July 2019, Volume XXXIII, No 4

Behavioral Health

Adolescent medicine

Meeting unique needs

dolescence. For many parents, educators, and health care providers, this word elicits some combination of terror, uncertainty, and excitement. Adolescence (defined by the World Health Organization as ages 10–19) is a time of tremendous change across physical, social, relational, and spiritual domains, as youth transition from dependence on caregivers to greater autonomy and independence. Young people strive to form their own identities and to separate from their families, while simultaneously becoming more connected to peer groups. The health care needs and experiences of teenagers are distinct from those of young children and early adults. Physicians and other health care professionals need to provide culturally appropriate and trauma-informed care and consider numerous complex issues such as confidentiality when supporting these young people.

Choices adolescents make can have lasting effects on long-term health. For example, contracting HIV, experiencing a traumatic injury that leads to paralysis, poorly controlling chronic health conditions such as diabetes, unintended pregnancies, or substance abuse can lead to future disease burden. It is essential that providers empower adolescents to take responsibility for their behaviors and for health-related decisions. Four specific domains of health that involve unique challenges for adolescence include substance use, depression and elevated risk for suicide, sexuality, and transitions of care from pediatric to adult-based primary care and specialty services. All of these domains of health, but particularly substance use and depression, are impacted by social determinants of health, as well as interpersonal, household, and community dynamics.

The developing brain

Prior to addressing these four domains, it is important to note how the adolescent brain is extremely plastic and malleable, able to learn and change very quickly. The limbic system (the reward center of the brain) matures well before the prefrontal cortex (the area responsible for planning, higher level decision-making, and executive function, which does not fully develop until the mid-20s). This mismatch in brain development sets up adolescents to be prone to risk-taking behaviors and impulsivity without considering all the potential consequences. If those risk-taking behaviors impair brain development, such as in the case of substance use, they can have significant long-term effects, particularly because the brain is so plastic at this stage.

Historically, risk-taking, experimentation, and exploration were considered pathologic in adolescents. However, our improved understanding of brain development has changed this thinking. These behaviors are now considered a normal part of development, and the challenge (for all who work with teenagers) is to help mitigate the potentially negative effects of risky behaviors through appropriate health behavior counseling and adult support. Understanding the etiology of some of adolescents’ risk-taking behaviors can help providers have more patience and engage in respectful, non-judgmental discussions with youth.

The adolescent brain is extremely plastic and malleable.

Substance use

Adolescent brain development and long-term health are closely linked to substance use. The plasticity of the adolescent brain, learning quickly and adapting to changes, makes it particularly susceptible to substance use disorder. According to 2014 data from the Substance Abuse and Mental Health Services Administration (SAMHSA), 74 percent of adults aged 18–30 who were admitted to long-term substance use treatment started using substances before the age of 17, and of the patients who were receiving treatment for multiple substances, more than 70 percent had started using before the age of 11.

Electronic cigarette use rates are rising; in the 2017 Minnesota Student Survey, 19 percent of high school students reported e-cigarette use, compared to 10 percent who reported conventional cigarette use. The Minnesota Department of Health has named e-cigarettes an emerging public health threat. The potential legalization of cannabis products also has significant implications for the well-being and brain development of adolescents.

For primary care physicians and health care professionals in all fields, screening, intervention, and prevention are imperative to decrease the burden of substance use disorders. Incorporating a SBIRT screening (Adolescent Screening, Brief Intervention, and Referral for Treatment; see www.tinyurl.com/mp-sbirt and www.tinyurl.com/mp-sbirt-toolkit), or the CRAFFT screener (Car, Relax, Alone, Forget, Family or Friends, Trouble; see www.tinyurl.com/mp-crafft) into your clinical practice can be useful to increase detection of these problems.

Mental health

Often intertwined with issues of substance abuse are mental health concerns. According to the Centers for Disease Control and Prevention (CDC), suicide is the second leading cause of death among youth ages 10–24, surpassed only by accidents. Further, many more teens attempt suicide than actually complete it. In the national 2017 Youth Risk Behaviors Survey, about 17 percent of teens (22 percent of females and 12 percent of males) had seriously considered attempting suicide and 7 percent (9 percent of females and 5 percent of males) reported that they had made at least one suicide attempt in the preceding year. Underlying these concerning statistics are numerous factors, including but not limited to mental illness, bullying, social isolation, substance abuse, family violence, LGBTQ status, loss, impulsivity, and hopelessness. Thus, it is important for health care professionals to screen adolescents for depression and suicidality, have processes in place for when there is imminent danger, and collaborate closely with mental health professionals to co-manage teens in significant distress.

Sexuality

Another aspect of health that is particularly notable in the adolescent period is sexuality. The teenage years are a time of normal exploration regarding one’s sexual attraction, fantasies, identity, and behaviors. However, rates of sexually transmitted infections are reaching record highs. The CDC says that almost half of all new cases of chlamydia in 2017 were in females 15 to 24 years old. Furthermore, rates of depression, substance abuse, and suicide are considerably elevated among LGBTQ youth, with recent data showing over half of female-to-male transgender youth have attempted suicide (Toomey et al., Transgender Adolescent Suicide Behavior, in Pediatrics; see www.tinyurl.com/mp-toomey.)

