Adolescent-Friendly Health Services Objectives Identify three key barriers to health care access faced by adolescents. Describe three elements of adolescent-friendly health services. Utilize the HEEADSSS model of patient interviewing. When Do Adolescents Seek Sexual and Reproductive Health (SRH) Services? The average teen waits ? months after becoming
sexually active to make her first family planning visit. The pregnancy test is an admission of unprotected sexual activity and an indication of the need for appropriate reproductive counseling.* Guttmacher Institute (2000). Adolescents For the most part, adolescents are: Healthy Resilient Independent yet vulnerable Adolescents are not:
Big children Little adults Peer dependent Egocentric The Culture of Adolescence Distinct language and dress Popular culture influence Ongoing search for identity
Why Focus on Adolescent Health? Reduce death and disease, now and for the rest of their lives Fulfill the rights of adolescents to health care, especially reproductive health care Increase the chances for healthy adulthood Changes during adolescence are shaped by Race/Ethnicity
Adolescence in Context Religion Socioeconomic Status Family Peers Early Stages of Adolescence: 11-14 Growth spurt Begin sexual maturation Increased interest in sexual anatomy Anxieties and questions about
size of genitals begins Self-exploration and evaluation Middle Stages of Adolescence: 15-17 Stronger sense of identity Relates more strongly to peer group More reflective thought Transitioning between dependence and independence Late Stages of Adolescence: 18+ The body fills out and takes its
adult form Distinct identity; ideas and opinions become more settled Focus on intimacy and formation of stable relationships Plans for future and commitments External Barriers to Care Perceived lack of confidentiality and restrictions (parental consent/notification) Poor communication by providers
Insensitive attitudes of care providers Lack of provider knowledge and skills Lack of money, insurance, and transportation Inaccessible locations and/or limited services Limited office hours AdolescentFriendly Services Adolescent-specific Adequate space Multi- and interdisciplinary
Confidential Accessible Flexible scheduling Financially affordable Comprehensive services Adolescent-focused materials on display Continuity of care
Peer educator component Help transitioning into the adult medical care system Preparing for Clinical Visits Case Discussion Michelle is a 15-year-old woman who has come to your clinic with her mother complaining of an ear infection. Her mother requests to
remain in the room for the exam. Do you allow Michelles mother to stay? Rationale for Confidentiality Confidentiality in Adolescent Health Care Clinically Essential Developmentally Expected Supported by Expert
Consensus Confidentiality: Parental Perspective Parents are not the enemy. Parents are experiencing their own adjustment to their childs adolescence. Providers have an opportunity to educate parents about the need for confidentiality in the providerpatient encounter. Discuss Confidentiality in Advance Inform parents about the confidentiality policy up
front before a visit. Send a letter home: Detail when parent will or will not be included in the clinical visit. Discuss billing issues (e.g., routine STI testing, etc.). Display materials discussing importance of doctor/patient confidentiality. Our Policy on Confidentiality Our discussions with you are private. We hope that you feel free to talk openly with us about yourself and your health. Information is not shared with other people unless we are concerned that someone is in danger.
Sample statement developed by URMC Department of Pediatrics Develop Referral Network Social worker Nutritionist Psychologist or counselor Abortion, adoption, and prenatal care services STD clinics Department of Health clinics Case 1
You have recently accepted a new position as practitioner at a pediatric office. The clinic sees a small population of adolescents but wishes to expand its efforts with this population. What are some initial steps that you take to ensure that your office is adolescent friendly? The Clinical Interview H: Home E: Education/Employment E: Eating Comprehensive
HEEADSSS A: Activities D: Drugs S: Sexuality S: Suicide/depression S: Safety *Additional questions: Strengths, Spirituality Klein DA, Goldenring JM & Adelman WP. Contemporary Pediatrics. 2014. S: Strengths/Spirituality H: Home E: Education/Employment E: Eating
SHEEADSSS A: Activities D: Drugs S: Sexuality S: Suicide/depression S: Safety Klein DA, Goldenring JM & Adelman WP. Contemporary Pediatrics. 2014. Strengths-Based Approach Identify strengths early and praise Look for examples of past difficulties that your patient has successfully overcome Use reflective listening and pause
Create a comfortable, trusting, nonjudgmental setting Share your concerns Spirituality* How do your beliefs influence your health and attitudes about sex and contraception? How important are your spiritual beliefs in your day-to-day life? How often do you participate in religious activities? What do you consider to be your religion?
