++
A general health assessment should include a review of systems and an evaluation of health-related behavior. This should include risk factors for accidents, STIs, including human immunodeficiency virus (HIV), pregnancy, interpersonal violence (including past physical or sexual abuse), nutrition, substance use, exercise, sleep, learning, and mental health problems. Guidance about promoting healthful behaviors and preventing disease should be integrated into the discussion. Inclusion of these factors is considered community standard of care for adolescents. Documentation of health encounters ideally should be done electronically; it is therefore recommended that a standard written protocol be developed so that all elements described above can be documented and searched for quality assessment. From the patient’s perspective, the clinician’s inquiries and assessment of some behaviors may be viewed as embarrassing, intrusive, or trivial. It is therefore helpful to explain, prior to questioning, that (1) the same questions are asked of all patients and that (2) the encounter goal is patient self-awareness and health education. During the interview it is important to reinforce and praise healthy decisions, such as sexual abstinence.
++
Certain ground rules are important. Ensure the adolescent that, unless homicide or suicide is threatened or ongoing abuse is reported, all conversations are confidential, and the information will not be shared with parents, teachers, or other authorities without permission. Discussions about sex and drugs should always occur in private unless otherwise requested by the patient. If the patient is accompanied by a parent, solicit parental concerns, and then ask the adult to leave the room and conduct the interview in private. It is also helpful to let the parent know (if present) about the confidential nature of the patient–clinician conversation.
++
Although most teenagers want to receive health information and discuss personal behavior, these discussions must generally be initiated by the physician. Many teenagers are not accustomed to interacting in such participatory, nonjudgmental conversations with adults. The willingness of a teenager to share personal or intimate information depends on the perceived receptiveness of the provider. Teenagers need to feel that they have permission to share personal, behavior-related information. For example, it is usually not difficult for patients and clinicians to discuss routine chronic medical conditions such as diabetes or asthma. Control of these conditions in some teenagers, however, may be related more to dietary indiscretions and cigarette use, than to insulin or inhaler use. Such health-compromising behaviors must be identified before they can be dealt with; comments, facial expressions, or body language indicating disapproval can undermine the patient’s willingness to disclose confidential behavior (Table 13-1).
++
++
Most electronic medical record systems now include patient web-portals that allow secure communication between patient and provider. This type of system potentially makes communication easier and faster for all involved. Issues around confidentially and parental access make independent use by minors problematic, although is often supported by many parents. Future systems will likely also include embedded video (telemedicine) linkage, and the same issues related to parental control will apply. See Table 13-2 for Quality and Safety suggestions.
++
++
Many practitioners worry about the legality of evaluating and treating teenagers without parental consent. Because laws vary by state, it is essential to become familiar with the applicable local statutes. Many states permit the diagnosis and treatment of teenagers with sex-, drug-, and alcohol-related problems without parental notification or consent. States do vary at the age about which teens can receive such services without parental permission. Likewise, most states permit medical care if a condition is potentially life threatening. Documentation of the rationale leading to the decision to proceed without parental permission, in a potential “life-threatening” situation, is essential.
+++
Interview Organization
++
A comprehensive health risk assessment should cover issues dealing with home, education, activities, drug use, sexual practices, and suicidal ideation (HEADSS). Using the HEADSS format helps with organization and standardization. Assessing cognitive ability using interactive dialogue needs to be done in the first few minutes of the interview. The following interview goals and questions facilitate communication.
++
Goal— Determine household structure, family structure and function, conflict-resolution skills, the possibility of domestic violence, and presence of chronic illness in the family (see Chapter 11).
Questions—“Who lives where you live?” If only one parent is at home, the interviewer should inquire about the other parent’s whereabouts, visitation pattern, reasons for leaving (especially domestic violence and substance abuse), and whether the teen moves back and forth between parents. Teenagers caught between divorced parents or those who feel neglected may “act out” and get into trouble to gain parental attention, sometimes in the hope that their problems will reunite separated parents. For single-parent families, the patient can be asked, “Does your mom or dad date? How do you get along with the people he or she dates?” Questions about domestic violence should include “What happens when people argue in your house?” and “Does anyone get hurt during arguments? How about you?” and “What if someone has been drinking or using drugs and they argue?” and “Have you ever seen your mother hit by anyone?” “Are there guns in your house?” If there are, ask if they are always locked and who has a key. Educate parents and patients about accidental gunshots. Ask about siblings, including their health and whereabouts. Somatization may be learned by observing a family member who receives attention for a chronic medical condition. Learning about extended family members living in the household is also important and will likely be revealed with the first question above.
++
Goal—Identify attention deficit hyperactivity disorder (ADHD) and other learning disabilities, school performance, cognitive ability, and vocational potential.
