Adolescent preventive counseling

Last updated: Jun 17, 2016

Contents

Introduction

This monograph presents a list of preventive service recommendations for the practitioner to consider when evaluating the individual adolescent. Adolescence (ages 11 to 21 years) is a time of relative health, with a low incidence of serious medical problems. Medical issues that arise during adolescence are more likely to be related to behavior and environmental factors than to organic disease. Many individuals establish lifelong habits during adolescence, so it is a critical time for health providers to invest in preventive services and screening in order to promote health. Preventive services are a mainstay of primary care for infants and children but are provided sporadically for adolescents, with physicians often avoiding sensitive issues. [1]

Resources for adolescent preventive services recommendations

In response to the need for improved preventive care for adolescents, many organizations provide evidence-based and expert consensus health recommendations for adolescent preventive services in the US. These include:

  • US Preventive Services Task Force (USPSTF) [2]

  • Guidelines for adolescent preventive services (GAPS) from the AMA [3]

  • The American Academy of Family Physicians' recommended clinical preventive services [4]

  • The Bright Futures (BF) guidelines from the Maternal and Child Health Bureau of the Health Resources and Services Administration and the Medicaid Bureau of the Health Care Financing Administration [5]

  • Guidelines for health supervision from the American Academy of Pediatrics (AAP). The AAP now collaborates with BF and updated recommendations for preventive adolescent health care are issued jointly through the AAP. [5]

While the organizations differ in their specific recommendations, [6] they all support the immunization schedule of the Advisory Committee on Immunization Practices (ACIP) [7] and all advocate health guidance for teens, although there is variability in the specific recommendations for screening. [8] Most organizations recommend annual visits and health guidance for parents. Where recommendations differ significantly among the groups, comment is provided on the differences.

Most adolescent preventive health recommendations in the US are the result of a formal process. Individual organizations, often through their scientific advisory panels (typically comprised of national experts, collaborating primary care medical organizations, and representatives from the health insurance industry), develop recommendations based on scientific evidence, where available. More commonly, expert opinion dictates the periodicity and content of preventive services. The USPSTF is a notable exception. As a strictly evidence-based panel, its recommendations are limited to those with research-generated evidence of either benefit or harm. As a result, most of their preventive service recommendations are in the evidence-based category of insufficient evidence to make a recommendation. Hence, there are multiple areas for future research within adolescent preventive health services.

Sexual maturity rating scale

While predictable in sequence, the changes of sexual maturation are highly variable and do not correlate well with chronologic age. Tanner developed a sexual maturity scale that is useful for assessing the degree of sexual maturation in the adolescent. [9]

/best-practice/images/bp/en-us/881-2-iline_default.gifTanner sexual maturity scaleAdapted from Tanner, JM. Growth at adolescence 2nd Edition. Oxford, England: Blackwell Scientific Publications; 1962

Health guidance for parents

A parent health guidance visit is recommended during early and middle adolescence, with an additional late adolescent visit considered optimal. [3] [4] [5] The physician should provide information about the following topics:

  • Normal adolescent physical, sexual, and emotional development

  • Parenting behaviors that promote healthy adolescent development

  • Signs and symptoms of disease and emotional distress

  • Importance of family connectedness, including family-based activities

  • Adult role modeling of appropriate behavior: avoidance of tobacco, responsible alcohol consumption, use of seat belts, not drinking alcohol and driving

  • Avoiding weapons in the home: if weapons are kept in the home, they should not be accessible to adolescents without supervision

  • Need for removal of weapons and potentially lethal medications from the household if adolescents show depression or suicidal tendency.

Early adolescence (ages 11-14 years; junior high/middle school; sexual maturity rating 1-4)

Early adolescence marks the start of the transition from childhood to adulthood. The early adolescent asserts greater independence, while looking to parents as a guide. Body image comes to the forefront during this stage as puberty begins. Intense same-sex friendships form and the role of peers gains increased prominence. Identity formation progresses as early adolescents ask themselves: am I normal? They develop increased self-interest and marked egocentrism. Thinking is concrete, with little or no capability for abstract thought; the early adolescent tends to understand instructions literally.

The early adolescent healthcare visit should include private time with the adolescent along with education of the parent or guardian as to the importance of this time. This activity allows the physician to build a relationship as the patient's advocate while the early adolescent gains exposure to greater independence during the medical visit. However, discussion with a parent or guardian is mandatory for reliable information about medical history, observations of behavior, and factors motivating the office visit. Common medical problems in the early adolescent include acne, overuse and unintentional injuries, and disorders of body image in females. [1]

A parent health guidance visit is recommended during early adolescence. [3] [4] [5] Information that should be provided is covered in the section on "Health guidance for parents".

Early adolescence (ages 11-14 years) healthcare visit: males

Annual history screening

  • Home environment: family and school connectedness is associated with protection against several health risk behaviors in this age group, including early sexual debut, substance use, depression, and suicide attempts. [10] [11] [B Evidence]

  • School performance: repeating a grade is associated with emotional distress; parental expectations for positive school achievement predicts a lower level of health risk behaviors. [10] [11] [B Evidence]

  • Tobacco use: grade repetition is associated with tobacco use in this age group. [10] [11] There is evidence that counseling interventions (increased cessation and abstinence rates) are beneficial for smokers in the age group. [12] [13] [14] [A Evidence]

  • Alcohol and other drug use: the American Academy of Pediatrics (AAP) committee on substance abuse recommends discussion of substance abuse as a part of routine health care for all children and adolescents. In addition, the AAP encourages physicians dealing with this population to be knowledgeable about: identifying those at risk for substance use; the physical, psychological, and social consequences of alcohol and other substance use; and assessing, intervening, and treating those with identified substance use. [15] [16] [17] [18] [19] [20] [21] [C Evidence]

  • Disordered eating behavior and body image: the AAP committee on adolescence recommends that primary care clinicians dealing with this patient population develop the knowledge and skills to provide early detection, initial evaluation, and ongoing management (in conjunction with specialist care, as necessary) of patients with disordered eating. [22]

  • Sexual activity: the physician should establish if the young adolescent is sexually active. If so, additional questioning may address: voluntary versus coerced participation in sexual activities; nature of sexual partners (sex, age); number of partners; and use of condoms and other contraception.

  • Physical, emotional, and sexual abuse: The physician should create a safe, confidential clinical environment for the adolescent in order to allow discussion of sensitive personal issues and to uncover potential situations of abuse. Appropriate reporting and referral to relevant mental health services may then follow. [1] [23] [C Evidence]

  • Depression and risk for suicide: USPSTF recommends screening of adolescents 12 to 18 years of age for major depressive disorder (MDD) when systems are in place to ensure accurate diagnosis, psychotherapy (cognitive-behavioral or interpersonal), and follow-up. [24] Integrated medical-behavioral care shows significant advantage for integrated care interventions relative to usual care on behavioral health outcomes. [25] The AAP recommends screening all adolescents for depression and identifying risk factors for suicide. The AAP encourages physicians working with these patients to ask questions about depression, suicidal thoughts, and other risk factors associated with suicide (such as the presence of firearms in the household) in routine history-taking throughout adolescence. [26] [C Evidence]

  • Determine adolescent strengths: this activity allows identification of potential sources of resilience for the adolescent. [5]

Physical assessment

The AAP and Bright Futures (BF) recommend annual full physical examinations. [5] The AMA's guidelines for adolescent preventive services recommend annual preventive medicine visits with at least 1 full physical examination in each stage of adolescence: early (11-14 years of age), middle (15-17), and late (18-21). [3]

  • Blood pressure: annually; if >95th percentile, then full physical exam. [3]

  • Height, weight, and BMI: annually; USPSTF recommends screening children age 6 years and older for obesity and offering them or referring them to comprehensive, intensive behavioral interventions to promote improvement in weight status. [27] [28] [29] [30] [31]

  • Full physical exam or early adolescent focused exam [5]

    • Skin exam: particular attention given to acne and nevi, which are characteristic skin findings in this age group, with the body surveyed for any suspicious or atypical skin lesions. USPSTF concluded that evidence is insufficient to assess balance of benefits and harms of a primary care skin examination for early detection of skin cancer in adults. [32] There are no current recommendations relating to skin examination in adolescents.

