Screening and Counseling Adolescents and Young Adults: A Framework for Comprehensive Care

 

Am Fam Physician. 2020 Feb 1;101(3):147-158.

Author disclosure: No relevant financial affiliations.

Healthy development is likely to occur when an adolescent's risk factors are limited and when protective factors are fostered. Healthy development is further encouraged when youth feel valued, empowered, and form healthy social connections. Threats to the well-being of adolescents typically result from experimentation and psychosocial stressors. SSHADESS (strengths, school, home, activities, drugs, emotions/eating, sexuality, safety) is a mnemonic to facilitate collection of psychosocial history of critical life dimensions emphasizing strengths within a youth's life experience instead of solely focusing on risks, which in isolation can provoke feelings of shame. Because adolescents are more likely to access health care and share sensitive information when confidentiality is assured, clinicians should regularly offer confidential screening and counseling. When limited for time, a brief psychosocial screen may include current stressors, availability of a confidant, and school or work experience as a proxy for well-being. Clinicians should provide education to prevent initiation of tobacco use. Long-acting reversible contraceptives are safe and effective in adolescents and should be offered as first-line options to prevent pregnancy. Sexually active females 24 years or younger should be screened for gonorrhea and chlamydia annually. Adolescents 12 years or older should be screened for major depressive disorder when systems are available to ensure accurate diagnosis, treatment, and follow-up. Adolescents with body mass index at the 95th percentile or higher should be referred for comprehensive behavioral interventions. Seatbelt use and avoidance of distracted or impaired driving should be discussed. Clinicians should discuss digital literacy and appropriate online boundary setting and display of personal information.

Adolescence, the life stage between childhood and adulthood, encompasses the physical, cognitive, and emotional changes of puberty resulting in maturity.1 For this reason, we use adolescence to refer to an expanded age range inclusive of what may be traditionally defined as young adulthood (e.g., 10 to 24 years) to reflect the complex biologic growth and social role transitions that occur during this period.1 Through exploration, an adolescent's thinking progresses from concrete to abstract with greater ability to appreciate consequences and independently seek advice with maturity.1,2 Threats to the well-being of adolescents typically result from experimentation and psychosocial stressors.35

WHAT'S NEW ON THIS TOPIC

Adolescents are more likely to access health care, have a more favorable attitude about their clinicians, and share sensitive information when confidentiality is assured. However, approximately 60% do not get time alone with their clinician for confidential discussion despite patient and parental preferences.

In the United States, 95% of youth 13 to 17 years of age report smartphone access, and almost 50% report nearly constant use.

Approximately one-half of new sexually transmitted infections occur in people 15 to 24 years of age. Rates of chlamydia, gonorrhea, and syphilis infections among adolescents increased from 2012 to 2016.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComment

Confidential screening and counseling should be offered to adolescents regularly,including care related to sexuality, substance use, and mental health services, according to local state laws.5,8,1315,17

C

Expert opinion

Education and/or brief counseling should be provided to adolescents to prevent initiation of, or stop, tobacco use.11

C

Consensus guidelines based on meta-analyses of randomized trials with disease-oriented outcomes

Long-acting reversible contraceptives are safe and effective in adolescents and should be offered as first-line options to prevent pregnancy.47,48

B

Consensus guidelines based on observational studies

Clinicians should annually screen for gonorrhea and chlamydia in sexually active females 24 years or younger.11,54

A

Consensus guidelines based on meta-analyses of randomized trials

Adolescents should be screened for obesity using body mass index percentile and referred to comprehensive, intensive behavioral interventions to treat obesity.11,57

C

Consensus guidelines based on meta-analyses of randomized trials with disease-oriented outcomes

Adolescents 12 to 18 years of age and adults should be screened for major depressive disorder when systems are in place to ensure accurate diagnosis, treatment, and follow-up.11,60,61

C

Consensus guidelines based on meta-analyses of randomized trials with disease-oriented outcomes

Adolescents should be encouraged to wear seatbelts, to adhere to graduated driver's licensing laws (e.g., nighttime, passenger restrictions), and to avoid distracted or impaired driving.70

B

Consensus guidelines based on observational studies


A = consistent,

The Authors

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DAVID A. KLEIN, MD, MPH, is the Chief of Medical Staff, 11th Medical Group, Joint Base Anacostia-Bolling, Washington, DC. He is an associate professor in the Department of Family Medicine at the Uniformed Services University of the Health Sciences, Bethesda, Md....

