Introduction
The American Academy of Pediatrics (AAP) developed the primary care medical home as a model of delivering primary care with the goal of addressing and integrating high-quality health promotion, acute care, and chronic condition management in a planned, coordinated, and family-centered manner. Children and adolescents may receive primary care by pediatric health care providers in a variety of settings, including hospital-based ambulatory clinics, neighborhood health centers, or school-based health centers, among other examples. It is important for pediatric and adolescent gynecology (PAG) providers to be familiar with components of well-care and preventive care for children and adolescents. 
Health services should be developmentally appropriate, inclusive, and culturally sensitive. Certified medical interpreters should be used to communicate clearly with the patient and/or parent/guardian in their preferred language if the provider is not already fluent in that language.
Guidelines for preventive care
Bright Futures is a national health promotion and prevention initiative led by the AAP and supported, in part, by the U.S. Department of Health and Human Services, Health Resources and Service Administration, Maternal and Child Health Bureau. The Bright Future Guidelines provide theory-based and evidence-driven guidance for preventive-care screenings and health supervision visits for newborns through age 21 years. The AAP/Bright Futures website ( https://www.aap.org/brightfutures ) has a compendium of useful resources for clinical practice, including a pictorial guide of specific screening recommendations by age, “Recommendations for Preventative Pediatric Health Care,” which can be printed and displayed for reference in the clinical setting ( https://downloads.aap.org/AAP/PDF/periodicity_schedule.pdf ). These recommendations contain links for additional information, evidence-based guidelines, and validated screening and assessment tools.
For adolescents, the goals of these guidelines are to (1) deter adolescents from participating in behaviors that jeopardize health; (2) detect physical, emotional, and behavioral problems early and intervene promptly; (3) reinforce and encourage behaviors that promote healthful living; and (4) provide immunization against infectious diseases. The Guidelines recommend that adolescents between ages 11 and 21 years have annual routine health visits. Table 1.1 lists recommendations for universal screening and selective screening after risk factor assessments at these visits.
| Universal | Selective | |
|---|---|---|
| Anemia | Screen all nonpregnant women every 5–10 y, starting in adolescence with HgB and/or HCT | Obtain HgB and/or HCT annually at minimum with ≥1 RF for anemia (diet low in iron-rich foods, history of iron deficiency anemia, excessive menstrual bleeding, poverty, food insecurities) annually |
| Depression | Screen youth ≥11 y annually with Patient Health Questionnaire-9 (PHQ9) tool: https://www.phqscreeners.com | |
| Dyslipidemia | Nonfasting lipid panel once between age 9 and 11 y and once between ages 11 and 17 y | Fasting lipid panel once ages 12–16 y if ≥1 RF in parent, grandparent, aunt/uncle, or sibling of myocardial infarction, angina, stroke, coronary artery bypass graft/stent/angioplasty, sudden cardiac death in males <55 y, females <65 y |
| Hypertension | Measure BP annually age ≥3 y for patients with normal BMI | Measure BP at every health care encounter for patients age ≥3 y if obese, have renal disease, a history of aortic arch obstruction or coarctation, or diabetes and/or take medication to manage high BP |
| Obesity |
| |
| Substance use | Screen youth ≥11 y annually with CRAFFT 2.1+N tool: https://crafft.org | |
| Tobacco use | Screen youth ≥11 y annually with CRAFFT 2.1+N tool: https://crafft.org | |
| Tuberculosis | Assess RF for TB infection annually with questionnaire: contact with people with confirmed or suspected contagious TB, radiographic or clinical findings suggesting TB, immigration (including international adoptees) from countries with endemic infection, history of significant travel to countries with endemic infection, current HIV infection; with ≥1 RF, administer TB skin test or interferon-gamma release assay |
Relating to the adolescent patient
Adolescence is one of the physically healthiest periods in life. Providers who care for adolescents need to be aware of cognitive, emotional, and psychosocial changes that influence adolescents’ health behaviors. Each teenager is a unique individual; however, there are common developmental stages, feelings, and behaviors that many youth experience during adolescence. Adolescence is a dynamic time, and the brain continues to develop throughout adolescence into young adulthood, allowing youth to develop insight, judgement, and maturity as they navigate adolescence. See Table 1.2 for components of adolescent psychological development.
| Middle School and Early High School Years | Late High School Years and Beyond | |
|---|---|---|
| Movement toward independence |
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| Future interests and cognitive changes |
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| Sexuality |
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| Morals, values, and self-direction |
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The majority of time during a routine health visit is devoted to screening and providing anticipatory guidance with a nonjudgmental, patient-centered focus. It can be helpful to have the patient complete a confidential health questionnaire before starting the visit. This can include questions about health concerns, updates of active health issues, medications, allergies, and changes in family history since the last routine health visit. The questionnaire may also include questions pertaining to risk behaviors and screening for depression (see later). There should be clear instructions for the young person to complete the questionnaire independently from an accompanying parent/guardian to ensure confidentiality about sensitive topics. There is evidence that youth may share health concerns and report risk behaviors more readily with a questionnaire format versus verbally to their provider. Care must be taken to ensure that electronic questionnaire data are protected in the electronic medical record for minors.
