, et al. Youth risk behavior surveil-lance: United States, 2003 [published correction appears in MMWR SurveillSumm. 2004;53:536]. MMWR Surveill Summ. 2004;53:1-96.

8. Abma JC, Martinez GM, Mosher WD, Dawson BS. Teenagers in theUnited States: sexual activity, contraceptive use, and childbearing, 2002. VitalHealth Stat 23. 2004;24:1-48.

9. McMillan JA, DeAngelis CD, Feigin RD, Warshaw JB, eds. Oski’sPediatrics: Principles and Practice. Philadelphia, Pa: Lippincott Williams &Wilkins; 1999.

10. Centers for Disease Control and Prevention. Web-based Injury StatisticsQuery and Reporting System (WISQARS) [Online]. National Center for InjuryPrevention and Control, Centers for Disease Control and Prevention; 2004.Available at: www.cdc.gov/ncipc/wisqars. Accessed April 4, 2005.

11. Department of Health and Human Services, Centers for Disease Controland Prevention Epidemiology Program Office, Division of Health Surveillanceand Informatics. CDC WONDER. Available at: http://wonder.cdc.gov. Ac-cessed April 1, 2005.

12. Centers for Disease Control and Prevention, National Center for HIV,STD, and TB Prevention, Division of Sexually Transmitted Diseases Preven-tion. 2003 Surveillance Report. Available at: www.cdc.gov/nchstp/dstd/Stats_Trends/Stats _and_Trends.htm. Accessed April 1, 2005.

13. Kann L, Warren CW, Harris WA, et al. Youth risk behavior surveillance:United States, 1993. MMWR CDC Surveill Summ. 1995;44:1-56.

14. Summary of Policy Recommendations for Periodic Health Examina-tions. Revision 5.7. Leawood, Kan: American Academy of Family Physicians;2005.

15. Ford CA, Millstein SG, Halpern-Felsher BL, Irwin CE Jr. Influence ofphysician confidentiality assurances on adolescents’ willingness to discloseinformation and seek future health care: a randomized controlled trial. JAMA.1997;278:1029-1034.

16. Sigman G, Silber TJ, English A, Epner JE. Confidential health care foradolescents: position paper of the Society for Adolescent Medicine. J AdolescHealth. 1997;21:408-415.

17. Cheng TL, Savageau JA, Sattler AL, DeWitt TG. Confidentiality inhealth care: a survey of knowledge, perceptions, and attitudes among highschool students. JAMA. 1993;269:1404-1407.

18. English A. Reproductive health services for adolescents: critical legalissues. Obstet Gynecol Clin North Am. 2000;27:195-211.

19. Lieberman D, Feierman J. Legal issues in the reproductive health care ofadolescents. J Am Med Womens Assoc. 1999;54:109-114.

20. English A. Treating adolescents: legal and ethical considerations. MedClin North Am. 1990;74:1097-1112.

CONCLUSION

Caring for female adolescent patients can be extremelyrewarding, although sometimes challenging. Knowledge ofthe normal growth and development patterns of adolescents,as well as the major health risks they face, helps physicianstake on the task with additional skill and confidence.



ADOLESCENT HEALTH

Questions About Health Care Maintenancein Female Adolescents

1. Which one of the following circumstances generallyhas a legal requirement for parental consent before theadolescent can be treated?

a. Emergency treatment when no parent is availableb. Care related to rape or assault when the minor is

aged 12 years or olderc. General health care delivery to a minor younger than

18 yearsd. Care related to alcoholism or substance abuse when

the minor is older than 12 yearse. Care related to STIs or testing for HIV

2. Which one of the following statements about BMI infemale adolescents is false?

a. The BMI is a useful tool for screening for obesityand underweight conditions

b. Adolescents should be screened for organic diseaseor an eating disorder if the BMI is below the 10thpercentile

c. Adolescents with a BMI from the 85th to the 94thpercentile are at risk of becoming overweight

