Delivery of Health Care to Adolescents

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Chapter 106 Delivery of Health Care to Adolescents

Adolescence provides a unique opportunity to prevent health conditions and behaviors that develop in the second decade of life and that can lead to substantial morbidity and mortality, such as trauma, cardiovascular and pulmonary disease, type 2 diabetes, reproductive health disease, and cancer. Health care providers play an important role in nurturing healthy behaviors among adolescents because the leading causes of death and disability among adolescents are preventable. Access to developmentally appropriate, affordable, high-quality health care during the adolescent years sets the stage for a lifetime of good health.

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.

Table 106-2 BRIGHT FUTURES ADOLESCENT SCREENING RECOMMENDATIONS

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

Gale R. Burstein

The rights of an individual including those of adolescents vary widely between nations. In the USA, the right of a minor to consent to treatment without parental knowledge differs between states and is governed by state-specific minor consent laws. Some minor consent laws are based on a minor’s status, such as minors who are emancipated, parents, married, pregnant, in the armed services, or mature. Minors can be considered emancipated if they are or have served in the armed services or are living apart from parents and are economically independent through gainful employment. A mature minor is a minor who is emotionally and intellectually mature enough to give informed consent and who lives under the supervision of a parent or guardian. Courts have held that if a minor is mature, a physician is not liable for providing beneficial treatment. There is no formal process for recognition of a mature minor. The determination is made by the health care provider.

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	Minor is self-reliant or independent: • Married • In military service • Emancipated by court ruling • Financially independent and living apart from parents

In some states, college students, runaways, pregnant minors, or minor mothers also may be included. The “mature minor” exception Minor is capable of providing informed consent to the proposed medical or surgical treatment—generally a minor 14 yr or older who is sufficiently mature and possesses the intelligence to understand and appreciate the benefits, risks, and alternatives of the proposed treatment and who is able to make a voluntary and rational choice. (In determining whether the mature minor exception applies, the physician must consider the nature and degree of risk of the proposed treatment and whether the proposed treatment is for the minor’s benefit, is necessary or elective, and is complex.) Exceptions based on specific medical condition

Minor seeks:

• Mental health services

• Pregnancy and contraceptive services

• Testing or treatment for human immunodeficiency virus infection or acquired immunodeficiency syndrome

• Sexually transmitted or communicable disease testing and treatment

• Drug or alcohol dependency counseling and treatment

• Care for crime-related injury

From Table 1 in Committee on Pediatric Emergency Medicine: Consent for emergency medical services for children and adolescents, Pediatrics 111:703–706, 2003.

Minors’ right to consent for contraceptive services varies from state to state. Nearly 50% of states and the District of Columbia explicitly authorize all minors to consent for their own contraceptive services; and 50% of states permit minors to consent for their own contraceptive services under specific circumstances, such as being married, a parent, currently or previously pregnant, over a certain age, or a high school graduate, or per physician’s discretion.

A minor’s right to consent for mental health care and substance abuse treatment services vary by state and age of minor, whether care is medical versus nonmedical (e.g., counseling), and whether care is delivered as an inpatient versus outpatient basis. Minor consent laws often contain provisions regarding confidentiality and disclosure, even when general state consent laws do not have such provisions.

The confidentiality of medical information and records of a minor who has consented for his or her own reproductive health care is governed by numerous federal and state laws. Laws in some states explicitly protect the confidentiality of STI or contraceptive services for which minors have given their own consent and do not allow disclosure of the information without the minor’s consent. In other states, laws grant physicians discretion to disclose information to parents.

The confidentiality of medical information and records of a minor who has consented for his or her own health care is also governed by numerous federal and state laws. Laws in some states explicitly protect the confidentiality of STI, contraceptive, or mental health services for which minors have given their own consent and do not allow disclosure of the information without the minor’s consent. In other states, laws grant physicians discretion to disclose information to parents. Title X and Medicaid both provide confidentiality protection for family planning services provided to minors with funding from these programs.

Federal regulations issued under the Federal Health Insurance Portability and Accountability Act of 1996, known as the HIPAA Privacy Rule, defer to state and “other applicable laws” with respect to the question of whether parents’ have access to information about care for which a minor has given consent. Thus both the state laws that either prohibit or permit disclosure of confidential information and the federal Title X and Medicaid laws that protect the confidentiality of care for adolescents are important under the HIPAA Privacy Rule in determining when confidential information about health services for minors can be disclosed to parents.