Questions—“What grade are you in?” “What type of grades do you get?” “How do they compare with your grades last year?” Falling grades may indicate family, mental health, or substance-abuse problems. “Have you ever been told you had a learning problem?” “Can you see the blackboard?” Most teenagers respond that everything in school is okay. Specific questions about courses and content need to be asked, including the student’s favorite and worst subjects and his or her career aspirations. Generally, teenagers who perform well in school are less likely to participate in multiple health risk behaviors. The teen should be asked about attendance, and truancy or other school troubles. Teenagers with drug problems may enjoy going to school because, although they may rarely attend class, school is where they visit friends and purchase or sell drugs. Students who get all “A’s” should be asked about school-related stress and what would happen if they did not receive high grades. Depression and even suicide can be related to unrealistic grade expectations by teenagers and their parents.
++
Goal—Evaluate the patient’s social interactions, Internet use and purposes of use, interests, and self-esteem.
Questions—“What do you do for fun?” “Are you involved in school, community, or religious activities, such as youth groups, clubs, or sports?” Self-esteem is often related to successful participation in these activities. Teenagers actively involved in “productive” activities are less likely to participate in delinquent behavior. The clinician should ask about gang or fraternity/sorority membership, either of which can be a source of inappropriate peer pressure. Gangs may provide the strongest sense of family or community available to some teenagers.
++
Questions should be asked about dietary habits, including the frequency and amount of “junk” food, who cooks, and dieting or self-induced vomiting (see Chapter 23). It is also important to inquire about patients’ physical activities, and to educate and to make recommendations about regular exercise, protective headgear, and seatbelts. Internet assessment should include types of sites visited and purpose of use.
++
Goal—Evaluate the patient’s current habits, patterns of use, and the genetic or environmental risk factors (Table 13-3). Distinguish between those who drink because of social, cultural, and peer pressure, those who are genetically predisposed, and those who drink or use illicit drugs because of comorbid mental health problems.
Questions—It is less threatening to begin by asking, “Are you aware of alcohol or drug use at your school?” and “Do any of your friends drink or use drugs?” followed by “Have you ever tried alcohol or drugs?” The physician should inquire specifically about cigarettes, alcohol, marijuana, recreational “pills” (e.g., ecstasy, ketamine), cocaine, lysergic acid diethylamide (LSD), crystal methamphetamine, anabolic steroids, and heroin. The quantity, frequency, circumstances, and family patterns of use are important. To learn about family drinking, ask specific questions about each parent and both maternal and paternal grandparents, including whether anyone in the family attends Alcoholics Anonymous (AA) or other self-help groups. When parents do not recognize or admit to a problem, a child may not identify them as alcoholics. The teenager should be asked to describe the parent’s pattern of alcohol use. “Have you ever seen your mother or father drunk?” If the answer is yes, then ask “When and how frequently?” The CRAFFT questions (Table 13-4) have been validated as a useful brief screening test for teenagers suspected of substance abuse. Two or more YES answers on the CRAFFT indicate a significant problem.
++
++
++
Recognition of a parental problem is also essential. Even the best treatment program will fail if a teenager is discharged back into the home of an actively using parent. The willingness of parents to change either their own drinking or family behavior patterns is one of the best predictors of adolescent treatment success.
++
Among many teenagers, the use of drugs and alcohol is often not considered abnormal or dangerous. Only about 5–10% of teenage drinkers or drug users develop substance-abuse problems as adults. Because serious physical consequences, other than accidents, usually do not occur until later in life, there is little negative association with alcohol or drug use. Abused, neglected, disabled, or chronically ill teenagers may consider drugs or alcohol one of the few things that, at least temporarily, make them feel good and accepted by peers. If legal involvement, school problems, or family conflict are present, it is important to assess the role of alcohol and drugs. Even if use seems minimal, it should be pointed out that problems are best solved sober.
++
Referral to a substance-abuse expert is indicated when use significantly interferes with school, family, or social functioning. Anticipatory guidance should address age-appropriate concerns. Advising teenagers to stop smoking cigarettes because of the possibility of future lung cancer and heart disease is usually meaningless. Talking about wrinkled skin, bad breath, and yellow teeth is much more relevant to body image concerns and far more likely to prevent or stop cigarette use. Similarly, the association between alcohol and date rape is more important to teenage girls than are other future consequences.
++
Goal—Determine the level of the patient’s sexual involvement and sexuality, use of birth control, protection against STIs, and any history of abuse.
Questions—An opening question such as “Have you ever been sexually involved with anyone?” is preferable to “Are you sexually active?” The word active is notoriously misinterpreted. Questions need to be open ended and should not assume heterosexual orientation. Assumptions about boyfriends or girlfriends inhibit discussion or questions about homosexual partners or feelings. Because teenagers frequently practice serial monogamy, the sequential number of different partners and their ages should be determined. Ask whether they have ever met anyone on the Internet for sexual reasons and the circumstances related to that encounter. A 15-year-old teenager with a peer group partner is at less risk for STIs, especially HIV, than is one with a substantially older partner. For the sexually involved, discuss birth control techniques and condoms. One of the most common reasons for not using a condom is the belief that birth control pills provide adequate protection against STIs. When appropriate, physicians should reinforce sexual abstinence with congratulations and support.
++
Sexual abuse is unfortunately common. A history of such incidents should be sought by asking, “Have you ever been touched sexually when you did not want to be?” Obtaining this history may be pivotal in helping a teenager who has developed abuse-related behavioral problems, such as sexual promiscuity, depression, substance abuse, delinquency, and an eating or somatization disorder.