d. Adolescents with a BMI greater than the 95thpercentile are overweight

e. The normal graph plotting BMI in children as theygrow is curvilinear

3. Which one of the following statements aboutcholesterol screening in adolescents is false?

a. Adolescents with a total cholesterol level lower than170 mg/dL should be retested in 5 years

b. Adolescents with an LDL level of 110 to 129 mg/dLshould be treated

c. The Expert Panel on Blood Cholesterol Levels inChildren and Adolescents recommends a goalLDL level lower than 110 mg/dL

d. Adolescents with an LDL level of 130 mg/dL orhigher should undergo further medical evaluationand treatment

e. A fasting lipoprotein analysis should be performedin adolescents with a total cholesterol level higherthan 170 mg/dL or a family history ofhyperlipidemia

4. Which one of the following is the No. 1 cause of deathin female adolescents?

a. Suicideb. Homicidec. Motor vehicle accidentsd. Cancere. Other unintentional injuries

5. Which one of the following physician activities has thegreatest effect on adolescent morbidity andmortality?

a. Performing a comprehensive examination annuallyb. Counseling all adolescents about safe sexual

practicesc. Recognizing and treating eating disorders and

depressiond. Providing anticipatory guidance regarding risk-

taking behaviorse. Providing anticipatory guidance for a healthy

lifestyle

Correct answers:1. c, 2. b, 3. b, 4. c, 5. d

21. United States Department of Health and Human Services. OCR privacybrief: summary of the HIPAA privacy rule. Available at: www.hhs.gov/ocr/privacysummary.pdf. Accessed October 11, 2005.

22. Rainey DY, Brandon DP, Krowchuk DP. Confidential billing accountsfor adolescents in private practice. J Adolesc Health. 2000;26:389-391.

23. Council on Scientific Affairs, American Medical Association. Confiden-tial health services for adolescents. JAMA. 1993;269:1420-1424.

24. Committee on Bioethics, American Academy of Pediatrics. Informedconsent, parental permission, and assent in pediatric practice. Pediatrics.1995;95:314-317.

25. National Center for Health Statistics. National health and nutrition ex-amination survey: 2000 CDC growth charts: United States. Available at:www.cdc.gov/growthcharts. Accessed May 19, 2005.

26. Smith RA, Cokkinides V, Eyre HJ. American Cancer Society guidelinesfor the early detection of cancer, 2005. CA Cancer J Clin. 2005;55:31-44.

27. United States Preventive Services Task Force. Screening for cervicalcancer. Available at: www.ahrq.gov/clinic/uspstf/uspscerv.htm. Accessed Oc-tober 11, 2005.

28. American Academy of Pediatrics. National Cholesterol Education Pro-gram: report of the Expert Panel on Blood Cholesterol Levels in Children andAdolescents. Pediatrics. 1992;89:525-584.

29. Committee on Practice and Ambulatory Medicine. Recommendationsfor preventive pediatric health care. Pediatrics. 2000;105:645-646.

30. American Diabetes Association. Screening for type 2 diabetes. DiabetesCare. 2004;27(suppl 1):S11-S14.

31. Long SS. ACIP votes to recommend adolescent pertussis booster: CDC,Academy policy likely to parallel ACIP recommendation. AAP News.2005;26:1-16.

32. American Academy of Pediatrics, Committee on Infectious Diseases.Prevention and control of meningococcal disease: recommendations for use ofmeningococcal vaccines in pediatric patients. Available at: www.aap.org/advocacy/releases/mengopolicyfinal.pdf. Accessed October 11, 2005.

33. Immunization of adolescents: recommendations of the Advisory Com-mittee on Immunization Practices, the American Academy of Pediatrics, theAmerican Academy of Family Physicians, and the American Medical Associa-tion. MMWR Recomm Rep. 1996;45:1-16.

34. Miller WR, Rollnick S. Motivational Interviewing: Preparing Peoplefor Change. New York, NY: Guilford Press; 2002.


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