    • Spine: examine back: Although the USPSTF recommends against screening of asymptomatic adolescents for scoliosis, clinicians should be prepared to evaluate idiopathic scoliosis when it is discovered incidentally or when the adolescent or parent expresses concern about scoliosis. If scoliosis screening is undertaken it is recommended that adolescent males be screened at age 13 or 14 years. [33] [C Evidence]

    • Male breast: observe for gynecomastia.

    • Genitalia: visual inspection for sexual maturity rating and signs of STIs. Explaining the nature and purposes of examinations can help lower the patient's anxiety level. [34] View image

    • Testicular exam: for hydrocele, hernias, varicocele, or masses. [34]

Recommended tests

  • Cholesterol: while the USPSTF does not recommend for or against such testing, the AAP recommends universal screening of adolescents for high cholesterol at least once between the ages of 9 and 11 and again between the ages of 17 and 21 years. [35] In addition, screening should occur among those with a FHx of high cholesterol or heart disease as well as those whose FHx is unknown or who have other factors for heart disease (obesity, HTN, diabetes). The recommended method for testing is a fasting lipid profile. If a child has values within the normal range, testing should be repeated in 3 to 5 years. For those with high LDL concentrations, cholesterol-reducing medications should be considered. [36] [C Evidence]

  • Screening for STIs (gonorrhea, chlamydia, visual genital inspection) in sexually active adolescents: the USPSTF states that evidence in support of screening this population for gonorrhea and chlamydia is inconclusive. [2] The AAP and BF recommend screening for both diseases in this population, with specific attention on adolescent males with previous STIs, new or multiple sexual partners, inconsistent condom use, or exchanging of sex for money or drugs. [5] [C Evidence]

  • HIV screen: well supported by evidence in adolescents with known risk factors, including unprotected sex with multiple partners, use of injection drugs, sex work, history of sex partners who are HIV-positive or bisexual, and history of STIs. The CDC's revised guidelines (September 2006) recommend that all individuals between 13 and 64 years of age be screened for HIV regardless of risk factors, but the USPSTF reviewed the information available in November 2006 and reaffirmed its conclusion that there is insufficient evidence to recommend HIV screening for those without known risk factors. [3] [37] [A Evidence]

  • Syphilis screen: well supported by evidence in adolescents with known risk factors. Those at risk include male adolescents who have sex with men and engage in high-risk sexual behavior, commercial sex workers, adolescents who exchange sex for drugs, and those in correctional facilities. The prevalence of syphilis in the US varies widely by region and ethnicity, so clinicians should consider the characteristics of the communities they serve in determining appropriate screening strategies. Adolescents diagnosed with other STIs (e.g., chlamydia, gonorrhea, genital herpes simplex, human papillomavirus, and HIV) may be more likely to engage in high-risk behavior, placing them at increased risk for syphilis. [2] [A Evidence]

  • Hematocrit or hemoglobin if at risk: adolescents with previously documented iron-deficiency anemia or with markedly abnormal nutritional habits should be tested. [3] [5]

  • TB screen if at risk: the USPSTF defers to CDC guidance. The CDC, the American Thoracic Society, the Infectious Diseases Society of America, as well as the AAP, the AMA's guidelines for adolescent preventive services (GAPS), and BF, recommend screening at-risk patients for TB with an intradermal test. [3] [5] Risk factors include: exposure to active TB; current or recent residence in a homeless shelter; current or recent incarceration; residence in a high-prevalence area; and HIV infection. [38]

  • Vision screening: recommended once in early adolescence. Elements of this screen include: ocular history; external inspection of the eyes and lids; ocular motility assessment; pupil examination; age-appropriate visual acuity measurement; and an attempt at ophthalmoscopy. [39]

  • Hearing screening: some states require a formal hearing screen during adolescence.

Immunizations [7]

  • At 11 or 12 years: tetanus and diphtheria toxoids and acellular pertussis vaccine (TdaP), and meningococcal vaccine (MCV4). May catch up at 13 to 18 years.

  • Offer HPV-4 immunization (recommended for boys and men age 9-26 years).

Catch-up immunizations [7]

  • Hepatitis B series.

  • Inactivated poliovirus vaccine (IPV) series.

  • Measles, mumps, and rubella vaccine (MMR) series.

  • Varicella series.

  • Hepatitis A series catch-up at 11 or 12 years.

Health guidance for early adolescents [3] [4] [5]

When offering this guidance, physicians should:

  • Praise the adolescent's strengths [5]

  • Provide education about normal physical, psychosocial, and psychosexual development [1]

  • Encourage an active involvement in healthcare decision-making

  • Review safety and injury prevention, including use of seat belts, [C Evidence] not riding in a car with a driver under the influence of alcohol or other drugs, [C Evidence] proper use of helmets for cycles and skateboards, appropriate use of athletic safety equipment, nonviolent conflict resolution with avoidance of weapons use, and promotion of weapons safety for any recreational uses

  • Strongly advise avoidance of tobacco, alcohol, and other drugs. The AAP encourages physicians to be knowledgeable about the health and safety hazards of these substances and to be able to provide objective information to adolescents [15] [21]

  • Provide basic education about good nutrition and dietary habits, including the consequences of excessive weight and obesity (impaired glucose tolerance, insulin resistance, elevated blood lipids, steatohepatitis, increased BP, and disturbed sleep with possible sleep apnea)

  • Encourage regular involvement in physical activity and conditioning [C Evidence]

  • Provide basic education about good dental health practices [40]

  • Provide education about safe sexual practices, including abstinence, and avoidance of STI transmission. [41] Brief, office-based counseling for adolescents and young adults results in decreased incidence of STIs. [42] [43] [44] [B Evidence] The USPSTF recommends behavioral counseling for all sexually active adolescents to prevent STIs. [45] Appropriate methods of birth control should be available to sexually active teens, with education on correct use [46] [47]

  • Address the issue of sexual orientation if concerns are raised by the adolescent. This should be approached in a confidential setting with the provision of current factual information in a nonjudgmental manner. [48]

Early adolescence (ages 11-14 years) healthcare visit: females

Annual history screening

  • Home environment: family and school connectedness is associated with protection against several health risk behaviors in this age group, including early sexual debut, substance use, depression, and suicide attempts. [10] [11] [B Evidence]

  • School performance: repeating a grade is associated with emotional distress; parental expectations for positive school achievement predicts a lower level of health risk behaviors. [10] [11] [B Evidence]

  • Tobacco use: grade repetition is associated with tobacco use in this age group. [10] [11] There is evidence that counseling interventions (increased cessation and abstinence rates) are beneficial for smokers in the age group. [12] [13] [14] [A Evidence]

  • Alcohol and other drug use: the American Academy of Pediatrics (AAP) committee on substance abuse recommends discussion of substance abuse as a part of routine health care for all children and adolescents. In addition, the AAP encourages physicians dealing with this population to be knowledgeable about: identifying those at risk for substance use; the physical, psychological, and social consequences of alcohol and other substance use; and assessing, intervening, and treating those with identified substance use. [15] [16] [17] [18] [19] [20] [21] [C Evidence]

  • Disordered eating behavior and body image: the AAP committee on adolescence recommends that primary care clinicians dealing with this patient population develop the knowledge and skills to provide early detection, initial evaluation, and ongoing management (in conjunction with specialist care, as necessary) of patients with disordered eating. [22]

  • Sexual activity: the physician should establish if the young adolescent is sexually active. If so, additional questioning may address: voluntary versus coerced participation in sexual activities; nature of sexual partners (sex, age); number of partners; and use of condoms and other contraception.