++
Unwanted pregnancy among teenagers is still at epidemic proportions. Risk factors are complex but include ignorance, lack of access to family planning services, cultural acceptance, and poor self-esteem.
++
Goal—Identify serious mental health problems and distinguish them from normal adolescent affect and moodiness. Primary risk factors are listed in Table 13-5.
Distinguishing significant psychiatric illness from normal fluctuations in a teenager’s affect is challenging. In spite of the general perception to the contrary, most teenagers are not maladjusted, and the rates of mental health problems are no higher than in adults. Few teenagers announce that they are feeling depressed or are in emotional turmoil. Depression may be reflected in sexual promiscuity, drug and alcohol abuse, or in the commission of violent and delinquent acts. Chronic somatic complaints such as headache, abdominal pain, or chest pain without an identifiable biological explanation may also indicate depression secondary to abuse.
Questions—Practitioners should identify vegetative signs of depression, such as sleep disturbance, decreased appetite, hopelessness, lethargy, continuous thoughts about suicide, hallucinations, or illogical thoughts. It should also be noted that many of these symptoms may also be caused by substance abuse. Evaluation of lethargy should be done from the patient’s perspective. Energy may be low relative to the parents’ desires or expectations—but sufficient for the teenager. There may be insufficient energy to clean, help with household chores, or complete homework but plenty of energy available to play sports, go on a date, party with friends, travel miles, and wait for hours to obtain concert tickets.
++
++
CASE ILLUSTRATION 1
Lauren is a 15-year-old girl admitted to the hospital with an arm fracture requiring surgical repair. The fracture occurred during cheerleading practice while climbing a pyramid of other cheerleaders. She reported being distracted while climbing, lost concentration, and fell to the ground. During the admission history the patient was talkative and easily distracted. Although she did not report taking any medications to the admitting nurse, when asked “are you supposed to be taking” any medications, Lauren reported that she should be taking medication for ADHD (see Chapter 27). She had not taken medication for the last several days because she was staying with a friend and did not want her friend to know that she took medication.
++
This case illustrates several important adolescent issues. First, teenagers may concretely interpret questions. When Lauren was asked by the nurse if she was taking any medication, she answered honestly. A combination of clinical judgment at the time of interview related to Lauren’s inattentiveness, knowledge that teenagers may interpret concretely, and that they may not make the connection between behavior and health consequences are all important to this case. Second, teenagers seek peer conformance. Medication compliance problems may relate to avoiding peer awareness of medications and, therefore, being labeled as different. Taking medication at school, camp, or at the house of a friend may all make a teenager feel different. Lastly, instructions about medications should be given in terms of what is important to the patient. Lauren may have known that medication was beneficial for school performance, but may not have realized that it would improve concentration with other tasks that required focus and attention.
++
CASE ILLUSTRATION 2
Two days after sustaining minor injuries in a traffic accident, Jeff, a 16-year-old teenager, comes to the physician’s office complaining of left shoulder pain. He is accompanied by his mother, who is concerned because Jeff was also recently arrested for driving under the influence of alcohol. There is no history of medical or behavioral problems, although, on questioning, his mother describes a 12-month history of moodiness and falling school grades. Using the HEADSS format assessment, the physician assesses Jeff’s health risks:
Home: Jeff lives at home with his biological mother and father. The parents are first-generation immigrants who both work full time. There are few arguments at home, and Jeff describes both parents as stoic, religious, and unemotional.
Education: Although he was an above-average student until last year, Jeff’s education is now being adversely affected by his truancy and lack of interest.
Activity: Although Jeff previously played several sports at school, watching television is now his favorite activity.
Drugs: Jeff admits to using drugs frequently. He drinks alcohol at least twice a week and smokes marijuana daily. Since this use is no more frequent than that of his friends, he does not consider it excessive.
Sex: Jeff has no steady sexual partners, but has had several short-term relationships.
Suicide: Jeff denies being suicidal or depressed. When asked about significant losses, however, he becomes tearful and talks hesitantly about his older brother, a construction worker, who died accidentally 2 years ago. Since the burial, his brother was never talked about at home.
++
The connection between increased substance use, declining grades, and the brother’s death seems obvious. Because the substance use began insidiously, and significant trouble did not occur until more than a year after his brother’s death, neither Jeff nor his parents associated the events. Furthermore, this is a family that seemingly does not share emotions, and Jeff never learned how to discuss his feelings. In this case, simply learning about his drug use, home situation, school performance, and activities was not enough. The facts all confirmed his substance abuse but did not explain it. With a teenager who previously has been without significant behavioral problems, it is crucial to search for personal or family events, including losses, that underlie and precipitate behavior change.
++
Both Jeff and his parents must be made aware of the connection between the substance use and the brother’s death. It is imperative that Jeff acknowledge his drug problem and be referred to a practitioner experienced in treating adolescents with substance-abuse problems (see Chapter 24). Although Jeff should respond to psychotherapy that addresses his grief and loss, psychotherapy may not be effective if mind-altering substances are being used concomitantly.