Spring 2011

The Middle Adolescent Health Maintenance Visit

Ellen Link, MD, University of Iowa Children’s Hospital

The major morbidities in adolescence are psychosocial, and the adolescent health maintenance visit is an important time to help prevent these. Primary care providers play a very important role in promoting healthy lifestyles and preventing adverse outcomes.

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:

1. Physical growth and development: Physical and oral health, body image, healthy eating, physical activity

2. Social and academic competence: Connectedness with family, peers, and community; interpersonal relationships; school performance

3. Emotional well-being: Coping; mood regulation and mental health; sexuality

4. Risk reduction: Tobacco, alcohol, or other drugs; pregnancy; STIs

5. Violence 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 GAPS forms 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 Bright Futures tool kit.

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 questions.

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 Iowa 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.

PHYSICAL EXAMINATION
Include a complete physical examination at every health supervision visit. Particular attention should be given to the following:

1. Measure, plot, and calculate blood pressure, height, weight, and BMI.

2. Inspect skin for acne, acanthosis nigricans, atypical nevi, tattoos, piercings, and signs of abuse or self-inflicted injury.

3. Examine the spine and breasts. Assess Tanner Stage in females and look for gynecomastia in males.

4. 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.