  • Physical, emotional, and sexual abuse: The physician should create a safe, confidential clinical environment for the adolescent in order to allow discussion of sensitive personal issues and to uncover potential situations of abuse. Appropriate reporting and referral to relevant mental health services may then follow. [1] [23] [C Evidence]

  • Depression and risk for suicide: USPSTF recommends screening of adolescents 12 to 18 years of age for major depressive disorder (MDD) when systems are in place to ensure accurate diagnosis, psychotherapy (cognitive-behavioral or interpersonal), and follow-up. [24] Integrated medical-behavioral care shows significant advantage for integrated care interventions relative to usual care on behavioral health outcomes. [25] The AAP recommends screening all adolescents for depression and identifying risk factors for suicide. The AAP encourages physicians working with these patients to ask questions about depression, suicidal thoughts, and other risk factors associated with suicide (such as the presence of firearms in the household) in routine history-taking throughout adolescence. [26] [C Evidence]

  • Determine adolescent strengths: this activity allows identification of potential sources of resilience for the adolescent. [5]

Physical assessment

The AAP and Bright Futures (BF) recommend annual full physical examinations. [5] The AMA's guidelines for adolescent preventive services recommend annual preventive medicine visits with at least 1 full physical examination in each stage of adolescence: early (11-14 years of age), middle (15-17), and late (18-21). [3]

  • Blood pressure: annually; if >95th percentile, then full physical exam. [3]

  • Height, weight, and BMI: annually; USPSTF recommends screening children age 6 years and older for obesity and offering them, or referring them, to comprehensive, intensive behavioral interventions to promote improvement in weight status. [27] [28] [29] [30] [31]

  • Last menstrual period: it is important for physicians dealing with this age group to educate young patients and their parents about what to expect of a first menstrual period and the range for normal cycle length of subsequent menses. Physicians should understand bleeding patterns in adolescents and be able to differentiate between normal and abnormal menstruation. [49]

  • Full physical exam or early adolescent focused exam [5]

    • Skin exam: particular attention given to acne and nevi, which are characteristic skin findings in this age group, with the body surveyed for any suspicious or atypical skin lesions. USPSTF concluded that evidence is insufficient to assess balance of benefits and harms of a primary care skin examination for early detection of skin cancer in adults. [32] There are no current recommendations relating to skin examination in adolescents.

    • Spine: examine back. Although the USPSTF recommends against screening of asymptomatic adolescents for scoliosis, clinicians should be prepared to evaluate idiopathic scoliosis when it is discovered incidentally or when the adolescent or parent expresses concern about scoliosis. If scoliosis screening is undertaken, it is recommended that adolescent females be screened at age 12 years. [33] [C Evidence]

    • Breast exam: visual inspection for sexual maturity (Tanner) rating.View image

    • Genitalia: visual inspection for sexual maturity rating and signs of STIs. Explaining the nature and purpose of examinations can help lower the patient's anxiety level.View image

    • Pelvic exam: if clinically warranted (e.g., in those with specific problems such as abdominal or pelvic pain, pubertal concern, or abnormal bleeding). Cervical dysplasia screening (i.e., pap smear) is not indicated until age 21. [50] [51]

Recommended tests

  • Cholesterol: while the USPSTF does not recommend for or against such testing, the AAP recommends universal screening of adolescents for high cholesterol at least once between the ages of 9 and 11 and again between the ages of 17 and 21 years. [35] In addition, screening should occur among those with a FHx of high cholesterol or heart disease as well as those whose FHx is unknown or who have other factors for heart disease (obesity, HTN, diabetes). The recommended method for testing is a fasting lipid profile. If a child has values within the normal range, testing should be repeated in 3 to 5 years. For those with high LDL concentrations, cholesterol-reducing medications should be considered. [36] [C Evidence]

  • HIV screen: well supported by evidence in adolescents with known risk factors, including unprotected sex with multiple partners, use of injection drugs, sex work, history of sex partners who are HIV-positive or bisexual, and history of STIs. The CDC's revised guidelines (September 2006) recommend that all individuals between 13 and 64 years of age be screened for HIV regardless of risk factors, but the USPSTF reviewed the information available in November 2006 and reaffirmed its conclusion that there is insufficient evidence to recommend HIV screening for those without known risk factors. [3] [37] [A Evidence]

  • Syphilis screen: well supported by evidence in adolescents with known risk factors, including high-risk sexual behavior, commercial sex work, exchanging sex for drugs, and time in correctional facilities. The prevalence of syphilis in the US varies widely by region and ethnicity, so clinicians should consider the characteristics of the communities they serve in determining appropriate screening strategies. Adolescents diagnosed with other STIs (e.g., chlamydia, gonorrhea, genital herpes simplex, human papillomavirus, HIV) may be more likely to engage in high-risk behavior, placing them at increased risk for syphilis. [2] [A Evidence]

  • Hematocrit or hemoglobin if at risk: the AAP and BF recommend screening all nonpregnant women during routine health exams, starting in adolescence and continuing every 5 to 10 years throughout their childbearing years. Annual screening is recommended for those with risk factors for iron deficiency, such as extensive menstrual or other blood loss, low iron intake, or a previous diagnosis of iron-deficiency anemia. [3] [5]

  • TB screen if at risk: the USPSTF defers to CDC guidance. The CDC, the American Thoracic Society, the Infectious Diseases Society of America, as well as the AAP, the AMA's guidelines for adolescent preventive services (GAPS), and BF recommend screening at-risk patients for TB with an intradermal test. Risk factors include: exposure to active TB; current or recent residence in a homeless shelter; current or recent incarceration; residence in a high-prevalence area; and HIV infection. [3] [5] [38]

  • Vision screening: recommended once in early adolescence. Elements of this screen include: ocular history; external inspection of the eyes and lids; ocular motility assessment; pupil examination; age-appropriate visual acuity measurement; and an attempt at ophthalmoscopy. [39]

  • Hearing screening: some states require a formal hearing screen during adolescence.

  • Screening for STIs (gonorrhea, chlamydia, visual genital inspection) in sexually active adolescents: the USPSTF, the AAP, and BF recommend these screenings for early adolescents, with specific attention on females with previous STIs, new or multiple sexual partners, or inconsistent condom use, and those who exchange sex for money or drugs. [2] [5] The prevalence of chlamydia varies widely, with a higher prevalence in African-American and Hispanic women in many communities and settings. [A Evidence] [B Evidence]

  • Pregnancy screen: sexually active females without contraception, or with late menses or amenorrhea, should be screened with urine hCG. [5]

  • Cervical dysplasia screening: cervical dysplasia screening (i.e., pap smear) is not indicated until age 21. [50]

Immunizations [7]

  • At 11 or 12 years: tetanus and diphtheria toxoids and acellular pertussis vaccine (TdaP), meningococcal vaccine (MCV4). May catch up at 13 to 18 years.

  • Offer HPV immunization (recommended for girls and women age 9 to 26 years).

Catch-up immunizations [7]

  • Hepatitis B series.

  • Inactivated poliovirus vaccine (IPV) series.

  • Measles, mumps, and rubella vaccine (MMR) series.

  • Varicella series.

  • Hepatitis A series for children of minimum age 12 months, with catch-up at 11 or 12 years.

Health guidance for early adolescents [3] [4] [5]

When offering this guidance physicians should:

  • Praise the adolescent's strengths [5]

  • Provide education about normal physical, psychosocial, and psychosexual development [1]

  • Encourage an active involvement in healthcare decision-making

  • Review safety and injury prevention, including use of seat belts, [C Evidence] not riding in a car with a driver under the influence of alcohol or other drugs, [C Evidence] proper use of helmets for cycles and skateboards, appropriate use of athletic safety equipment, nonviolent conflict resolution with avoidance of weapons use, and promotion of weapons safety for any recreational uses

  • Strongly advise avoidance of tobacco, alcohol, and other drugs. The AAP encourages physicians to be knowledgeable about the health and safety hazards of these substances and to be able to provide objective information to adolescents [15] [21]

  • Provide basic education about good nutrition and dietary habits, including the consequences of excessive weight and obesity (impaired glucose tolerance, insulin resistance, elevated blood lipids, steatohepatitis, increased BP, and disturbed sleep with possible sleep apnea)

  • Encourage regular involvement in physical activity and conditioning [C Evidence]

  • Provide basic education about good dental health practices [40]

  • Provide education about safe sexual practices, including abstinence, and avoidance of STI transmission. [41] Brief, office-based counseling for adolescents and young adults results in decreased incidence of STIs. [42] [43] [44] [B Evidence] The USPSTF recommends behavioral counseling for all sexually active adolescents to prevent STIs. [45] Appropriate methods of birth control should be available to sexually active teens, with education on correct use [46] [47]

  • Address the issue of sexual orientation if concerns are raised by the adolescent. This should be approached in a confidential setting with the provision of current factual information in a nonjudgmental manner. [48]

Middle adolescence (15-17 years; high school; sexual maturity rating 4-5)

During middle adolescence, the physical changes of puberty are largely complete. Increased autonomy with the increased workload of high school offers new challenges. Peer behaviors are the best predictors of risky behaviors as middle adolescence is the peak of peer group influence and conformity. Teens that have trouble during this stage usually have conflicts about control, as part of a continued struggle for freedom. Independence and self-identity continue to progress, with teens trying different behaviors in an experimentation-without-commitment manner. Most adolescents gain abstract reasoning abilities and enhanced creative thinking during this time, and they are capable of propositional (if..., then...-type) reasoning. The practitioner should spend the majority of the middle adolescent healthcare visit with the patient, facilitating discussion of sensitive issues.