SCOTT L. PARADISE, MD, is a sports medicine fellow at Naval Hospital, Camp Pendleton, Calif.

CORINNE A. LANDIS, MD, is a family physician at Naval Hospital, Guam.

Address correspondence to David A. Klein, MD, MPH, Fort Belvoir Community Hospital, 9300 Dewitt Loop, Fort Belvoir, VA 22060 (email: david.a.klein26.mil@mail.mil). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

References

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1. Sawyer SM, Azzopardi PS, Wickremarathne D, et al. The age of adolescence. Lancet Child Adolesc Health. 2018;2(3):223–228....

2. Ham P, Allen C. Adolescent health screening and counseling. Am Fam Physician. 2012;86(12):1109–1116. Accessed July 17, 2019. https://www.aafp.org/afp/2012/1215/p1109.html

3. Cunningham RM, Walton MA, Carter PM. The major causes of death in children and adolescents in the United States. N Engl J Med. 2018;379(25):2468–2475.

4. Kann L, McManus T, Harris WA, et al. Youth risk behavior surveillance—United States, 2017. MMWR Surveill Summ. 2018;67(8):1–114.

5. Klein DA, Goldenring JM, Adelman WP. HEEADSSS 3.0: the psychosocial interview for adolescents updated for a new century fueled by media; January 1, 2014. Accessed August 13, 2019. https://bit.ly/33Sx9Tc

6. Eaton DK, Kann L, Kinchen S, et al. Youth risk behavior surveillance—United States, 2007. MMWR Surveill Summ. 2008;57(4):1–131.

7. Division of Adolescent and School Health, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention. Youth risk behavior survey. Accessed September 18, 2019. https://www.cdc.gov/healthyyouth/data/yrbs/pdf/trendsreport.pdf

8. Ginsburg KR, Kinsman SB, eds. Reaching Teens: Strength-Based Communication Strategies to Build Resilience and Support Healthy Adolescent Development. American Academy of Pediatrics; 2014.

9. Nordin JD, Solberg LI, Parker ED. Adolescent primary care visit patterns. Ann Fam Med. 2010;8(6):511–516.

10. Park E, Kwon M. Health-related internet use by children and adolescents: systematic review. J Med Internet Res. 2018;20(4):e120.

11. U.S. Preventive Services Task Force. Published recommendations. Accessed May 17, 2019. https://www.uspreventiveservicestaskforce.org/BrowseRec/Index?age=Pediatric,Adolescent

12. Levy SJ, Williams JF; Committee on Substance Use and Prevention. Substance use screening, brief intervention, and referral to treatment. Pediatrics. 2016;138(1):e20161211.

13. Santelli JS, Klein JD, Song X, et al. Discussion of potentially sensitive topics with young people. Pediatrics. 2019;143(2):e20181403.

14. Grilo SA, Catallozzi M, Santelli JS, et al. Confidentiality discussions and private time with a health-care provider for youth, United States, 2016. J Adolesc Health. 2019;64(3):311–318.

15. Ford CA, Millstein SG, Halpern-Felsher BL, et al. Influence of physician confidentiality assurances on adolescents' willingness to disclose information and seek future health care. JAMA. 1997;278(12):1029–1034.

16. Song X, Klein JD, Yan H, et al. Parent and adolescent attitudes towards preventive care and confidentiality. J Adolesc Health. 2019;64(2):235–241.