Billing for confidential services is complex. Commercial health plans send home an explanation of benefit (EOB) to the primary insured or the primary beneficiary listing services rendered by the provider and reimbursed by the health plan. An EOB documenting that confidential health services were rendered to their adolescent dependent that is received by a parent may disclose those services. In addition, co-payments automatically generated with certain billing codes for office visits and medications can be a barrier for adolescents receiving care, including treatment.

Providers may elect to establish a policy of discussing with their adolescent patients when medical records and other information will be disclosed and developing a mechanism to alert office staff as to what information in the chart is confidential. For legal and other reasons, a chaperone should be present whenever an adolescent female patient is examined by a male physician.

Bibliography

American Academy of Pediatrics Committee on Pediatric Emergency Medicine. Policy Statement. Consent for emergency medical services for children and adolescents. Pediatrics. 2003;111:703-706.

Ford C, English A, Sigmond G. Confidential healthcare for adolescents: position paper of the Society for Adolescent Medicine. J Adolesc Health. 2004;35:1-8.

Fox HB, Limb SJ. State policies affecting the assurance of confidential care for adolescents. Washington, DC: Incenter Strategies, April 2008, www.incenterstrategies.org/jan07/factsheet5.pdf.

The Alan Guttmacher Institute. Minors’ access to STI services. State policies in brief. Guttmacher Institute. June 1, 2010. www.guttmacher.org/statecenter/spibs/spib_MASS.pdf. Accessed June 17, 2010

Weiss C. Protecting minors’ health information under the federal medical privacy regulations. American Civil Liberties Union; 2003.

106.2 Screening Procedures

Gale R. Burstein

Interviewing the Adolescent

The preparation for a successful interview with an adolescent patient varies based on the history of the relationship with the patient. Patients (and their parents) who are going from preadolescence to adolescence while seeing the same provider, should be guided through the transition. Although the rules for confidentiality are the same for new and continuing patients, the change in the physician-patient relationship, allowing more privacy during the visit and more autonomy in the health process, may be threatening for the parent as well as the adolescent. For new patients, the initial phases of the interview are more challenging given the need to establish rapport rapidly with the patient in order to meet the goals of the encounter. Issues of confidentiality and privacy should be explicitly stated along with the conditions under which that confidentiality may need to be altered, that is, in life- or safety-threatening situations. For new patients, the parents should be interviewed with the adolescent or before the adolescent to ensure that the adolescent does not perceive a breach of confidentiality. The clinician who takes time to listen avoids judgmental statements and the use of street jargon and shows respect for the adolescent’s emerging maturity will have an easier time communicating with him or her. The use of open-ended questions, rather than closed-ended questions, will further facilitate history taking. (The closed-ended question “Do you get along with your father?” leads to the answer “yes” or “no,” in contrast to the question, “What would you like to change in your relationship with your mother?” which may lead to an answer such as “I would like her to stop always worrying about me.”)

The goals of the interview or clinical encounter are to establish an information base, identify problems and issues from the patient’s perspective, and identify problems and issues from the perspective of the clinician based on knowledge of the health and other issues relevant to the adolescent age group. The adolescent should be given an opportunity to express concerns and the reasons for seeking medical attention. The adolescent as well as the parent should be given an opportunity to express the strengths and successes of the adolescent, in addition to communicating problems.

Barriers to an effective interview occur when the interviewer is distracted by other events or individuals in the office, when there are extreme time limitations obvious to either party, or when there is expressible discomfort with either the patient or the interviewer. The need for an interpreter when a patient is hearing impaired or if the patient and interviewer are not language compatible provides a challenge but not necessarily a barrier under most circumstances (Chapter 4). Observations during the interview can be useful to the overall assessment of the patient’s maturity, presence or absence of depression, and the parent-adolescent relationship. Given the key role of a successful interview in the screening process, adequate training and experience should be sought by clinicians wishing to give comprehensive care to adolescent patients.

Psychosocial Assessment

A few questions should be asked to detect the adolescent who is having difficulty with peer relationships (“Do you have a best friend with whom you can share even the most personal secret?”), self-image (“Is there anything you would like to change about yourself?”), depression (“What do you see yourself doing 5 yr from now?”), school (“How are your grades this year compared with last year?”), personal decisions (“Are you feeling pressured to engage in any behavior for which you do not feel you are ready?”), and an eating disorder (“Do you ever feel that food controls you rather than vice versa?”). Bright Futures materials provide questions and patient encounter forms to structure the assessments that are available at their website (brightfutures.aap.org/index.html). The HEADS/SF/FIRST mnemonic, basic or expanded, can be useful in guiding the interview if encounter forms are not available (Table 106-4). Based on the assessments, appropriate counseling or referrals are recommended for more thorough probing or for in-depth interviewing.