A parent health guidance visit is recommended during middle adolescence. [3] [4] [5] Information that should be provided is covered in the section on "Health guidance for parents".

Common medical problems encountered in middle adolescence include: [1]

  • Sexual problems, such as disease and pregnancy concerns

  • Use of tobacco, alcohol, and other substances

  • Intentional injury, such as suicide

  • Unintentional injury, such as overuse injury and motor vehicle-related accidents.

Middle adolescence (15-17 years) healthcare visit: males

Annual history screening

  • Home environment: family, and school connectedness is associated with protection against several health risk behaviors in this age group, including early sexual debut, substance use, depression, and suicide attempts. [10] [11] [B Evidence]

  • School performance: repeating a grade is associated with emotional distress; parental expectations for positive school achievement predicts a lower level of health risk behaviors. [10] [11] [B Evidence]

  • Tobacco use: grade repetition is associated with tobacco use in this age group. [10] [11] There is evidence that counseling interventions (increased cessation and abstinence rates) are beneficial for smokers in the age group. [12] [13] [14] [A Evidence]

  • Alcohol and other drug use: the AAP committee on substance abuse recommends discussion of substance abuse as a part of routine health care for all children and adolescents. In addition, the AAP encourages physicians dealing with this population to be knowledgeable about: identifying those at risk for substance use; the physical, psychological, and social consequences of alcohol and other substance use; and assessing, intervening, and treating those with identified substance use. [15] [16] [17] [18] [19] [20] [21] [C Evidence]

  • Disordered eating behavior and body image: the AAP committee on adolescence recommends that primary care clinicians dealing with this patient population develop the knowledge and skills to provide early detection, initial evaluation, and ongoing management (in conjunction with specialist care, as necessary) of patients with disordered eating. [22]

  • Sexual activity: the physician should establish if the middle adolescent is sexually active. If so, additional questioning may address: voluntary versus coerced participation in sexual activities; nature of sexual partners (sex, age); number of partners; use of condoms and contraception; and suspected or known STIs in self or partners.

  • Physical, emotional, and sexual abuse: The physician should create a safe, confidential clinical environment for the adolescent in order to allow discussion of sensitive personal issues and to uncover potential situations of abuse. Appropriate reporting and referral to relevant mental health services may then follow. [1] [23] [C Evidence]

  • Depression and risk for suicide: USPSTF recommends screening of adolescents 12 to 18 years of age for major depressive disorder (MDD) when systems are in place to ensure accurate diagnosis, psychotherapy (cognitive-behavioral or interpersonal), and follow-up. [24] Integrated medical-behavioral care shows significant advantage for integrated care interventions relative to usual care on behavioral health outcomes. [25] The AAP recommends screening all adolescents for depression and identifying risk factors for suicide. The AAP encourages physicians working with these patients to ask questions about depression, suicidal thoughts, and other risk factors associated with suicide (such as the presence of firearms in the household) in routine history-taking throughout adolescence. [26] [C Evidence]

  • Determine adolescent strengths: this activity allows identification of potential sources of resilience for the adolescent. [5]

Physical assessment

The AAP and Bright Futures (BF) recommend annual full physical examinations. [5] The AMA's guidelines for adolescent preventive services recommend annual preventive medicine visits with at least 1 full physical examination in each stage of adolescence: early (11-14 years of age), middle (15-17), and late (18-21). [3]

  • Blood pressure: annually; if >95th percentile, then full physical exam. [3]

  • Height, weight, and BMI: annually; USPSTF recommends screening children age 6 years and older for obesity and offering them or referring them to comprehensive, intensive behavioral interventions to promote improvement in weight status. [27] [28] [29] [30] [31]

  • Full physical exam, or middle adolescent focused exam [5]

    • Skin exam: particular attention given to acne and nevi, which are characteristic skin findings in this age group, with the body surveyed for any suspicious or atypical skin lesions. USPSTF concluded that evidence is insufficient to assess balance of benefits and harms of a primary care skin examination for early detection of skin cancer in adults. [32] There are no current recommendations relating to skin examination in adolescents.

    • Spine: examine back. Although the USPSTF recommends against screening of asymptomatic adolescents for scoliosis, clinicians should be prepared to evaluate idiopathic scoliosis when it is discovered incidentally or when the adolescent or parent expresses concern about scoliosis. [33] [C Evidence]

    • Male breast: observe for gynecomastia.

    • Genitalia: visual inspection for sexual maturity rating and signs of STIs. Explaining the nature and purpose of examinations can help lower the patient's anxiety level. [34] View image

    • Testicular exam: for hydrocele, hernias, varicocele, or masses. [34]

Recommended tests

  • Cholesterol: while the USPSTF does not recommend for or against such testing, the AAP recommends universal screening of adolescents for high cholesterol at least once between the ages of 9 and 11 and again between the ages of 17 and 21 years. [35] In addition, screening should occur among those with a FHx of high cholesterol or heart disease as well as those whose FHx is unknown or who have other factors for heart disease (obesity, HTN, diabetes). The recommended method for testing is a fasting lipid profile. If a child has values within the normal range, testing should be repeated in 3 to 5 years. For those with high LDL concentrations, cholesterol-reducing medications should be considered. [36] [C Evidence]

  • Screening for STIs (gonorrhea, chlamydia, visual genital inspection) in sexually active adolescents: the USPSTF states that evidence in support of screening this population for gonorrhea and chlamydia is inconclusive. [2] The AAP and BF recommend screening for both diseases in this population, with specific attention on adolescent males with previous STIs, new or multiple sexual partners, inconsistent condom use, or exchanging of sex for money or drugs. [5] [C Evidence]

  • HIV screen: well supported by evidence in adolescents with known risk factors, including unprotected sex with multiple partners, use of injection drugs, sex work, history of sex partners who are HIV-positive or bisexual, and history of STIs. The CDC's revised guidelines (September 2006) recommend that all individuals between 13 and 64 years of age be screened for HIV regardless of risk factors, but the USPSTF reviewed the information available in November 2006 and reaffirmed its conclusion that there is insufficient evidence to recommend HIV screening for those without known risk factors. [3] [37] [A Evidence]

  • Syphilis screen: well supported by evidence in adolescents with known risk factors, including high-risk sexual behavior, commercial sex workers, adolescents who exchange sex for drugs, and those in correctional facilities. The prevalence of syphilis in the US varies widely by region and ethnicity, so clinicians should consider the characteristics of the communities they serve in determining appropriate screening strategies. Adolescents diagnosed with other STIs (e.g., chlamydia, gonorrhea, genital herpes simplex, human papillomavirus, and HIV) may be more likely to engage in high-risk behavior, placing them at increased risk for syphilis. [A Evidence]

  • TB screen, if at risk: the USPSTF defers to CDC guidance. The CDC, the American Thoracic Society, the Infectious Diseases Society of America, as well as the AAP, the AMA's guidelines for adolescent preventive services (GAPS), and BF, recommend screening at-risk patients for TB with an intradermal test. Risk factors include: exposure to active TB; current or recent residence in a homeless shelter; current or recent incarceration; residence in a high-prevalence area; and HIV infection. [3] [5] [38]

  • Vision screening. [39]

  • Hearing screening: some states require a formal hearing screen during adolescence.

Immunizations [7]

  • Offer HPV-4 immunization (recommended for boys and men age 9 to 26 years).

  • Meningococcal vaccine (MCV4) booster at age 16.

Catch-up immunizations [7]

  • Tetanus and diphtheria toxoids, and acellular pertussis vaccine (TdaP).

  • Meningococcal vaccine (MCV4).

  • Hepatitis B series.

  • Inactivated poliovirus vaccine (IPV) series.

  • Measles, mumps, and rubella vaccine (MMR) series.

  • Varicella series.

Clinical discretion immunizations [7]

  • Serogroup B meningococcal (Men B) vaccines: MenB-4c (Bexsero) or MenB-FHbp (Trumenba).