17. American Academy of Family Physicians. Adolescent health care, confidentiality. Accessed May 17, 2019. http://www.aafp.org/about/policies/all/adolescent-confidentiality.html

18. Society for Adolescent Health and Medicine; American Academy of Pediatrics. Confidentiality protections for adolescents and young adults in the health care billing and insurance claims process. J Adolesc Health. 2016;58(3):374–377.

19. Marting R. Protecting adolescent patient privacy: four key questions. Fam Pract Manag. 2019;26(1):7–10. Accessed August 13, 2019. https://www.aafp.org/fpm/2019/0100/p7.html

20. American Academy of Family Physicians. Adolescent and young adult health. Accessed August 28, 2019. https://www.aafp.org/patient-care/public-health/adolescent-young-adult.html

21. Fergus S, Zimmerman MA. Adolescent resilience: a framework for understanding healthy development in the face of risk. Annu Rev Public Health. 2005;26:399–419.

22. Resnick MD, Bearman PS, Blum RW, et al. Protecting adolescents from harm. Findings from the National Longitudinal Study on Adolescent Health. JAMA. 1997;278(10):823–832.

23. Chang S, Lee TH. Beyond evidence-based medicine. N Engl J Med. 2018;379(21):1983–1985.

24. Harris SK, Aalsma MC, Weitzman ER, et al. Research on clinical preventive services for adolescents and young adults: where are we and where do we need to go? J Adolesc Health. 2017;60(3):249–260.

25. Hawton K, O'Grady J, Osborn M, et al. Adolescents who take overdoses. Br J Psychiatry. 1982;140:118–123.

26. Anderson M, Jiang J. Teens, social media and technology 2018. May 31, 2018. Accessed May 17, 2019. http://www.pewinternet.org/2018/05/31/teens-technology-methodology/

27. Reid Chassiakos YL, Radesky J, Christakis D, et al.; Council on Communications and Media. Children and adolescents and digital media. Pediatrics. 2016;138(5):e20162593.

28. Clark DL, Raphael JL, McGuire AL. HEADS4: social media screening in adolescent primary care. Pediatrics. 2018;141(6):e20173655.

29. Boers E, Afzali MH, Newton N, et al. Association of screen time and depression in adolescence. JAMA Pediatr. 2019;173(9):853–859.

30. U.S. Department of Health and Human Services. Physical activity guidelines for Americans, 2nd edition; 2018. Accessed May 17, 2019. https://health.gov/paguidelines/second-edition/pdf/Physical_Activity_Guidelines_2nd_edition.pdf

31. Ryan SA, Ammerman SD; Committee on Substance Use and Prevention. Counseling parents and teens about marijuana use in the era of legalization of marijuana. Pediatrics. 2017;139(3):e20164069.

32. Mitchell SG, Kelly SM, Gryczynski J, et al. The CRAFFT cut-points and DSM-5 criteria for alcohol and other drugs. Subst Abus. 2014;35(4):376–380.

33. U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress. A Report of the Surgeon General. 2014. Accessed May 17, 2019. https://www.ncbi.nlm.nih.gov/books/NBK179276/pdf/Bookshelf_NBK179276.pdf

34. Miech R, Johnston L, O'Malley PM, et al. Adolescent vaping and nicotine use in 2017–2018—U.S. national estimates. N Engl J Med. 2019;380(2):192–193.

35. Barrington-Trimis JL, Kong G, Leventhal AM, et al. E-cigarette use and subsequent smoking frequency among adolescents. Pediatrics. 2018;142(6):e20180486.

36. Audrain-McGovern J, Stone MD, Barrington-Trimis J, et al. Adolescent e-cigarette, hookah, and conventional cigarette use and subsequent marijuana use. Pediatrics. 2018;142(3):e20173616.

37. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. E-Cigarette use among youth and young adults. A report of the Surgeon General. 2016. Accessed September 18, 2019. https://e-cigarettes.surgeongeneral.gov/documents/2016_sgr_full_report_non-508.pdf

38. Fanshawe TR, Halliwell W, Lindson N, et al. Tobacco cessation interventions for young people. Cochrane Database Syst Rev. 2017;(11):CD003289.

