Middle School Visit

Case: A mother brings her 12 y/o daughter in to clinic to have school forms filled out. The mother also states that concerns about her daughter’s performance in school and the new group of friends her daughter has been hanging out with.

Adolescence is a pivotal developmental period – pediatricians must play role in preventative and health-promoting services. Usually considered a period of good health; however, this time period also is accompanied by dramatic physical, cognitive, social and emotional changes that present opportunities and challenges for the adolescent, their families, health professionals and the community.

Challenges can result in physical, emotional and social morbidities –the opportunity to see adolescents, no matter the underlying reason (school forms, sports physicals, common ailments, etc), should be used to address these issues

Remember that early adolescents are concrete thinkers who live in the present. They often do no understand that what is now done may affect their future. This concrete thinking makes these visits more challenging when issues arise.

AAP Bright Futures Priorities- Early Adolescents:  Address parental & adolescent concerns  Physical Growth  Social & academic competence  Emotional well being  Risk Reduction  Violence & injury prevention

IMPORTANT FEATURES OF THE HISTORY:

Some social concerns specific to adolescence:  High-risk behaviors - alcohol, tobacco, drug use, and sexual behaviors (see below)  Mental health concerns - eating disorders and depression (see below)  Education concerns - learning disabilities and school dropout  Family issues - abuse and neglect  Nutrition - poor diet and inadequate physical activity  Leading causes of death - unintentional injuries, homicide and suicide  Confidentiality in a 12+ y/o - the interview should take place in two parts, one with both the patient and guardian in the room and the other with the patient alone.

What is GAPS that appears on our EPSDT forms? AKA: Guidelines for Adolescent Preventative Services 24 recommendations that encompass health care delivery, health guidance, screening and immunizations See attached recommendations from the AMA

Numerous Mnemonics have been developed for screening adolescents to aid in obtaining this information. We are more familiar with HEADDSS or HEEADSSS, but also SBIRT is a quick screening tool.

SBIRT: S: Screening- 3 questions BI: Behavioral intervention R: Referral & treatment Three Questions in this order: in the last 12 months have you 1. Drank alcohol (more than a few sips)? 2. Smoke any marijuana? 3. Used anything else to get high? If positive, use CRAFT 1.Have you ever ridden in a CAR driven by someone who is “high” or had been using alcohol or drugs** 2.Do you every used alcohol or drugs to RELAX, feel better about yourself, or fit in? 3.Do you ever use alcohol or drugs while you are by yourself, or ALONE? 4.Do you FORGET things you did while using alcohol or drugs? 5.Do your FAMILY or FRIENDS ever tell you that you should cut down on your drinking or drug use? 6.Have you ever gotten into TROUBLE while you were using alcohol or drugs? Behavioral intervention: Level 1 (neg screen): Congratulate Level 2 (+screen, CRAFFT neg): Advise to quit Level 3 (+screen, +CRAFFT): Negotiate plan Level 4 (+screen, +’s CRAFFT): Referral to Rehab **Overall evidence shows one of the best interventions for all adolescents is to advise against driving impaired or driving with someone impaired**

HEEADSSS: Below are some suggested questions, done in different formats for black/white printing Normal font = essential questions Italic= as time permits Bold = optional or when situation requires

Home ------Education and employment ------Eating ------Activities ------Drugs ------Sexuality ------Suicide and depression ------Safety

(see Heeadsss pdf attached for additional guidance)

PHYSICAL DEVELOPMENT:

During adolescence there is physical, psychological and sexual growth – including the appearance of secondary sexual characteristics and the ability to reproduce. While the events of puberty occur in a predictable sequence, the timing and velocity of changes is variable. Girls:  Thelarche = the development of breast buds o 85% of girls begin puberty with breast enlargement  Adrenarche = pubic hair & body odor o 15% have axillary hair as first sign  Peak height velocity o Usually occurring at time of menarche  Menarche (usually tanner stage 3-4: 9-16 y/o) o Mean time between thelarche and menarche is around 2 years o Duration of puberty is around 4.5 years o Puberty onset often occurs earlier in non-Hispanic black girls than other races

Boys:  Testicular enlargement  Penile enlargement  Adrenarche = pubic hair development & body odor  Peak growth velocity (usually tanner 4) o Nearly all boys begin puberty with testicular enlargement, followed in ~ 6 months by pubic hair & 6-12 months later by phallic enlargement. o Puberty lasts an average of 3.5 years o Puberty begins an average of 2 years later than it does in girls o Puberty onset often occurs earlier in non-Hispanic black boys than other races o Some degree of breast hypertrophy occurs (usually bilateral) in 40-65% of boys during tanner stage 2-3 due to excessive estrogen stimulation. . If <4 cm 90% will resolve within 3 years . Gynecomastia occurring in the absence of puberty may be pathologic PHYSICAL EXAM: perform all GU exams with chaperone (both same sex & opposite sex, use staff)

 Measure height, weight and calculate BMI – plot on growth chart  Check for evidence of eating disorders (extreme wt loss or gain, erosion of tooth enamel)  Sports injuries or other orthopedic problems  Dental Caries, developmental dental anomalies, etc  Acne and common dermatoses  Scoliosis or kyphosis (screen annually)  Evidence of abuse or neglect  Tattoos, piercing  For Females: external genital exam for normal development, check for condyloma/lesions, vulvovaginitis.  For Males: external genital exam for normal development, check for varicoceles, hernias, condyloma/lesions, testicular cancer. Evaluate for gynecomastia.  Complete physical exam with Tanner Staging (Sexual Maturity Rating) Pubic hair (both male and female) Tanner I: no pubic hair at all (prepubertal state) [typically age 10 and younger] Tanner II: small amount of long, downy hair with slight pigmentation at the base of the penis and scrotum (males) or on the labia majora (females) [10–11.5] Tanner III : hair becomes more coarse and curly, and begins to extend laterally [11.5– 13] Tanner IV: adult-like hair quality, extending across pubis but sparing medial thighs [13– 15] Tanner V: hair extends to medial surface of the thighs [15+]