    • Adolescents and young adults ages 16 to 23 (preferred age range is 16 to 18 years) may be vaccinated with either a 2-dose series of Bexsero or a 3-dose series of Trumenba vaccine to provide short-term protection against most strains of serogroup B meningococcal disease. The two Men B vaccines are not interchangeable. The same vaccine product must be used for all doses.

Health guidance for middle adolescents [3] [4] [5]

When offering this guidance, physicians should:

  • Praise the adolescent's strengths [5]

  • Provide education about normal physical, psychosocial, and psychosexual development [1]

  • Encourage an active involvement in healthcare decision-making

  • Review safety and injury prevention, including use of seat belts, [C Evidence] not riding in a car with a driver under the influence of alcohol or other drugs, [C Evidence] proper use of helmets for cycles and skateboards, appropriate use of athletic safety equipment, nonviolent conflict resolution with avoidance of weapons use, and promotion of weapons safety for any recreational uses

  • Strongly advise avoidance of tobacco, alcohol, and other drugs. The AAP encourages physicians to be knowledgeable about the health and safety hazards of these substances, and to be able to provide objective information to adolescents [15] [21]

  • Provide basic education about good nutrition and dietary habits, including the consequences of excessive weight and obesity (impaired glucose tolerance, insulin resistance, elevated blood lipids, steatohepatitis, increased BP, and disturbed sleep with possible sleep apnea)

  • Encourage regular involvement in physical activity and conditioning [C Evidence]

  • Provide basic education about good dental health practices [40]

  • Provide education about safe sexual practices, including abstinence and avoidance of STI transmission. [41] Brief, office-based counseling for adolescents and young adults results in decreased incidence of STIs. [42] [43] [44] [B Evidence] The USPSTF recommends behavioral counseling for all sexually active adolescents to prevent STIs. [45] Appropriate methods of birth control should be available to sexually active teens, with education on correct use [46] [47]

  • Address the issue of sexual orientation if concerns are raised by the adolescent. This should be approached in a confidential setting with the provision of current factual information in a nonjudgmental manner. [48]

Middle adolescence (15-17 years) healthcare visit: females

Annual history screening

  • Home environment: family and school connectedness is associated with protection against several health risk behaviors in this age group, including early sexual debut, substance use, depression, and suicide attempts. [10] [11] [B Evidence]

  • School performance: repeating a grade is associated with emotional distress; parental expectations for positive school achievement predicts a lower level of health risk behaviors. [10] [11] [B Evidence]

  • Tobacco use: grade repetition is associated with tobacco use in this age group. [10] [11] There is evidence that counseling interventions (increased cessation and abstinence rates) are beneficial for smokers in the age group. [12] [13] [14] [A Evidence]

  • Alcohol and other drug use: the AAP committee on substance abuse recommends discussion of substance abuse as a part of routine health care for all children and adolescents. In addition, the AAP encourages physicians dealing with this population to be knowledgeable about: identifying those at risk for substance use; the physical, psychological, and social consequences of alcohol and other substance use; and assessing, intervening, and treating those with identified substance use. [15] [16] [17] [18] [19] [20] [21] [C Evidence]

  • Disordered eating behavior and body image: the AAP committee on adolescence recommends that primary care clinicians dealing with this patient population develop the knowledge and skills to provide early detection, initial evaluation, and ongoing management (in conjunction with specialist care, as necessary) of patients with disordered eating. [22]

  • Sexual activity: the physician should establish if the adolescent is sexually active. If so, additional questioning may address: voluntary versus coerced participation in sexual activities; nature of sexual partners (sex, age); number of partners; use of condoms and contraception; suspected or known STIs in self or partners; and pregnancy concerns.

  • Physical, emotional, and sexual abuse: The physician should create a safe, confidential clinical environment for the adolescent in order to allow discussion of sensitive personal issues and to uncover potential situations of abuse. Appropriate reporting and referral to relevant mental health services may then follow. [1] [23] [C Evidence]

  • Depression and risk for suicide: USPSTF recommends screening of adolescents 12 to 18 years of age for major depressive disorder (MDD) when systems are in place to ensure accurate diagnosis, psychotherapy (cognitive-behavioral or interpersonal), and follow-up. [24] Integrated medical-behavioral care shows significant advantage for integrated care interventions relative to usual care on behavioral health outcomes. [25] The AAP recommends screening all adolescents for depression and identifying risk factors for suicide. The AAP encourages physicians working with these patients to ask questions about depression, suicidal thoughts, and other risk factors associated with suicide (such as the presence of firearms in the household) in routine history-taking throughout adolescence. [26] [C Evidence]

  • Determine adolescent strengths: this activity allows identification of potential sources of resilience for the adolescent. [5]

Physical assessment

The AAP and Bright Futures (BF) recommend annual full physical examinations. [5] The AMA's guidelines for adolescent preventive services recommend annual preventive medicine visits with at least 1 full physical examination in each stage of adolescence: early (11-14 years of age), middle (15-17), and late (18-21). [3]

  • Blood pressure: annually; if >95th percentile, then full physical exam. [3]

  • Height, weight, and BMI: annually. USPSTF recommends screening children age 6 years and older for obesity and offering them or referring them to comprehensive, intensive behavioral interventions to promote improvement in weight status. [27] [28] [29] [30] [31]

  • Last menstrual period: it is important for physicians dealing with this age group to have an understanding of bleeding patterns in adolescents and be able to differentiate between normal and abnormal menstruation. [49]

  • Full physical exam, or middle adolescent focused exam [5]

    • Skin exam: particular attention given to acne and nevi, which are characteristic skin findings in this age group, with the body surveyed for any suspicious or atypical skin lesions. USPSTF concluded that evidence is insufficient to assess balance of benefits and harms of a primary care skin examination for early detection of skin cancer in adults. [32] There are no current recommendations relating to skin examination in adolescents.

    • Spine: examine back. Although the USPSTF recommends against screening of asymptomatic adolescents for scoliosis, clinicians should be prepared to evaluate idiopathic scoliosis when it is discovered incidentally or when the adolescent or parent expresses concern about scoliosis. [33] [C Evidence]

    • Breasts: visual inspection for sexual maturity (Tanner) rating.View image

    • Genitalia: visual inspection for sexual maturity rating and signs of STIs. Explaining the purposes of genitalia examination and the examinations that will be performed can help lower the patient's anxiety level.View image

    • Pelvic exam: if clinically warranted (e.g., in those with specific problems such as abdominal or pelvic pain, pubertal concern, or abnormal bleeding). Cervical dysplasia screening (i.e., pap smear) is not indicated until age 21. [50] [51]

Recommended tests

  • Cholesterol: while the USPSTF does not recommend for or against such testing, the AAP recommends universal screening of adolescents for high cholesterol at least once between the ages of 9 and 11 and again between the ages of 17 and 21 years. [35] In addition, screening should occur among those with a FHx of high cholesterol or heart disease, as well as those whose FHx is unknown or who have other factors for heart disease (obesity, HTN, diabetes). The recommended method for testing is a fasting lipid profile. If a child has values within the normal range, testing should be repeated in 3 to 5 years. For those with high LDL concentrations, cholesterol-reducing medications should be considered. [36] [C Evidence]

  • HIV screen: well supported by evidence in adolescents with known risk factors, including unprotected sex with multiple partners, use of injection drugs, sex work, history of sex partners who are HIV-positive or bisexual, and history of STIs. The CDC's revised guidelines (September 2006) recommend that all individuals between 13 and 64 years of age be screened for HIV regardless of risk factors, but the USPSTF reviewed the information available in November 2006 and reaffirmed its conclusion that there is insufficient evidence to recommend HIV screening for those without known risk factors. [3] [37] [A Evidence]

  • Syphilis screen: well supported by evidence in adolescents with known risk factors, including high-risk sexual behavior, commercial sex workers, adolescents who exchange sex for drugs, and those in correctional facilities. The prevalence of syphilis in the US varies widely by region and ethnicity, so clinicians should consider the characteristics of the communities they serve in determining appropriate screening strategies. Adolescents diagnosed with other STIs (e.g., chlamydia, gonorrhea, genital herpes simplex, human papillomavirus, and HIV) may be more likely to engage in high-risk behavior, placing them at increased risk for syphilis. [A Evidence]

  • Hematocrit or hemoglobin, if at risk: the AAP and BF recommend screening all nonpregnant women during routine health exams, starting in adolescence and continuing every 5 to 10 years throughout their childbearing years. Annual screening is recommended for those with risk factors for iron deficiency, such as extensive menstrual or other blood loss, low iron intake, or a previous diagnosis of iron-deficiency anemia. [3] [5]

  • TB screen, if at risk: the USPSTF defers to guidance provided by the Centers for Disease Control (CDC) in this matter. The CDC, American Thoracic Society, Infectious Diseases Society of America, as well as the AAP, the AMA's guidelines for adolescent preventive services (GAPS), and BF recommend screening at-risk patients for tuberculosis with an intradermal test. Risk factors include: exposure to active TB, current or recent residence in a homeless shelter, current or recent incarceration, residence in a high prevalence area, HIV-positive. [3] [5] [38]

  • Vision screening. [39]

  • Hearing screening: some states require a formal hearing screen during adolescence.