39. Kaner EF, Beyer FR, Muirhead C, et al. Effectiveness of brief alcohol interventions in primary care populations. Cochrane Database Syst Rev. 2018;(2):CD004148.

40. Gobbi G, Atkin T, Zytynski T, et al. Association of cannabis use in adolescence and risk of depression, anxiety, and suicidality in young adulthood. JAMA Psychiatry. 2019;76(4):426–434.

41. Miech R, Johnston L, O'Malley PM, et al. Prescription opioids in adolescence and future opioid misuse. Pediatrics. 2015;136(5):e1169–e1177.

42. Committee on Substance Use and Prevention. Medication-assisted treatment of adolescents with opioid use disorders. Pediatrics. 2016;138(3):e20161893.

43. Seifert SM, Schaechter JL, Hershorin ER, et al. Health effects of energy drinks on children, adolescents, and young adults [published correction appears in Pediatrics2016;137(5):e20160454]. Pediatrics. 2011;127(3):511–528.

44. Kulak JA, Griswold KS. Adolescent substance use and misuse. Am Fam Physician. 2019;99(11):689–696. Accessed August 12, 2019. https://www.aafp.org/afp/2019/0601/p689.html

45. Leftwich HK, Alves MV. Adolescent pregnancy. Pediatr Clin North Am. 2017;64(2):381–388.

46. Lindberg LD, Santelli JS, Desai S. Changing patterns of contraceptive use and the decline in rates of pregnancy and birth among U.S. adolescents, 2007–2014. J Adolesc Health. 2018;63(2):253–256.

47. ACOG Committee Opinion No. 735: adolescents and long-acting reversible contraception. Obstet Gynecol. 2018;131(5):e130–e139.

48. Diedrich JT, Klein DA, Peipert JF. Long-acting reversible contraception in adolescents. Am J Obstet Gynecol. 2017;216(4):364.e1–364.e12.

49. Goodman M, Onwumere O, Milam L, et al. Reducing health disparities by removing cost, access, and knowledge barriers. Am J Obstet Gynecol. 2017;216(4):382.e1–382.e5.

50. Algur E, Wang E, Friedman HS, et al. A systematic global review of condom availability programs in high schools. J Adolesc Health. 2019;64(3):292–304.

51. Secura GM, Adams T, Buckel CM, et al. Change in sexual behavior with provision of no-cost contraception. Obstet Gynecol. 2014;123(4):771–776.

52. Committee Opinion No. 651: menstruation in girls and adolescents: using the menstrual cycle as a vital sign. Obstet Gynecol. 2015;126(6):e143–e146.

53. Centers for Disease Control and Prevention; National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention. Sexually transmitted disease surveillance 2017. Accessed May 17, 2019. https://www.cdc.gov/std/stats17/2017-STD-Surveillance-Report_CDC-clearance-9.10.18.pdf

54. Marcell AV, Burstein GR; Committee on Adolescence. Sexual and reproductive health care services in the pediatric setting. Pediatrics. 2017;140(5):e20172858.

55. Skinner AC, Ravanbakht SN, Skelton JA, et al. Prevalence of obesity and severe obesity in US children, 1999–2016 [published correction appears in Pediatrics. 2018;142(3):e20181916]. Pediatrics. 2018;141(3):e20173459.

56. Styne DM, Arslanian SA, Connor EL, et al. Pediatric obesity-assessment, treatment, and prevention: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2017;102(3):709–757.

57. Militello LK, Kelly S, Melnyk BM, et al. A review of systematic reviews targeting the prevention and treatment of overweight and obesity in adolescent populations. J Adolesc Health. 2018;63(6):675–687.

58. Locke A, Schneiderhan J, Zick SM. Diets for health: goals and guidelines. Am Fam Physician. 2018;97(11):721–728. Accessed August 13, 2019. https://www.aafp.org/afp/2018/0601/p721.html

59. Society for Adolescent Health and Medicine, Golden NH, Katzman DK, Sawyer SM, et al. Position paper of the Society for Adolescent Health and Medicine: medical management of restrictive eating disorders in adolescents and young adults. J Adolesc Health. 2015;56(1):121–125.