Confidentiality
Confidentiality is an essential component of health care for adolescents. For more than 25 years, national medical organizations have supported the need to provide confidential care for adolescents, including the AAP, the Society for Adolescent Health and Medicine (SAHM), the American Academy of Family Practice, the American College of Obstetricians and Gynecologists (ACOG), and the North American Society for Pediatric and Adolescent Gynecology. Adolescents are more likely to disclose sensitive information, have positive perceptions of care, feel more actively involved in their own health care, and return for future care if providers assure confidentiality.
An important aspect of providing confidential health care for minor adolescents is having awareness of federal and state laws that govern a minor’s ability to consent for medical treatment without consent from a parent or guardian. This is particularly relevant for PAG practices that provide sexual and reproductive health care for minors. The Guttmacher Institute is a leading research and policy organization committed to advancing sexual and reproductive health and rights (SRHR) worldwide ( https://www.guttmacher.org ). It has a robust website detailing high-quality research and statistics, evidence-based advocacy, and regularly updated federal and state policies pertaining to SRHR topics, including an overview of individual state minor consent laws.
The patient interview
Effective interviewing and counseling skills, characterized by respect, compassion, and a nonjudgmental attitude toward all patients, are essential to obtaining a thorough history and delivering effective prevention and health education messages. The AAP and SAHM recommend that providers have some time alone with their patients during visits starting in early adolescence to convey to the teenagers and their parents/guardians that this is a standard part of adolescent health care. This also provides an opportunity for the provider to develop an open and trusting relationship with the young person and support the adolescent’s individualization and developing autonomy. It is helpful to address confidentiality at the beginning of the clinical encounter and remind the adolescent that sensitive issues are discussed because they are important for health and to assure them that what you talk about is confidential, unless the behavior is life-threatening.
Obtaining a psychosocial history
The HEADSS assessment
The major causes of morbidity and mortality for adolescents are associated with risk behaviors , including alcohol and substance use, violence, sexual activity, and the existence of undiagnosed and untreated behavioral health problems. In addition to using a questionnaire, health care providers who see adolescents must be able to take a developmentally appropriate psychosocial history. The HEADSS (Home, Education/employment, Activities, Drugs, Sexuality, and Suicide/depression) assessment acronym is useful for organizing this history ( Table 1.3 ). The sensitive aspects of the history should be obtained with the adolescent alone , and providers may need to be flexible with history taking to allow for this to happen after the parent/guardian leaves the examination room. Many questions can be asked in each area of the HEADSS assessment , and providers should determine which questions are most relevant to the patient population they care for. Providers in pediatric and gynecology clinics may consider using a tailored HEADSS assessment for their encounters. The adolescent’s responses to the HEADSS questions may reveal what is going well in their life while also identifying risk behaviors that they may be engaged in. The provider can praise and encourage the positive behaviors and provide education, intervention , and/or treatment as needed for the unhealthy behaviors.
| Questions | Rationale | |
|---|---|---|
| Home and environment |
| Home life has an important impact on an adolescent’s ability to succeed. It is important to know whether they live in a safe and supportive environment. |
| Education and employment |
| School is likely the primary social activity in the adolescent’s life. Problems in school, academically or socially, can be an indicator of other issues. Future goals and plans can be important motivators in high-risk behavior change. |
| Activities |
| Disengagement and withdrawal can be a sign of other problems. |
| Drugs | Many young people experiment with marijuana, drugs, smoking cigarettes, or drinking alcohol. Have you or your friends ever tried them? What did you try? How often do you use these things? Do you ever operate a vehicle under the influence of drugs or alcohol or ride with an impaired driver? | Positive answers can lead to diagnoses of nicotine and/or substance use disorders and need for intervention and treatment. |
| Sexuality/relationships | Are you in a romantic relationship or have you been in one in the past? Tell me about your partner. Do you feel you have a healthy relationship? How do you define a healthy relationship? How do you identify your gender? How do you identify your sexuality? How do you define sex? Have you had sex? How do you feel about it? Have you ever been forced to have sex when you didn’t want to? | It is important to normalize sexual feelings even in the absence of sexual activity. Teens not having sex can still have conversations about sexuality, including masturbation. It is also important to avoid assumptions about patients’ sexual orientation and to be nonjudgmental about sexual practices. |
| Suicide/depression |
| Responses may reveal indicators of depression and/or suicidal ideation. |
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