  • Screening for STIs (gonorrhea, chlamydia, visual genital inspection) in sexually active adolescents: the USPSTF, the AAP, and BF recommend these screenings for adolescents, with specific attention on females with previous STIs, new or multiple sexual partners, or inconsistent condom use, and those who exchange sex for money or drugs. [2] [5] The prevalence of chlamydia varies widely, with a higher prevalence in African-American women and Hispanic women in many communities and settings. [A Evidence] [B Evidence]

  • Pregnancy screen: sexually active females without contraception, or with late menses or amenorrhea, should be screened with urine hCG. [5]

  • Cervical dysplasia screening: cervical dysplasia screening (i.e., pap smear) is not indicated until age 21. [50]

Immunizations [7]

  • Offer HPV immunization (recommended for girls and women age 9 to 26 years).

  • Meningococcal vaccine (MCV4) booster at age 16.

Catch-up immunizations [7]

  • Tetanus and diphtheria toxoids, and acellular pertussis vaccine (TdaP).

  • Meningococcal vaccine (MCV4).

  • Hepatitis B series.

  • Inactivated poliovirus vaccine (IPV) series.

  • Measles, mumps, and rubella vaccine (MMR) series.

  • Varicella series.

Clinical discretion immunizations [7]

  • Serogroup B meningococcal (Men B) vaccines: MenB-4c (Bexsero) or MenB-FHbp (Trumenba).

    • Adolescents and young adults ages 16 to 23 (preferred age range is 16 to 18 years) may be vaccinated with either a 2-dose series of Bexsero or a 3-dose series of Trumenba vaccine to provide short-term protection against most strains of serogroup B meningococcal disease. The two Men B vaccines are not interchangeable. The same vaccine product must be used for all doses.

Health guidance for middle adolescents [3] [4] [5]

When offering this guidance the physicians should:

  • Praise the adolescent's strengths [5]

  • Provide education about normal physical, psychosocial, and psychosexual development [1]

  • Encourage an active involvement in healthcare decision-making

  • Review safety and injury prevention, including use of seat belts, [C Evidence] not riding in a car with a driver under the influence of alcohol or other drugs, [C Evidence] proper use of helmets for cycles and skateboards, appropriate use of athletic safety equipment, nonviolent conflict resolution with avoidance of weapons use, and promotion of weapons safety for any recreational uses

  • Strongly advise avoidance of tobacco, alcohol, and other drugs. The AAP encourages physicians to be knowledgeable about the health and safety hazards of these substances and to be able to provide objective information to adolescents [15] [21]

  • Provide basic education about good nutrition and dietary habits, including the consequences of excessive weight and obesity (impaired glucose tolerance, insulin resistance, elevated blood lipids, steatohepatitis, increased BP, and disturbed sleep with possible sleep apnea)

  • Encourage regular involvement in physical activity and conditioning [C Evidence]

  • Provide basic education about good dental health practices [40]

  • Provide education about safe sexual practices, including abstinence, and avoidance of STI transmission. [41] Brief, office-based counseling for adolescents and young adults results in decreased incidence of STIs. [42] [43] [44] [B Evidence] The USPSTF recommends behavioral counseling for all sexually active adolescents to prevent STIs. [45] Appropriate methods of birth control should be available to sexually active teens, with education on correct use [46] [47]

  • Address the issue of sexual orientation if concerns are raised by the adolescent. This should be approached in a confidential setting with the provision of current factual information in a nonjudgmental manner. [48]

Late adolescence (age 18-21 years; college and work; sexual maturity rating 5)

Late adolescence is the final transition to adulthood, as individuals try to answer the question, who am I in relation to society? The late adolescent moves toward social, financial, and moral independence, and develops formal reasoning with a sense of future and specific financial goals. Preventive services focus on specific, adult-oriented issues, as well as lifelong health strategies.

A parent health guidance visit in late adolescence is considered optimal. [3] [4] [5] Information that should be provided is covered in the section on "Health guidance for parents".

Common medical problems encountered in late adolescence include: [1]

  • Eating disorders (especially bulimia nervosa)

  • STIs and pregnancy

  • Overuse, vehicular, and other unintentional injuries

  • Intentional injuries, such as suicide

  • Stress-induced physical symptoms and illness.

Late adolescence (18-21 years) healthcare visit: males

Annual history screening

  • Home environment: family and school/college/work connectedness is associated with protection against several health risk behaviors in this age group, including substance use, depression, and suicide attempts. Parental disapproval of early sexual debut is associated with a later age of onset of intercourse. [10] [11] [B Evidence]

  • School or college performance, including learning or school problems: repeating a grade is associated with emotional distress; parental expectations for positive school/college achievement predicts a lower level of health risk behaviors. [10] [11] [B Evidence]

  • Tobacco use: the USPSTF strongly recommends the provision of tobacco cessation interventions (brief behavioral counseling and pharmacotherapy) for identified young adult users of tobacco products. The evidence for tobacco use screening and brief interventions in adolescent populations is inconclusive. [12] [14] [A Evidence]

  • Alcohol and other drug use: the USPSTF recommends screening of young adults for problematic alcohol use and provision of behavioral counseling interventions for those with problematic use patterns. The evidence for use of these practices in adolescent populations is inconclusive. [2] There is no evidence supporting such interventions for other drug use in primary care settings. [15] [16] [17] [18] [B Evidence] [C Evidence]

  • Disordered eating behavior and body image: the AAP committee on adolescence recommends that primary care clinicians dealing with this patient population develop the knowledge and skills to provide early detection, initial evaluation, and ongoing management (in conjunction with specialist care, as necessary) of patients with disordered eating. [22]

  • Sexual activity: the physician should establish if the late adolescent is sexually active. If so, additional questioning may address: voluntary versus coerced participation in sexual activities; nature of sexual partners (sex, age); number of partners; use of condoms and other contraception; and suspected or known STIs in self or partners.

  • Physical, emotional, and sexual abuse: The physician should create a safe, confidential clinical environment for the adolescent in order to allow discussion of sensitive personal issues and to uncover potential situations of abuse. Appropriate reporting and referral to relevant mental health services may then follow. [1] [23] [C Evidence]

  • Depression and risk for suicide: the USPSTF supports the screening of adults for depression, with provision of follow-up care or referral for such care. [26] [B Evidence]

  • Determine young adult strengths: this activity identifies potential sources of resilience for the young adult. [5]

Physical assessment

The AAP and Bright Futures (BF) recommend annual full physical examinations. [5] The AMA's guidelines for adolescent preventive services (GAPS) recommend annual preventive medicine visits with at least 1 full physical examination in each stage of adolescence: early (11-14 years of age), middle (15-17), and late (18-21). [3]

  • Blood pressure: annually. [3] [4] [5] [A Evidence]

  • Height, weight, and BMI: annually. [B Evidence] The USPSTF identified fair-to-good evidence that high-intensity counseling about diet, exercise, or both, together with behavioral interventions aimed at skill development, motivation, and support strategies, produces modest, sustained weight loss (typically 3-5 kg for 1 year or more) in adults who are obese (defined as BMI >30). [2]

  • Full physical exam or late adolescent focused exam [3] [4] [5]

    • Skin exam: acne continues to be a concern for many late adolescents and should be addressed. USPSTF concluded that evidence is insufficient to assess balance of benefits and harms of a primary care skin examination for early detection of skin cancer in adults. [32]

    • Male breast: visual inspection for gynecomastia.