60. U.S. Preventive Services Task Force. Final recommendation statement: depression in children and adolescents: screening. Accessed May 17, 2019. https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/depression-in-children-and-adolescents-screening1

61. U.S. Preventive Services Task Force. Depression in adults: screening. Accessed May 17, 2019. https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/depression-in-adults-screening1?ds=1&s=depression

62. Patient Health Questionnaire (PHQ) Screeners. Accessed August 8, 2019. http://www.phqscreeners.com

63. Zuckerbrot RA, Cheung A, Jensen PS, et al.; GLAD-PC Steering Group. Guidelines for adolescent depression in primary care (GLAD-PC): part I. Practice preparation, identification, assessment, and initial management. Pediatrics. 2018;141(3):e20174081.

64. Richardson LP, Rockhill C, Russo JE, et al. Evaluation of the PHQ-2 as a brief screen for detecting major depression among adolescents. Pediatrics. 2010;125(5):e1097–e1103.

65. Richardson LP, McCauley E, Grossman DC, et al. Evaluation of the Patient Health Questionnaire-9 item for detecting major depression among adolescents. Pediatrics. 2010;126(6):1117–1123.

66. Olfson M, Wall M, Wang S, et al. Suicide after deliberate self-harm in adolescents and young adults. Pediatrics. 2018;141(4):e20173517.

67. Cheung AH, Zuckerbrot RA, Jensen PS, et al.; GLAD-PC STEERING GROUP. Guidelines for adolescent depression in primary care (GLAD-PC): part II. Treatment and ongoing management. Pediatrics. 2018;141(3):e20174082.

68. March J, Silva S, Petrycki S, et al. Fluoxetine, cognitive-behavioral therapy, and their combination for adolescents with depression: Treatment for Adolescents With Depression Study (TADS) randomized controlled trial. JAMA. 2004;292(7):807–820.

69. Selph SS, McDonagh MS. Depression in children and adolescents. Am Fam Physician. 2019;100(10):609–617. Accessed December 4, 2019. https://www.aafp.org/afp/2019/1115/p609.html

70. Alderman EM, Johnston BD; Committee on Adolescence; Council on Injury, Violence, and Poison Prevention. The teen driver. Pediatrics. 2018;142(4):e20182163.

71. Bryan MA, Rowhani-Rahbar A, Comstock RD, et al.; Seattle Sports Concussion Research Collaborative. Sports- and recreation-related concussions in US youth. Pediatrics. 2016;138(1):e20154635.

72. McCrory P, Meeuwisse W, Dvořák J, et al. Consensus statement on concussion in sport—the 5th International Conference on Concussion in Sport held in Berlin, October 2016. Br J Sports Med. 2017;51(11):838–847.

73. David-Ferdon C, Vivolo-Kantor AM, Dahlberg LL, et al.; Division of Violence Prevention; National Center for Injury Prevention and Control; Centers for Disease Control and Prevention. A comprehensive technical package for the prevention of youth violence and associated risk behaviors; 2016. Accessed May 17, 2019. https://www.cdc.gov/violenceprevention/pdf/yv-technicalpackage.pdf

74. Grossman DC, Mueller BA, Riedy C, et al. Gun storage practices and risk of youth suicide and unintentional firearm injuries. JAMA. 2005;293(6):707–714.

75. Stephens MB. Preventive health counseling for adolescents. Am Fam Physician. 2006;74(7):1151–1156. Accessed August 5, 2019. https://www.aafp.org/afp/2006/1001/p1151.html

76. Montalto NJ. Implementing the guidelines for adolescent preventive services. Am Fam Physician. 1998;57(9):2181–2188. Accessed July 17, 2019. https://www.aafp.org/afp/1998/0501/p2181.html

 

 

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