Chapter 106 Delivery of Health Care to Adolescents
The Society for Adolescent Medicine identified 10 program and policy characteristics to ensure comprehensive and high-quality care to adolescents. Health insurance coverage that is affordable, continuous, and not subject to exclusion for preexisting conditions should be available for all adolescents and young adults who have no access to private insurance. Comprehensive, coordinated benefits should meet the developmental needs of adolescents, particularly for reproductive, mental health, dental, and substance abuse services. Safety net providers and programs, such as school-based health centers, community health centers, family planning services, and clinics that treat sexually transmitted infections (STIs) in adolescents and young adults, need to have assured funding for viability and sustainability. Quality of care data should be collected and analyzed by age so that the performance measures for age-appropriate health care needs of adolescents are monitored. Affordability is important for access to preventive services. Family involvement should be encouraged, but confidentiality and adolescent consent are critically important. Health plans and providers should be adequately compensated to support the range and intensity of services required to address the developmental and health service needs of adolescents. Health care providers, trained and experienced, to care for adolescents should be available in all communities. The creation and dissemination of provider education about adolescent preventive health guidelines have been demonstrated to improve the content of recommended care (Table 106-1). The ease of recognition or expectation that an adolescent’s needs can be addressed in a setting relates to the visibility and flexibility of sites and services. Staff at sites should be approachable, linguistically capable, and culturally competent. Health services should be coordinated to respond to goals for adolescent health at the local, state, and national levels. The coordination should address service financing and delivery in a manner that reduces disparities in care.
Table 106-1 BRIGHT FUTURES/AMERICAN ACADEMY OF PEDIATRICS RECOMMENDATIONS FOR PREVENTIVE HEALTH CARE FOR 11-21 YEAR OLDS
| PERIODICITY AND INDICATIONS | |
|---|---|
| HISTORY | Annual |
| MEASUREMENTS | |
| Body mass index | Annual |
| Blood pressure | Annual |
| SENSORY SCREENING | |
| Vision | At 11, 15, and 18 year visits or if risk assessment positive |
| Hearing | If risk assessment positive |
| DEVELOPMENTAL/BEHAVIORAL ASSESSMENT | |
| Developmental surveillance | Annual |
| Psychosocial/behavioral assessment | Annual |
| Alcohol and drug use assessment | If risk assessment positive |
| PHYSICAL EXAMINATION | Annual |
| PROCEDURES | |
| Immunization* | Annual |
| Hematocrit or hemoglobin | If risk assessment positive |
| Tuberculin test | If risk assessment positive |
| Dyslipidemia screening | If risk assessment positive |
| STI screening | If sexually active |
| Cervical dysplasia screening† | Annual beginning at age 21 yr |
| ORAL HEALTH | Annual refer to dental home or administer oral health risk assessment |
| ANTICIPATORY GUIDANCE | Annual‡ |
* Schedules as per the AAP Committee on Infectious Diseases, published annually in the January issue of Pediatrics.
† American College of Obstetrics and Gynecology: Cervical cytology screening. ACOG Practice Bulletin No. 109, Obstet Gynecol 114:1409–1420, 2009.
‡ Refer to specific guidance by age as listed in Bright Futures Guidelines.
Adapted from American Academy of Pediatrics and Bright Futures Periodicity Schedule. In Hagan JF, Shaw JS, Duncan PM, editors: Bright futures: guidelines for health supervision of infants, children, and adolescents, ed 3, Elk Grove Village, IL, 2008, American Academy of Pediatrics. brightfutures.aap.org/pdfs/Guidelines_PDF/20-Appendices_PeriodicitySchedule.pdf. Accessed April 16, 2010.