Table 106-4 HEADS/SF/FIRST

Home. Space, privacy, frequent geographic moves, neighborhood.

Education/School. Frequent school changes, repetition of a grade/in each subject, teachers’ reports, vocational goals, after-school educational clubs (language, speech, math, etc.), learning disabilities.

Abuse. Physical, sexual, emotional, verbal abuse; parental discipline.

Drugs. Tobacco, alcohol, marijuana, inhalants, “club drugs,” “rave” parties, others. Drug of choice, age at initiation, frequency, mode of intake, rituals, alone or with peers, quit methods, and number of attempts.

Safety. Seat belts, helmets, sports safety measures, hazardous activities, driving while intoxicated.

Sexuality/Sexual Identity. Reproductive health (use of contraceptives, presence of sexually transmitted infections, feelings, pregnancy)

Family and Friends. Family: Family constellation, genogram, single/married/separated/divorced/blended family, family occupations and shifts; history of addiction in 1st- and 2nd-degree relatives, parental attitude toward alcohol and drugs, parental rules; chronically ill physically or mentally challenged parent. Friends: peer cliques and configuration (“preppies,” “jocks,” “nerds,” “computer geeks,” cheerleaders), gang or cult affiliation.

Image. Height and weight perceptions, body musculature and physique, appearance (including dress, jewelry, tattoos, body piercing as fashion trends or other statement).

Recreation. Sleep, exercise, organized or unstructured sports, recreational activities (television, video games, computer games, Internet and chat rooms, church or community youth group activities [e.g., Boy/Girl Scouts; Big Brother/Sister groups, campus groups]). How many hours per day, days per week involved?

Spirituality and Connectedness. Use HOPE* or FICA^† acronym; adherence, rituals, occult practices, community service or involvement.

Threats and Violence. Self-harm or harm to others, running away, cruelty to animals, guns, fights, arrests, stealing, fire setting, fights in school.

* HOPE: hope or security for the future; organized religion; personal spirituality and practices; effects on medical care and end of life issues.

^† FICA: faith beliefs; importance and influence of faith; community support.

From Dias PJ: Adolescent substance abuse. Assessment in the office, Pediatr Clin North Am 49:269–300, 2002.

Physical Examination

Audiometry

Highly amplified music of the kind enjoyed by many adolescents may result in hearing loss (Chapter 629). A hearing screening is recommended by the Bright Futures guidelines for adolescents who are exposed to loud noises regularly, have had recurring ear infections, or report problems.

Vision Testing

The pubertal growth spurt may involve the optic globe, resulting in its elongation and myopia in genetically predisposed individuals. Vision testing should, therefore, be performed in order to detect this problem before it affects school performance.

Blood Pressure Determination

Criteria for a diagnosis of hypertension are based on age-specific norms that increase with pubertal maturation (Chapter 439). An individual whose blood pressure exceeds the 95th percentile for his or her age is suspect for having hypertension, regardless of the absolute reading. Those adolescents with blood pressure between the 90th and 95th percentiles should receive appropriate counseling relative to weight and have a follow-up examination in 6 mo. Those with blood pressure above the 90th percentile should have their blood pressure measured on three separate occasions to determine the stability of the elevation before moving forward with an intervention strategy. The technique is important; false-positive results may be obtained if the cuff covers less than two thirds of the upper arm. The patient should be seated, and an average should be taken of the 2nd and 3rd consecutive readings, using the change rather than the disappearance as the diastolic pressure. Most adolescents with elevations of blood pressure have labile hypertension. If the blood pressure is below 2 standard deviations for age, anorexia nervosa and Addison disease should be considered.

Scoliosis (Chapter 671)

Approximately 5% of male and 10-14% of female adolescents have a mild curvature of the spine. This is 2 to 4 times the rate in younger children. Scoliosis is typically manifested during the peak of the height velocity curve, at approximately 12 yr in females and 14 yr in males. Curves measuring greater than 10 degrees should be monitored by an orthopedist until growth is complete.

Breast Examination (Chapters 109 and 545)

Examination of the female adolescent’s breasts is performed to detect masses, evaluate progression of sexual maturation, provide reassurance about development, and teach the technique of self-examination with the hope that this practice will continue into the higher risk later years. However, there is disagreement on the justification for promoting this routinely, given the rare instances of malignant breast masses in this age group.

Scrotum Examination

The peak incidence of germ cell tumors of the testes is in late adolescence and early adulthood. Palpation of the testes may have an immediate yield and should serve as a model for instruction of self-examination. Because varicoceles often appear during puberty, the examination also provides an opportunity to explain and reassure the patient about this entity (Chapter 539).