    • Genitalia: visual inspection for sexual maturity rating and signs of STIs. Explaining the nature and purpose of examinations can help lower the patient's anxiety level. [34] View image

    • Testicular exam: for hydrocele, hernias, varicocele, or masses. [34]

Recommended tests

  • Lipid panel: the USPSTF recommends screening men aged 20 to 35 years for lipid disorders if they are at increased risk for coronary heart disease (CHD). This includes those with diabetes, previous personal history of CHD, or noncoronary atherosclerosis (e.g., abdominal aortic aneurysm, peripheral artery disease, carotid artery stenosis), FHx of cardiovascular disease before age 50 in male relatives or age 60 in female relatives, tobacco use, HTN, and obesity (BMI >30). [36] [C Evidence] [A Evidence] The AAP recommends universal screening of adolescents for high cholesterol at least once between the ages of 9 and 11 and again between the ages of 17 and 21 years. [35] In addition, screening should occur among those with a FHx of high cholesterol or heart disease as well as those whose FHx is unknown or who have other factors for heart disease (obesity, high BP, diabetes). The recommended method for testing is a fasting lipid profile. If a child has values within the normal range, testing should be repeated in 3 to 5 years. For those with high LDL concentrations, cholesterol-reducing medications should be considered. [36] [C Evidence]

  • Screening for STIs (gonorrhea, chlamydia, visual genital inspection) in sexually active adolescents: the USPSTF states that evidence in support of screening this population for gonorrhea and chlamydia is inconclusive. [2] The AAP and BF recommend screening for both diseases in this population, with specific attention on adolescent males with previous STIs, new or multiple sexual partners, inconsistent condom use, or exchanging of sex for money or drugs. [5] [C Evidence]

  • HIV screen: well supported by evidence in adolescents with known risk factors, including unprotected sex with multiple partners, use of injection drugs, sex work, history of sex partners who are HIV-positive or bisexual, and history of STIs. The CDC's revised guidelines (September 2006) recommend that all individuals between 13 and 64 years of age be screened for HIV regardless of risk factors, but the USPSTF reviewed the information available in November 2006 and reaffirmed its conclusion that there is insufficient evidence to recommend HIV screening for those without known risk factors. [3] [37] [A Evidence]

  • Syphilis screen: well supported by evidence in adolescents and young adults with known risk factors. Those at risk include men who have sex with men (MSM) and engage in high-risk sexual behavior, commercial sex workers, adolescents who exchange sex for drugs, and those in correctional facilities. The prevalence of syphilis in the US varies widely by region and ethnicity, so clinicians should consider the characteristics of the communities they serve in determining appropriate screening strategies. Those diagnosed with other STIs (e.g., chlamydia, gonorrhea, genital herpes simplex, human papillomavirus, HIV) may be more likely to engage in high-risk behavior, placing them at increased risk for syphilis. [A Evidence]

  • TB screen, if at risk: the USPSTF defers to CDC guidance. The CDC, the American Thoracic Society, the Infectious Diseases Society of America, as well as the AAP, GAPS, and BF, recommend screening at-risk patients for TB with an intradermal test. Risk factors include: exposure to active TB; current or recent residence in a homeless shelter; current or recent incarceration; residence in a high-prevalence area; and HIV infection. [3] [5] [38]

  • Vision screening. [39]

  • Hearing screening: some states require a formal hearing screen during adolescence.

  • Type 2 diabetes mellitus screening: in young adults with sustained BP 135/80 mm Hg or higer. The USPSTF found good evidence that available screening tests accurately detect type 2 diabetes during an early, asymptomatic phase. Additionally, they found adequate evidence that, in adults who have HTN and diabetes, lowering BP below conventional target values reduces the incidence of cardiovascular events and cardiovascular mortality. [B Evidence]

Immunizations [52]

  • Offer HPV-4 immunization (recommended for boys and men age 9 to 26 years).

Catch-up immunizations [7]

  • Tetanus and diphtheria toxoids, and acellular pertussis vaccine (TdaP): catch up by age 18 years.

  • Meningococcal vaccine (MCV4): catch up by age 18 years.

  • Hepatitis B series.

  • Inactivated poliovirus vaccine (IPV) series.

  • Measles, mumps, and rubella vaccine (MMR) series.

  • Varicella series.

Clinical discretion immunizations [7]

  • Serogroup B meningococcal (Men B) vaccines: MenB-4c (Bexsero) or MenB-FHbp (Trumenba).

    • Adolescents and young adults ages 16 to 23 (preferred age range is 16 to 18 years) may be vaccinated with either a 2-dose series of Bexsero or a 3-dose series of Trumenba vaccine to provide short-term protection against most strains of serogroup B meningococcal disease. The two Men B vaccines are not interchangeable. The same vaccine product must be used for all doses.

Health guidance for late adolescents [3] [4] [5]

When offering this guidance to adolescents and young adults, physicians should:

  • Praise young adult strengths [5]

  • Provide education about normal physical, psychosocial, and psychosexual development [1]

  • Encourage an active involvement in healthcare decision-making

  • Review safety and injury prevention, including use of seat belts, [C Evidence] not riding in a car with a driver under the influence of alcohol or other drugs, [C Evidence] proper use of helmets for cycles and skateboards, appropriate use of athletic safety equipment, nonviolent conflict resolution with avoidance of weapons use, and promotion of weapons safety for any recreational uses

  • Strongly advise avoidance of tobacco, alcohol, and other drugs. The AAP encourages physicians to be knowledgeable about the health and safety hazards of these substances and to be able to provide objective information to adolescents [15] [21]

  • Provide basic education about good nutrition and dietary habits, including the consequences of excessive weight and obesity (impaired glucose tolerance, insulin resistance, elevated blood lipids, steatohepatitis, increased BP, and disturbed sleep with possible sleep apnea)

  • Encourage regular involvement in physical activity and conditioning [C Evidence]

  • Provide basic education about good dental health practices [40]

  • Provide education about safe sexual practices, including abstinence and avoidance of STI transmission. [41] Brief, office-based counseling for adolescents and young adults results in decreased incidence of STIs. [42] [43] [44] [B Evidence] The USPSTF recommends behavioral counseling for all sexually active adolescents to prevent STIs. [45] Appropriate methods of birth control should be available to sexually active teens, with education on correct use [46] [47]

  • Address the issue of sexual orientation if concerns are raised by the adolescent. This should be approached in a confidential manner with the provision of current factual information in a nonjudgmental manner. [48]

Late adolescence (18-21 years) healthcare visit: females

Annual history screening

  • Home environment: family and school/college/work connectedness is associated with protection against several health risk behaviors in this age group, including substance use, depression, and suicide attempts. Parental disapproval of early sexual debut is associated with a later age of onset of intercourse. [10] [11] [B Evidence]

  • School/college performance including learning or school problems: Repeating a grade is associated with emotional distress; parental expectations for positive school/college achievement predicts a lower level of health risk behaviors. [10] [11] [B Evidence]

  • Tobacco use: the USPSTF strongly recommends the provision of tobacco cessation interventions (brief behavioral counseling and pharmacotherapy) for identified young adult users of tobacco products. The evidence for tobacco use screening and brief interventions in adolescent populations is inconclusive. [12] [14] [A Evidence]

  • Alcohol and other drug use: the USPSTF recommends screening of young adults for problematic alcohol use and provision of behavioral counseling interventions for those with problematic use patterns. The evidence for use of these practices in adolescent populations is inconclusive. [2] There is no evidence supporting such interventions for other drug use in primary care settings. [15] [16] [17] [18] [B Evidence] [C Evidence]

  • Disordered eating behavior and body image: the AAP committee on adolescence recommends that primary care clinicians dealing with this patient population develop the knowledge and skills to provide early detection, initial evaluation, and ongoing management (in conjunction with specialist care, as necessary) of patients with disordered eating. [22]

  • Sexual activity: the physician should establish if the late adolescent is sexually active. If so, additional questioning may address: voluntary versus coerced participation in sexual activities; nature of sexual partners (sex, age); number of partners; use of condoms and other contraception; and suspected or known STIs in self or partners.