Home Where do you live and who lives there with you? What are relationships like at home? Home Can you talk to anyone at home about stress? Who? What are the rules like at home? Is there a gun in your home? Ever been homeless or in shelter care? Ever been in foster care or group home? Education and
Employment Education Tell me about school. Do you feel connected to your school? Do you feel as if you belong? How many days have you missed in the past year and what was the reason? Have you ever had any educational setbacks? Why? Have there been any recent school changes? What are your educational and life goals? Employment Are you working? Where? How much? What type of work do you do?
How many hours a week? Do you help to pay for things at home? What are your future career interests? Do you have any home chores? Allowance? Eating Case 2 A 15-year-old female patient comes to your office. You notice that she has gained a bit of weight. When you ask her to stand on the scale, she begins to cry.
What questions do you ask her regarding her health and body weight? How do you approach the subject sensitively? Eating Does your weight or body shape cause you any stress? If so, tell me about it. Have there been any recent changes in your weight? Have you dieted in the past year? How? How often? What do you like and not like about your body? Tell me about your exercise routine.
Whats your diet like? Do you think your diet is healthy or unhealthy? If healthy/unhealthy, whats good or bad about it? Diet/Weight How do you feel about your current weight? Do you worry that you weigh too much or too little? Depending on response to above. . .could ask more eating disorder questions, for which there are several validated questionnaires
Obesity in US High School Students Percent 100 80 60 40 20 13.9 16.8 10.8 13.0 15.2 14.5 12.7
0 National Youth Risk Behavior Survey, 2015 16.8 16.4 12.4 100 US High School Students Who Are Overweight Title
US High School Students: Trying to Lose Weight Title 80 60.6 60 44.3 45.7 45.7 47.3 45.6 40
31.4 20 0 National Youth Risk Behavior Survey, 2015 53.1 39.4 44.1 Activities What do you like to do for physical activity? How
much do you do in a week? Do you feel youre getting enough physical activity to be healthy? Activities How do you like to spend your free time? Hobbies, clubs, religious/spiritual activities? Do you play any sports? How many hours of television/computer per day? Per week? US High School Students: 100 Physically Active at least 60 min/day on 5+days
Title 80 60 40 57.8 53.7 48.6 50.2
39.1 20 0 National Youth Risk Behavior Survey, 2015 46.5 43.5 52.7 43.5 43.4 US High School Students: 100
Played at least 1 Sport Title 80 60 57.6 63.0 62.2 53.0 59.2 57.0 40
20 0 National Youth Risk Behavior Survey, 2015 50.8 62.4 57.6 48.5 US High School Students: 100
Played Video/Computer Games/Computer 3+Hours/day Title 80 60 40 41.7 40.6 42.8 45.4 43.4
Drugs and Alcohol Does anyone you hang out with smoke, drink, or use drugs? How frequently and how much? Do you use tobacco? Do you use electronic cigarettes? Do you drink alcohol? What kind: beer, wine, hard liquor? Any blackouts? Ever pass out? Vomit? CRAFFT Questions: Identify Problem Use Have you ever ridden in a Car driven by someone who
was high or had been using alcohol or drugs? Do you ever use alcohol or drugs to Relax, feel better about yourself, or fit in? Do you ever use drugs or alcohol when you are Alone? Do you Forget things while using drugs or alcohol? Do your family or Friends ever tell you that you should cut down on your drinking or drug use? Have you ever gotten into Trouble while using drugs or alcohol? Copyright Children's Hospital Boston. All rights reserved 100 US High School Students:
Currently Drink Alcohol Title 80 60 40 32.8 38.0 32.2 33.5 23.4 29.0
20 0 National Youth Risk Behavior Survey, 2015 42.4 34.4 35.2 23.8 US High School Students: Drank 5+more Alcoholic Drinks in a Row 11.0% - 13.9% 14.0% - 15.4%
15.5% - 17.0% 17.1% - 20.7% No Data State Youth Risk Behavior Surveys, 2015 100 US High School Students: Currently use Marijuana Title 80 60