Pelvic Examination

See Chapter 542.

Laboratory Testing

The increased incidence of iron-deficiency anemia after menarche mandates the performance of a hematocrit annually in young women with moderate to heavy menses. The reference standard for this test changes with progression of puberty, as estrogen suppresses erythropoietin (Chapter 440). Populations with nutritional risk should also have the hematocrit monitored. Androgens have the opposite effect, causing the hematocrit to rise during male puberty; Sexual Maturity Rating 1 males (Chapter 104) have an average hematocrit of 39%, whereas those who have completed puberty (Sexual Maturity Rating 5; Chapter 104) have an average value of 43%. Tuberculosis testing on an annual basis is important in adolescents with risk factors, such as an adolescent with HIV, living in the household with someone with HIV, the incarcerated adolescent, or those with other risk factors, because puberty has been shown to activate this disease in those not previously treated. Hepatitis C virus screening should be offered to adolescents who report risk factors, such as injection drug use, received blood products or organ donation before 1992, long-term hemodialysis, or high prevalence setting (i.e., correctional facilities or STI clinics).

Sexually active adolescents should undergo screening for STIs regardless of symptoms (Chapter 114). There are clear indications for chlamydia and gonorrhea screening of females 25 yr old and younger, but less sufficient evidence to support routine screening in young men. Screening young men is a clinical option and with newer noninvasive testing. HIV screening should be discussed with those who are sexually active, especially men who have sex with men, and injection drug users. Syphilis screening is recommended for pregnant adolescents and those at increased risk of infection. For sexually active females, the guidelines for Pap smears for cervical cancer screening suggest that annual screening can be delayed safely up to 3 yr after the onset of sexual activity or age 21 yr, whichever is earlier; HPV DNA testing should not be used routinely for females 29 yr and younger since the results would not influence management.

Bibliography

ACOG Committee on Gynecological Practice. ACOG committee opinion No. 431: routine pelvic examination and cervical cytology screening. Obstet Gynecol. 2009;113:1190-1193.

Duncan PM, Duncan ED, Swanson J. Bright futures: the screening table recommendations. Pediatr Ann. 2008;37:152-158.

Myers E, Huh WK, Wright JD, et al. The current and future role of screening in the era of HPV vaccination. Gynecol Oncol. 2008;109:S31-S39.

Qaseem A, Snow V, Shekelle P, et al. Clinical Efficacy Assessment Subcommittee, American College of Physicians. Screening for HIV in health care settings: a guidance statement from the American College of Physicians and HIV Medicine Association. Ann Intern Med. 2009;150:125-131.

Williams SB, O’Connor EA, Eder M, et al. Screening for child and adolescent depression in primary care settings: a systematic evidence review for the US Preventive Services Task Force. Pediatrics. 2009;123:e716-e735.

106.3 Health Enhancement

Gale R. Burstein

Adolescence is a critical period for developing behaviors that create a strong foundation for healthy living over the full life span. Health care providers play an important role in fostering healthy behaviors among adolescents by applying principles of prevention and anticipatory guidance. Since adolescents may not utilize routine preventive health care, incorporating these services into the episodic “sick visit” optimizes comprehensive adolescent health care delivery. Offering needed immunizations at any adolescent visit will maximize protection against vaccine-preventable diseases. STI and pregnancy prevention are important issues to address with both male and female adolescents and a discussion should be integrated into all visits with sexually active adolescents. Prevention of illicit drug and alcohol use and the potential for related consequences should be reviewed. Prevention of behaviors that can lead to substantial morbidity and mortality, such as motor vehicle accidents, violence, and tobacco use, should also be discussed. All adolescents should be screened for mental health care needs and provided with appropriate care either in the primary care site or through specialty referral. Facilitating an optimal health outcome for the adolescent patient also includes supporting him or her in successfully negotiating adolescence through school, job, and personal and family relations.

Bibliography

American Academy of Pediatrics Committee on Adolescence. Achieving quality health services for adolescents. Pediatrics. 2008;121:1263-1270.

American Academy of Pediatrics Committee on Adolescence and Committee on Child Health Financing. Underinsurance of adolescents: recommendations for improved coverage of preventive, reproductive, and behavioral health care services. Pediatrics. 2009;123:191-196.

American Academy of Pediatrics Committee on Psychosocial Aspects of Child and Family. The future of pediatrics: mental health competencies for pediatric primary care. Pediatrics. 2009;124:410-421.