Male Genitals: Tanner I: prepubertal (testicular volume less than 1.5 ml; small penis of 3 cm or less) [typically age 9 and younger] Tanner II: testicular volume between 1.6 and 6 ml; skin on scrotum thins, reddens and enlarges; penis length unchanged [9-11] Tanner III: testicular volume between 6 and 12 ml; scrotum enlarges further; penis begins to lengthen to about 6 cm [11-12.5] Tanner IV: testicular volume between 12 and 20 ml; scrotum enlarges further and darkens; penis increases in length to 10 cm and circumference [12.5-14] Tanner V: testicular volume greater than 20 ml; adult scrotum and penis of 15 cm in length [14+]

Female Breast: Tanner I: no glandular tissue: areola follows the skin contours of the chest (prepubertal) [typically age 10 and younger] Tanner II: breast bud forms, with small area of surrounding glandular tissue; areola begins to widen [10-11.5] Tanner III: breast begins to become more elevated, and extends beyond the borders of the areola, which continues to widen but remains in contour with surrounding breast [11.5-13] Tanner IV: increased breast size and elevation; areola and papilla form a secondary mound projecting from the contour of the surrounding breast [13-15] Tanner V: breast reaches final adult size; areola returns to contour of the surrounding breast, with a projecting central papilla. [15+]

SCREENING:  Vision – objective measure at age 12, 15 & 18. Other ages assess annually  Hearing –assess annually  Anemia – screen at risk adolescents, assess annually  Hyperlipidemia – assess risk and screen as needed  BP – annually  TB (via PPD) – if meets any risk criteria (exposure, XRay or clinical findings, immigration for high prevalence area, residence/travel in high prevalence area, IVDU, homelessness, h/o incarceration in pt or family member, HIV infection in pt or cohabitant, employment or volunteer work in health care setting)  STI’s: see attached CDC 2010 recommendations for more information o Chlamydia: Screen sexually active adolescents . Females: annually <25 y/o . Males: annually in areas with high prevalence o Gonorrhea: screen sexually active adolescents . Females: annually if at risk (previous infection, other STD’s, new or multiple partners, inconsistent condom use, commercial sex work, drug use) o Discuss & encourage screening for HIV in sexually active adolescents or injection drug users o No further recommendations for screening asymptomatic adolescents for syphilis, trichomoniasis, BV, HSV, HPV, and HAV/HBV. Recommended in young men who have sex with men & pregnant adolescent females.  USPSTF & ACOG recommend cervical cancer screening with pap beginning at 21. IMMUNIZATIONS:  TdaP booster (11 y/o)  Menactra (11 y/o), Menactra booster (16 y/o)  HPV vaccine with female/male patients  +/- Flu (depending on time of the year)  Varicella #2 ANTICIPATORY GUIDANCE: -Promote Healthy and Safe Habits -Adequate sleep (8-9 hrs/night), regular physical activity, limit TV, computer and video games -Parents should model and encourage healthy eating habits -Injury Prevention: Seat belts while riding in cars, helmets while biking, skateboarding, riding on motorcycles or ATVs, learn to swim -Do not drink alcohol, especially when swimming, boating, riding a bike, etc -Limit time in sun and apply sunscreen before going outside -Do not carry weapons of any kind, unload weapons kept in the house and keep locked and out of reach of children -Oral Health: Pt should brush teeth twice a day and floss daily, oral health appts should be made every 6 months -Promoting Social Competence: Children should be praised for efforts and accomplishments -Parents should encourage their child to read and develop hobbies -Promote interaction and friendship with peers through social activities, community groups and team sports -Encourage developing the ability to withstand peer pressure

Back to the Case:  Even a visit for school forms to be filled out gives an opportunity to address many issues facing the adolescent population as well as their guardians.  The key to these visits is to ensure both the patient and their guardian are comfortable with the format and understand the confidentiality issues. This allows the adolescent to grow to trust the physician and feel comfortable opening up and getting the care they need.  Some physicians recommend reminding patients and guardians about the change in the structure of the 12+ y/o visits prior so when the patient turns 12 it isn’t a shock to the patient & guardian.

Additional Resources for Health Care Providers- The CDC Division of Adolescent and School Health Web site: http://www.cdc.gov/HealthyYouth/index.htm

USPSTF Preventive Health Guidelines Web site: http://www.ahrq.gov/clinic/prevenix.htm

AMA Guidelines for Adolescent Preventive Services Web site: http://www.ama- assn.org/ama/pub/category/1980.html

The Society for Adolescent Medicine Web site: http://www.adolescenthealth.org Telephone: 816-224-8010

References: 1. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents - http://www.brightfutures.org/bf2/pdf/pdf/AD.pdf. 2. Stephens, Mark B. Preventive Health Counseling for Adolescents. American Family Physician. http://www.aafp.org/afp/20061001/1151.html 3. Goldenring JM, Rosen DS. Getting into adolescent heads: An essential update. Contemporary Pediatrics: 2004. 4. Grossman, Kate. Middle School Visit. http://pediatrics.uchicago.edu/chiefs/ClinicCurriculum/documents/MiddleSchoolVisit2.p df 5. Kliegman, RM et al. Nelson Textbook of Pediatrics 18th edition. Philadelphia: WB Saunders Company, 2007.