  • Physical, emotional, and sexual abuse: The physician should create a safe, confidential clinical environment for the adolescent in order to allow discussion of sensitive personal issues and to uncover potential situations of abuse. Appropriate reporting and referral to relevant mental health services may then follow. [1] [23] [C Evidence]

  • Depression and risk for suicide: the USPSTF supports the screening of adults for depression, with provision of follow-up care or referral for such care. [26] [B Evidence]

  • Determine young adult strengths: this activity identifies potential sources of resilience for the young adult. [5]

Physical assessment

The AAP and Bright Futures (BF) recommend annual full physical examinations. [5] The AMA's guidelines for adolescent preventive services (GAPS) recommend annual preventive medicine visits with at least 1 full physical examination in each stage of adolescence: early (11-14 years of age), middle (15-17), and late (18-21). [3]

  • Blood pressure: annually. [3] [4] [5] [A Evidence]

  • Height, weight, and BMI: annually. [B Evidence] The USPSTF identified fair-to-good evidence that high-intensity counseling about diet, exercise, or both, together with behavioral interventions aimed at skill development, motivation, and support strategies, produces modest, sustained weight loss (typically 3-5 kg for 1 year or more) in adults who are obese (defined as BMI >30). [2]

  • Last menstrual period: It is important for physicians dealing with this age group to have an understanding of bleeding patterns in adolescents and the ability to differentiate between normal and abnormal menstruation. [49]

  • Full physical exam or late adolescent focused exam [3] [4] [5]

    • Skin exam: acne continues to be a concern for many late adolescents and should be addressed. USPSTF concluded that evidence is insufficient to assess balance of benefits and harms of a primary care skin examination for early detection of skin cancer in adults. [32]

    • Breast exam: visual inspection for sexual maturity (Tanner) rating, and clinical exam starting at age 20 years. [53] [C Evidence] View image

    • Genitalia: visual inspection for sexual maturity rating and signs of STIs. Explaining the nature and purpose of examinations can help lower the patient's anxiety level. [34] View image

    • Pelvic exam: if clinically warranted (e.g., in those with specific problems such as abdominal or pelvic pain, pubertal concern, or abnormal bleeding). Cervical dysplasia screening (i.e., pap smear) is not indicated until age 21. [50] [51]

Recommended tests

  • Lipid panel: The AAP recommends universal screening of adolescents for high cholesterol at least once between the ages of 9 and 11 and again between the ages of 17 and 21 years. [35] In addition, screening should occur among those with FHx of high cholesterol or heart disease, as well as those whose FHx is unknown or who have other factors for heart disease (obesity, high BP, diabetes). The recommended method for testing is a fasting lipid profile. If a child has values within the normal range, testing should be repeated in 3 to 5 years. For those with high LDL concentrations, cholesterol-reducing medications should be considered. [36] [C Evidence]

  • HIV screen: well supported by evidence in adolescents with known risk factors, including unprotected sex with multiple partners; use of injection drugs; sex work; history of sex partners who are HIV-positive, bisexual, or injection drug users; and history of STIs. The CDC's revised guidelines (September 2006) recommend that all individuals between 13 and 64 years of age be screened for HIV regardless of risk factors, but the USPSTF reviewed the information available in November 2006 and reaffirmed its conclusion that there is insufficient evidence to recommend HIV screening for those without known risk factors. [3] [37] [A Evidence]

  • Syphilis screen: screening for syphilis in adolescents and young adults with known risk factors. Risk factors for women include: engaging in high-risk sexual behavior; commercial sex work; exchanging sex for drugs; and being in correctional facilities. The prevalence of syphilis in the US varies widely by region and ethnicity, so clinicians should consider the characteristics of the communities they serve in determining appropriate screening strategies. Those diagnosed with other STIs (e.g., chlamydia, gonorrhea, genital herpes simplex, human papillomavirus, HIV) may be more likely to engage in high-risk behavior, placing them at increased risk for syphilis. [A Evidence]

  • Hematocrit or hemoglobin if at risk: the AAP and BF recommend screening all nonpregnant women during routine health exams, starting in adolescence and continuing every 5 to 10 years throughout their childbearing years. Annual screening is recommended for women having risk factors for iron deficiency (such as extensive menstrual or other blood loss, low iron intake, or a previous diagnosis of iron-deficiency anemia). [3] [5]

  • TB screen if at risk: the USPSTF defers to CDC guidance. The CDC, the American Thoracic Society, the Infectious Diseases Society of America, as well as the AAP, GAPS, and BF recommend screening at-risk patients for TB with an intradermal test. Risk factors include: exposure to active TB; current or recent residence in a homeless shelter; current or recent incarceration; residence in a high-prevalence area; and HIV infection. [3] [5] [38]

  • Vision screening. [39]

  • Hearing screening: some states require a formal hearing screen during adolescence.

  • Screening for STIs (gonorrhea, chlamydia, visual genital inspection) in sexually active young adults: the USPSTF, the AAP, and BF recommend these screenings with specific attention on females with previous STIs, new or multiple sexual partners, or inconsistent condom use, and those who exchange sex for money or drugs. [2] [5] The prevalence of chlamydia varies widely, with a higher prevalence in African-American women and Hispanic women in many communities and settings. [A Evidence] [B Evidence]

  • Pregnancy screen: sexually active females without contraception, or with late menses or amenorrhea, should be screened with urine hCG. [5]

  • Cervical dysplasia screening: cervical dysplasia screening (i.e., pap smear) is not indicated until age 21. [50] [51]

  • Type 2 diabetes mellitus screening: in young adults with sustained BP equal to or greater than 135/80 mm Hg. The USPSTF found good evidence that available screening tests accurately detect type 2 diabetes during an early, asymptomatic phase. Additionally, they found adequate evidence that, in adults who have HTN and diabetes, lowering BP below conventional target values reduces the incidence of cardiovascular events and cardiovascular mortality. [B Evidence]

Immunizations [52]

  • Offer HPV immunization (recommended for girls and women age 9 to 26 years).

Catch-up immunizations [7]

  • Tetanus and diphtheria toxoids, and acellular pertussis vaccine (TdaP): catch up by age 18 years.

  • Meningococcal vaccine (MCV4): catch up by age 18 years.

  • Hepatitis B series.

  • Inactivated poliovirus vaccine (IPV) series.

  • Measles, mumps, and rubella vaccine (MMR) series.

  • Varicella series.

Clinical discretion immunizations [7]

  • Serogroup B meningococcal (Men B) vaccines: MenB-4c (Bexsero) or MenB-FHbp (Trumenba).

    • Adolescents and young adults ages 16 to 23 (preferred age range is 16 to 18 years) may be vaccinated with either a 2-dose series of Bexsero or a 3-dose series of Trumenba vaccine to provide short-term protection against most strains of serogroup B meningococcal disease. The two Men B vaccines are not interchangeable. The same vaccine product must be used for all doses.

Health guidance for late adolescents [3] [4] [5]

When offering this guidance to adolescents/young adults, physicians should:

  • Praise young adult strengths [5]

  • Provide education about normal physical, psychosocial, and psychosexual development [1]

  • Encourage an active involvement in healthcare decision-making

  • Review safety and injury prevention, including use of seat belts, [C Evidence] not riding in a car with a driver under the influence of alcohol or other drugs, [C Evidence] proper use of helmets for cycles and skateboards, appropriate use of athletic safety equipment, nonviolent conflict resolution with avoidance of weapons use, and promotion of weapons safety for any recreational uses

  • Strongly advise avoidance of tobacco, alcohol, and other drugs. The AAP encourages physicians to be knowledgeable about the health and safety hazards of these substances and to be able to provide objective information to adolescents [15] [21]

  • Provide basic education about good nutrition and dietary habits, including the consequences of excessive weight and obesity (impaired glucose tolerance, insulin resistance, elevated blood lipids, steatohepatitis, increased BP, and disturbed sleep with possible sleep apnea)

  • Encourage regular involvement in physical activity and conditioning [C Evidence]

  • Provide basic education about good dental health practices [40]

  • Provide education about safe sexual practices, including abstinence and avoidance of STI transmission. [41] Brief, office-based counseling for adolescents and young adults results in decreased incidence of STIs. [42] [43] [44] [B Evidence] The USPSTF recommends behavioral counseling for all sexually active adolescents to prevent STIs. [45] Appropriate methods of birth control should be available to sexually active teens, with education on correct use [46] [47]

  • Address the issue of sexual orientation if concerns are raised by the adolescent. This should be approached in a confidential manner with the provision of current factual information in a nonjudgmental manner. [48]

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