Broder KR, Cohn AC, Schwartz B, et al. Adolescent immunizations and other clinical preventive services: a needle and a hook? Pediatrics. 2008;121(Suppl 1):S25-S34.

English A, Ford CA. The HIPAA privacy rule and adolescents: legal questions and clinical challenges. Perspect Sex Reprod Health. 2004;36:80-86.

Fishbein DB, Broder KR, Markowitz L, et al. New, and some not-so-new, vaccines for adolescents and diseases they prevent. Pediatrics. 2008;121:S5-S14.

Ford CA, English A, Davenport AF, et al. Increasing adolescent vaccination: barriers and strategies in the context of policy, legal, and financial issues. J Adolesc Health. 2009;44:568-574.

Ford CA, English A, Sigman G. Confidential healthcare for adolescents: a position paper for the Society for Adolescent Medicine. J Adolesc Health. 2004;35:1-8.

Hagan JFJr, Shaw JS, Duncan P, editors. Bright futures: guidelines for health supervision of infants, children, and adolescents, ed 3, Elk Grove Village, IL: American Academy of Pediatrics, 2008.

Kreipe RE. Introduction to interviewing: the art of communication with adolescents. Adolesc Med. 2008;10:1-17.

Mulye TP, Park MJ, Nelson CD, et al. Trends in adolescent and young adult health in the United States. J Adolesc Health. 2009;45:8-24.

Society for Adolescent Medicine. Access to health care for adolescents and young adults: position paper of the Society for Adolescent Medicine. J Adolesc Health. 2004;35:342-344.

U.S. Preventive Services Task Force. Guide to Clinical Preventive Services, 2008. Recommendations of the U.S. Preventive Services Task Force. (AHRQ Publication No. 08-05122) (website) www.ahrq.gov/clinic/pocketgd.htm Accessed April 16, 2010

106.4 Transitioning to Adult Care

Barbara Cromer

Transition to adult care is a crucial aspect of the health of all adolescents. The transition is especially important for those young people with chronic medical conditions. Delayed transition or transfer to an inappropriate adult health service may result in disrupted care, nonadherence to treatment, and adverse health outcomes. With improved survival into adulthood among children with complex medical conditions resulting from improved technology and medical therapy, there has been increasing focus on designing effective programs for optimizing the transition process to adult care.

Many obstacles exist that may challenge this transition. The adolescent may feel overwhelmed with the prospect of self-managing his or her condition. He or she may have difficulty giving up the trusted relationship with the pediatric health care provider. Second, the families may feel that the adolescent is incapable of caring for himself or herself independently. They also may view the new health service as impersonal or incompetent as well as feel threatened by losing control of caring for their child’s health. For the pediatric provider, he or she may experience some of the same separation issues as the patients and families. From the adult provider perspective, concerns may include intimidation regarding the complexity of the case and a tendency to embark on extensive clinical testing that may be disconcerting to the patient and family. Last, there is always the threat of loss of insurance coverage in the transition to adult care.

Given such potentially daunting obstacles, several models have been developed, although largely untested, that describe key elements to the transition process (Table 106-5). Most authors suggest an early start sometime during mid-adolescence although this timeframe should be flexible depending on the developmental stage of the patient. One person, usually the primary care provider, should take the lead for working with the patient and family on drawing up the transition plan. Optimally the plan should be written down and revised periodically with input from all key parties. One of the key aspects of the transition process is skills training for the adolescent in communication, self-advocacy, and self-care. Also important is support for transition to the adult world beyond health care that includes attention to the educational, psychosocial, and vocational needs of the patient. Crucial for effective communication with the adult service is a comprehensive and portable medical summary of the patient’s condition and treatment. Last, as mentioned earlier, it is crucial to ensure continuity of care by ensuring uninterrupted insurance coverage. The ultimate goal is to help these young people maximize their potential as their transition to adulthood.

Table 106-5 KEY ELEMENTS OF TRANSITIONAL CARE

An early start—When children enter a pediatric service, they should know when the can expect to leave it.

A key worker for each individual

A written transition policy between pediatric and adult services

A flexible policy on timing of events

Skills training in communication, decision making, creative problem solving, assertiveness, self care, self determination, and self advocacy

An education program for patient and parent which addresses medical, psychosocial, and educational/vocation aspects of care.

A written individualized healthcare transition plan in place by age 14 yr, created with the young person and family, with regular review and update

Administrative support, including provision of a medical summary that is portable and accessible

Affordable continuous health insurance coverage (if appropriate) throughout adolescence and adulthood

Adapted from McDonagh JE, Viner RM: Lost in transition? Between paediatric and adult services, BMJ 332:435–436, 2006.

Bibliography