Thus, issues surrounding sexuality are important and highly relevant for physicians to address with youth. However, physicians often do not discuss sexuality at all, and such discussions, when they do occur, can be brief and awkward. Providers may feel unsure about what terms to use, worry about offending the teen and damaging the therapeutic relationship, and have insufficient time to discuss sensitive issues. Similarly, teens may feel embarrassed, worry about potential disclosure of their personal information, worry about the provider’s judgment, and not understand medical terminology.

For example, during a prenatal visit, a 17-year-old girl who was 24 weeks pregnant described her experience at her school’s Sexual Health Fair. She had listed “gay-curious,” and was subsequently told she was at low risk for STIs or pregnancy. The screener missed the fact that she was having sex with males and was pregnant. In general, explaining to teenagers your medical rationale for assessing their sexual behavior, reassuring them about confidentiality and its limits, asking open-ended questions, using inclusive and person-centered language, and emphasizing that your goal is to help them make good choices can be useful strategies when discussing this domain of health.

It is essential that providers empower adolescents to take responsibility for their behaviors.

Autonomy

As adolescents begin to desire and gain more autonomy, it is important to foster independence in interactions with medical providers. Adolescents should be encouraged to be the main focus of the visit and answer most of the provider’s questions—transitioning away from prior visits in which parents or caregivers did most of the talking. Teenagers should be interviewed and examined separately from their parent or caregiver to give them the opportunity to engage with medical providers confidentially, and to empower them to take control of their health and medical interactions.

In Minnesota, minors can seek care without parental consent for a select number of conditions, including pregnancy testing and care, sexually transmitted infections, and alcohol or drug abuse. Providers should assure teens that what they share will be kept confidential, except in the case of suspected abuse or intent to harm themselves or others. However, if a parent’s insurance is to be billed for any testing, parents may find out indirectly what was discussed. Generally, providers should encourage teens to talk openly with their parents, but empower them with the knowledge that they have the right to privacy should they choose not to do so.

Transitioning into adult care

Additionally, adolescents with special health needs or chronic disease need to begin to transition from a pediatric-focused health care approach to an adult approach. For children living with chronic diseases, the pediatric specialist clinic serves as their medical home; often these pediatric patients do not have a regular primary care provider. However, in adult health care, primary care providers (PCPs) are the first contact point for acute and chronic needs; PCPs consult with specialists as indicated and assist with coordination of care. This change in health care models can be challenging for adolescents and their families. It is important to help teens begin to take responsibility for their health, independent of their parents or caregivers. Accessible providers and clearly defined role expectations for each provider involved in care can minimize confusion and frustration.

Additional training in adolescent medicine

The specialty of adolescent medicine is relatively new. The Society of Adolescent Health and Medicine was founded in 1968, and is celebrating its 50th anniversary this year.

Physicians who have completed residencies in family medicine, pediatrics, internal medicine, or combined internal medicine/pediatrics and who seek additional training in working with adolescents may consider speciality fellowships, most of which are three years. Fellowships provide additional experience as well as access to cutting-edge research and training in best practices in working with adolescents. Multiple professional societies also have continuing education and conferences about adolescent health, including the Society for Adolescent Health and Medicine, the American Academy of Pediatrics, the American Academy of Family Physicians, the American College of Physicians, and the International Association for Adolescent Health.

The Society of Adolescent Health and Medicine has an excellent repository of learning modules and links to materials to improve skills and knowledge about working with adolescents, including modules about sexual and reproductive health, transitioning to adult care models, and substance use and abuse. See www.tinyurl.com/mp-curriculum.

Conclusion

It is important for health care professionals, parents/caregivers, and teens themselves to be aware of the unique developmental and social needs of adolescents, and to seek appropriate care. Interdisciplinary, holistic approaches to health, partnerships with community resources, and diverse well-trained providers who are nonjudgmental and easily accessible are key tenets of effective care for adolescents.

Andrea Westby, MD, is an assistant professor in the University of Minnesota Medical School’s Department of Family Medicine and Community Health and core clinical faculty at the North Memorial Family Medicine Residency Program in North Minneapolis.

Michelle D. Sherman, PhD, LP, ABPP, is a board-certified couple and family psychologist and a professor in the Department of Family Medicine and Community Health at the University of Minnesota–Twin Cities. She is the director of behavioral health at the North Memorial Family Medicine Residency Program.

James Smith, MD, MPH, is a first-year family medicine resident at the University of Minnesota’s Family Medicine Residency program. He earned an MPH at the University of Minnesota. He has a particular clinical interest in adolescent health. 

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James Smith, MD, MPH, is a first-year family medicine resident at the University of Minnesota’s Family Medicine Residency program. He earned an MPH at the University of Minnesota. He has a particular clinical interest in adolescent health.