US High School Students: Ever Used Cocaine 3.4% - 4.4% 4.5% - 4.8% 4.9% - 6.1% 6.2% - 9.2% No Data State Youth Risk Behavior Surveys, 2015 Sexuality Sexuality
Have you ever been in a romantic relationship? Tell me about the people that youve dated. Have any of your relationships ever been sexual relationships (such as involving kissing or touching)? Are you attracted to anyone now? Are you interested in boys? Girls? Both? Not yet sure? Sexual Behavior Questions There are many ways of being sexual or intimate with another person: kissing, hugging, touching, having oral sex, anal sex, or vaginal sex. Have you ever had any of these
experiences? Which ones? With males, females, both or other genders? What kind of protection did you use at last sex? Condoms? Pills? Something else? 100 US High School Students: Ever Had Sex Title 80
58.1 60 40 41.2 43.2 49.6 39.2 35.7 24.1
20 0 National Youth Risk Behavior Survey, 2015 48.5 42.5 39.9 100 US High School Students: Currently Having Sex Title
80 60 46.0 40 20 30.1 35.5 30.3 29.8 25.5 15.7
0 National Youth Risk Behavior Survey, 2015 33.1 30.3 30.3 US High School Students: Contraceptive Use YRBS Question
US Percentage of students who used a condom at last sex 56.9% Percentage of students who used birth control pills at last sex 18.2% Percentage of students who used Depo-Provera, NuvaRing, Implanon, or any IUD before last sex
8.6% Suicide and Depression Leading Causes of Death Among Persons Aged 10 24 Years in the United States, 2014 17% Deaths Among Young People From Suicide Motor Vehicle
Crashes 23% Other  Homicide 14% MMWR / June Other Unintentional Injuries 10, 17%
2016 / Vol. 65 / No. 6 Suicide 17% Do you feel stressed or anxious more than usual? Do you feel sad or down more than usual? Suicide and Depression Have you ever received counseling and/or therapy?
Are you having trouble getting to sleep? Tell me about a time when you felt sad while using social media sites like Facebook. Have you ever thought of hurting yourself or someone else? US High School Students: Felt Sad or Hopeless 100 Title 80 60
Have you ever been forced to have sex or been touched in a way against your will? Sexual and Physical Abuse By whom and is this still going on? Who did you tell? How does it affect your day-to-day life? In what ways does that experience affect your sexual
relationships now? Has anyone ever hurt you on a repeated basis? At home, in school, or in your neighborhood? Interpersonal Violence includes Child abuse Battering Domestic violence Partner violence School, peer, community violence Sexual harassment Sexual abuse Sexual assault Hate crime
US High School Students: Ever Physically Forced to Have Sex 100 Title 80 60 40 20 6.7 3.1
10.3 5.6 5.9 7.6 7.6 0 National Youth Risk Behavior Survey, 2015 7.3 7.0 6.0 US High School Students: 100 Experienced Physical Dating Violence Title
80 60 40 20 9.6 7.4 11.7 8.1 9.6 10.1 10.5 0
National Youth Risk Behavior Survey, 2015 10.5 9.7 9.0 100 US High School Students: Experienced Sexual Dating Violence Title 80 60 40 20
10.6 15.6 5.4 10.8 11.8 10.3 9.2 0 National Youth Risk Behavior Survey, 2015 10.0 10.6 10.1 Have you ever been seriously injured? (How?)
How about anyone else you know? Do you always wear a seatbelt in the car? Safety When was the last time you sent a text message while driving? Tell me about a time when you have ridden with a driver who was drunk or high. When? How often? 23% Deaths Among Young People From Car Crashes
MMWR / June 10, 2016 / Vol. 65 / No. 6 US High School Students: Rode with a Driver Drinking Alcohol 100 Title 80 60 40 20 20.0
US High School Students: Texted or E-Mailed while Driving Title 80 61.4 60 40 41.5 47.9
42.4 40.4 25.0 20 45.2 32.8 35.8 15.9 0 National Youth Risk Behavior Survey, 2015 Wrap Up
Emphasize that your approach is nonjudgmental and that you welcome future visits Im here for you, and I want you to feel comfortable confiding in me. If you have something personal to talk about, Ill try to give you my best advice and answer your questions AMAZE: online sex education resource Resources http://amaze.org/ CDC Youth Risk Behavior Surveillance System
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