Adolescents have the lowest annual rate of visits to office-based physicians compared with all other age groups. Adolescents 10-19 yr of age are less likely to have had a recent health care visit than children <10 yr of age. In 2005, 83% of adolescents had one or more contacts with a health care professional compared with 91% of children <10 yr of age. Uninsured adolescents are the least likely to receive care. In 2005, the proportion of adolescents without health insurance who had not visited a health care provider in the past year was more than 3 times as high as insured adolescents. Older teens and young adults are more likely to be uninsured (Fig. 106-1). In 2006, while 86% of 11-12 yr olds were covered by either public or private health insurance, only 67% of 19-20 yr olds and 56.5% of 23-24 yrs olds had were covered by health care insurance. Even for insured adolescents and young adults, health care expenses present a barrier to care. In 2004, 80% of adolescents 10-21 yr of age incurred out-of-pocket expenses for health care; on average, this was $1,514 annually. Adolescents with health insurance were considerably more likely to have incurred out-of-pocket expenses and the average annual out-of-pocket amount spent was higher for insured compared to uninsured adolescents.
Figure 106-1 Full-year private and public health insurance coverage by age, 2006.
(Data from Public Policy Analysis and Education Center for Middle Childhood, Adolescent and Young Adults Health. National Health Interview Survey, 2006. Adapted from Mulye TP, Park MJ, Nelson CD, et al: Trends in adolescent and young adult health in the United States, J Adolesc Health 45:8-24, 2009.)
The complexity and interaction of physical, cognitive, and psychosocial developmental processes during adolescence require sensitivity and skill on the part of the health professional (Chapter 104). Health education and promotion as well as disease prevention should be the focus of every visit. In 2008, the American Academy of Pediatrics in collaboration with the U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau, published the 3rd edition of Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, that offers providers a strategy for delivery of adolescent preventive health services with screening and counseling recommendations for early, middle, and late adolescence (Table 106-2). Bright Futures is rooted in the philosophy of preventive care and reflects the concept of caring for children in a “medical home.” These guidelines emphasize effective partnerships with parents and the community to support the adolescent’s health and development.
The Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices (ACIP) currently recommends 3 routine adolescent vaccines, tetanus–diphtheria–acellular pertussis vaccine (Tdap), the meningococcal conjugate vaccine (MCV4) and the human papillomavirus (HPV) vaccine, for universal administration beginning at the 11-12 yr old visit or as soon as possible (Chapter 165). ACIP recommends a second varicella vaccine, annual influenza vaccination, and hepatitis A vaccination in states or communities where routine hepatitis A vaccination has been implemented and for travelers, men who have sex with men, injection drug users, and those with chronic liver disease or clotting factor disorders.
The time spent on various elements of the screening will vary with the issues that surface during the assessment. For gay and lesbian youth (Chapter 104.3), emotional and psychologic issues related to their experiences, from fear of disclosure to the trauma of homophobia, may direct the clinician to spend more time assessing emotional and psychologic supports in the young person’s environment. For youths with chronic illnesses or special needs, the assessment of at-risk behaviors should not be omitted or de-emphasized by assuming they do not experience the “normal” adolescent vulnerabilities.
106.1 Legal Issues
Some minor consent laws are based on services a minor is seeking, such as emergency care, sexual health care, substance abuse, or mental health care (Table 106-3). All 50 states and the District of Columbia explicitly allow minors to consent for their own health services for STIs. About 25% of states require that minors be a certain age (generally 12-14 yr) before they are allowed to consent for their own care for STIs. No state requires parental consent for STI care or requires that providers notify parents that an adolescent minor child has received STI services, except in limited or unusual circumstances.
Table 106-3 TYPES OF MINOR CONSENT STATUTES OR RULES OF COMMON LAW THAT ALLOW FOR THE MEDICAL TREATMENT OF A MINOR PATIENT WITHOUT PARENTAL CONSENT
| LEGAL EXCEPTIONS TO INFORMED CONSENT REQUIREMENT | MEDICAL CARE SETTING |
|---|---|
| The “emergency” exception | Minor seeks emergency medical care. |
| The “emancipated minor” exception |
From Table 1 in Committee on Pediatric Emergency Medicine: Consent for emergency medical services for children and adolescents, Pediatrics 111:703–706, 2003.
