The first priority of the visit always is to address patient and parent
concerns. In addition, the Bright Futures Adolescence Expert Panel has
given priority to discussion of the following topics. It may not be
possible to include all of the topics at every visit, but they should be
covered over the middle adolescent years. The topics include:
Physical growth and development:
Physical and oral health, body image, healthy eating, physical
Social and academic competence:
Connectedness with family, peers, and community; interpersonal
relationships; school performance
Coping; mood regulation and mental health; sexuality
Tobacco, alcohol, or other drugs; pregnancy; STIs
and injury prevention: Safety belt and helmet use, driving
(graduated license), substance abuse, guns, interpersonal
violence (dating violence), bullying
History can be obtained using a variety of styles. An adolescent
pre-visit questionnaire can be helpful to begin the visit. The Guidelines for Adolescent Preventive Services
(GAPS) questionnaire and the
Bright Futures pre-visit questionnaire are both options. The
include depression screening questions.
The Bright Futures forms
specifically list questions that screen for risk factors that would
necessitate additional evaluation, such as dyslipidemia.
The Bright Futures questionnaires can be
purchased in the
Screening questionnaire responses that elicit concern can further be
explored by asking questions that encourage in-depth discussion.
Questions can be asked of both teens and parents. Much of the visit
should occur with the teen alone, but observation of the
parent-adolescent interaction can occur when both are in the room. It is
particularly important to observe whether the parent is encouraging
self-management and independence, and allowing the teen to answer
In addition to observation and the physical exam, discussion with the
teen offers an opportunity for developmental surveillance. Exploring
whether the teen engages in a healthy lifestyle and forms caring,
supportive relationships with family and peers is important. Teens’
sense of self-confidence, hopefulness, and well-being, as well as their
ability to cope with stress, should be assessed.
The adolescent visit can be documented on the
Child Health and
Development Records (CHDR). If these forms are completed, the provider will satisfy all of the
requirements of an EPSDT well-child visit.
Include a complete physical examination at every
health supervision visit. Particular attention should be given to the
Measure, plot, and calculate blood pressure, height, weight,
Inspect skin for acne,
acanthosis nigricans, atypical
nevi, tattoos, piercings, and signs of abuse or self-inflicted injury.
Examine the spine and breasts. Assess Tanner Stage in females
and look for gynecomastia in males.
Examine genitalia. In females, assess Tanner Stage and observe
for signs of STIs. Perform a pelvic exam if clinically warranted. In
males, assess Tanner Stage and observe for signs of STIs. Examine
testicles for hydrocele, hernias, varicocele, or masses.
Vision screens should be done universally during each period
of adolescence or in anyone with vision complaints.
Obtain a fasting lipoprotein profile in late
adolescence or if risk factors are present and the teen has not
previously been screened. Risk factors include parents or grandparents
who had an MI, angina, peripheral vascular disease, cerebral vascular
disease, coronary atherosclerosis, or sudden cardiac death at or before age 55, or parents who have elevated cholesterol.
Consider doing a lipid profile if the adolescent has other risk factors
such as overweight, smoking, hypertension, diabetes, and/or physical
The following areas should be screened selectively based on
Anemia – Starting in adolescence, screen all non-pregnant women for
anemia every 5 to 10 years. Annually screen women with risk factors
including excessive menstrual or other blood loss, low iron intake, or
previous iron deficiency anemia.
Hearing – Screen if teen has any concerns such as trouble hearing on the
phone or while watching TV.
Tuberculosis – Screen if there is contact with someone with TB or a
family member has had a positive TB skin test; if the teen was born in a
high-risk country (any other than the U.S., Canada, Australia, New
Zealand, or Western European countries); or has traveled to a high-risk
country for longer than one week. Anyone infected with HIV or
incarcerated should have annual TST.
Sexually Transmitted Infections/Pregnancy – Screen sexually active
young women annually for chlamydia, gonorrhea and pregnancy. HIV
screening is encouraged for all who are sexually active and older than
13. HIV and syphilis screening should be done in adolescents with risk
factors, such as males who have sex with other males, teens who trade sex
for money or drugs, injection drug users, patients who have had
unprotected sex with multiple partners, or those who have been
Alcohol or Drug
Use - Administer an alcohol or drug screening tool (such
as the CRAFFT screening test) to adolescents who answer in the
affirmative to risk screening questions, including “Have you ever had an
alcoholic drink or used marijuana or any other drug to get high?”
Review immunizations at all visits. Give particular
attention to Tdap, MCV-4, HPV, and influenza (TIV or LAIV), if in
season. Confirm that the teen has received two
as well as two hepatitis A vaccines.
The following priority areas should be discussed
over the course of adolescence:
Physical Growth and Development
Balanced diet including three or more daily servings of low-fat
dairy, three nutritious meals, and family meals as often as possible.
Physical activity for one hour on most days of the week.
Limit TV, video games, DVDs, or computer use (outside of
homework) to no more than two hours per day.
Brush/floss teeth twice daily, see a dentist regularly, and use
a mouth guard for contact sports.
Wear hearing protection when exposed to loud noise.
Social and Academic Competence
Parents should set age appropriate limits and expectations for
Promote independent decision-making.
Encourage teens to stay connected with their family, as well as
develop relationships with positive friends. Parents should maintain a
positive relationship with their adolescents, be affectionate, and give
praise for efforts and achievements. They should monitor their
adolescent’s whereabouts and friends.
Encourage community involvement, as well as involvement in
activities of interest.
Emphasize the importance of school and have the teen take
responsibility for getting homework done. Parents should help out with
organizational issues or new activities as needed. Plan for after high
Emotional Well Being
Involve teens in family decision-making and help them find ways
to deal with stress.
Explore mental health, including symptoms of depression.
Encourage communication about issues of puberty and sexuality.
Explore use of alcohol, tobacco, and drugs taken for
recreational purposes. Particularly discourage use while on the water or
while operating motor vehicles. Encourage avoiding situations where
alcohol and drugs are readily available.
Inform teens that abstaining from sexual intercourse is the
safest way to prevent pregnancy and STIs. Encourage them to avoid risky
places and relationships. If they are sexually active, encourage
contraceptive and condom use.
Violence and Injury Prevention
Tell teens always to wear a safety belt in a vehicle and a
helmet when riding a bike, a motorcycle, or an ATV, or when
Have parents set limits and expectations about driving,
including the number of passengers, amount of night driving, and
Explore exposure to guns, carrying weapons, or fighting. If
parents need to keep guns in the home, they should be stored unloaded
and locked, with the ammunition locked in a separate location.
Encourage teens to manage conflict nonviolently, to walk away
if necessary, and to avoid high-risk situations and violent people.
Encourage healthy dating relationships based on respect, concern, and
doing things both people enjoy. Remind them that saying “No” is OK and
“No” means NO.
For additional information, consult the following resources:
ed. AM:STARs: Evaluation and Management of Adolescent Issues,
Elk Grove Village, IL: American Academy of Pediatrics: 2008: 1-17.
Immunization Practice Toolkit
Immunization Action Coalition
For her review of this article, thanks to
Mary Larew, MD, University of
Iowa Children’s Hospital.