Adolescent Medicine

Ma. Louisa Uson- Peralta , MD

Professor
Faculty of Medicine and Surgery
University of Santo Tomas
 Why Focus on Adolescent Health?

• Reduce death and disease, now and for the rest of

their lives

• Fulfill the rights of adolescents to health care,

especially reproductive health care

• Increase the chances for healthy adulthood


• Culture of adolescents
- peer dependent
- egocentric
- distinct dialect and dress
- popular culture influence
- ongoing search for identity
• For most part , adolescents are :
- healthy
- resilient
- independent but vulnerable

• Adolescent are not:

- big children
- little adult


 Epidemiology
Adolescent Medicine

• 81 % of middle adolescent have excellent health.

• 10% have learning disabilities.
• 12 % have ADHD
• 9% insured
• The leading cause of morbidity and mortality are
unintentional and intentional causes
 Epidemiology of Adolescent in the
Philippines

• 4 million street dwellers and working children .

• 2.2 million are forced to stop schooling .
• 37 % work from 5-8 hours a day .
• 9% work more than 8 hours a day and some even work
at night.
• They have no insurance nor benefits from parents’
health plans too.
• Disabilities of adolescent Filipino :
overall disabilities - 4%
- 35% speech
- 33 % hearing
- 22 % moving and mobilities
 Threats
• Increasing rates of HIV and STDs
- early engagement in health risk behavior
without protection .
- serious gaps of the knowledge on the
dangers of drugs.
- dangers of indiscriminate tatooing and
body piercing .
- inadequate population education
• CDC recommends universal voluntary HIV
screening for all sexually active persons
beginning at age 13.
• AAP recommends routine HIV screening for all
adolescent at least once for 16-18 years old
and younger if at risk.
• US Preventive Task Force recommends HIV
screening to all adolescents 15 years and older
at least once and younger if at risk.
• Patient who test positive for HIV should
receive prevention and counseling and
referral to health care before leaving the
testing site.
 Philippines AIDS Law
• The government will provide appropriate
confidential HIV testing.
• HIV/AIDS testing can only be done with consent
of the person to be tested.
• It will provide anonymous HIV/AIDS testing.
• Counseling will be provided before and after
testing.
• DOH will make adequate and affordable HIV/AIDS
testing to all.
Rationale for Confidentiality

Confidentiality in Adolescent Health Care

Supported by
Clinically Developmentally
Expert
Essential Expected
Consensus
• Among adolescents confidentiality affects
their decision to seek care, disclosure of
behavior and follow care.
• Confidentiality is developmentally expected:
- emotional need for autonomy.
- increasing intellectual capacity to give
informed consent.
- opportunity to take responsibility for health.
 Confidentiality: Adolescent’s
Perspective
• More privacy and autonomy.
• Listen but avoid judgmental statements.
• Show respect for the adolescent’s emerging
maturity
• Opportunity to express concern and reason
for seeking medical attention
 Confidentiality: Parental Perspective

• Parents are not the enemy.

• Parents are experiencing their own adjustment to their

child’s adolescence.

• Providers have an opportunity to educate parents about

the need for confidentiality in the provider-patient
encounter.


 External Barriers to Care

• Perceived lack of confidentiality and restrictions

(parental consent/notification)
• Poor communication by providers
• Insensitive attitudes of care providers
• Lack of provider knowledge and skills
• Lack of money, insurance, and transportation
• Inaccessible locations and/or limited services
• Limited office hours


• Adolescent-specific • Adequate space
• Multi- and • Confidential
interdisciplinary • Flexible scheduling
• Accessible • Comprehensive
• Financially affordable services
• Adolescent-focused • Continuity of care
materials on display • Help transitioning into
• Peer educator the adult medical care
component system
 Physical examination
• Vision testing to rule out myopia
• Hearing screening
• Blood pressure monitoring
• Scoliosis monitoring
• Breast examination
• Scrotal examination
• Pelvic examination
• Laboratory examination
 Comprehensive HEEADSSS
 H: Home
 E: Education/Employment
 E: Eating
 A: Activities
 D: Drugs
 S: Sexuality
 S: Suicide/depression
 S: Safety
 *Additional questions:
 Strengths, Spirituality

Klein DA, Goldenring JM & Adelman WP. Contemporary Pediatrics. 2014.

 Home

 Where do you live and who lives there with you?

 What are relationships like at home?

 Can you talk to anyone at home about stress? Who?
 What are the rules like at home?
 Is there a gun in your home?
 Ever been homeless or in shelter care?
 Ever been in foster care or group home?


 Employment

 Are you working? Where? How much?

 What type of work do you do?

 How many hours a week?
 Do you help to pay for things at home?
 What are your future career interests?
 Do you have any home chores?
Allowance?


 Education

 Tell me about school.

 Do you feel connected to your school? Do you feel as

if you belong?
 How many days have you missed in the past year
and what was the reason?
 Have you ever had any educational setbacks? Why?
 Have there been any recent school changes?
 What are your educational and life goals?


Eating
 Eating

 Does your weight or body shape cause you any

stress? If so, tell me about it.

 Have there been any recent changes in your weight?

 Have you dieted in the past year? How? How often?
 What do you like and not like about your body?
 Tell me about your exercise routine.


 Diet/Weight
 What’s your diet like? Do you think your diet is
healthy or unhealthy? If healthy/unhealthy, what’s
good or bad about it?

 How do you feel about your current weight? Do you

worry that you weigh too much or too little?

 Depending on response to above. . .could ask more

eating disorder questions, for which there are several
validated questionnaires


 Activities
 What do you like to do for physical activity? How
much do you do in a week? Do you feel you’re
getting enough physical activity to be healthy?

 How do you like to spend your free time?

 Hobbies, clubs, religious/spiritual activities?

 Do you play any sports?

 How many hours of television/computer per day? Per

week?

 Drugs


 Physical examination

 Vision testing to rule out myopia

 Hearing screening
 Blood pressure monitoring
 Scoliosis monitoring
 Breast examination
 Scrotal examination
 Pelvic examination
 Laboratory examination
 Drugs and Alcohol

 Does anyone you hang out with smoke, drink, or

use drugs? How frequently and how much?

 Do you use tobacco?

 Do you use electronic cigarettes?
 Do you drink alcohol?
 What kind: beer, wine, hard liquor?
 Any blackouts? Ever pass out? Vomit?


CRAFFT Questions: Identify Problem Use

 Have you ever ridden in a Car driven by someone

who was high or had been using alcohol or drugs?
 Do you ever use alcohol or drugs to Relax, feel better
about yourself, or fit in?
 Do you ever use drugs or alcohol when you are
Alone?
 Do you Forget things while using drugs or alcohol?
 Do your family or Friends ever tell you that you
should cut down on your drinking or drug use?
 Have you ever gotten into Trouble while using drugs
or alcohol?


Copyright © Children's Hospital Boston. All rights reserved

 Sex & Sexuality


 Sexuality
 Have you ever been in a romantic relationship?
Tell me about the people that you’ve dated.

 Have any of your relationships ever been sexual

relationships (such as involving kissing or touching)?

 Are you attracted to anyone now?

 Are you interested in boys? Girls? Both? Not yet

sure?


 Sexual Behavior Questions
 There are many ways of being sexual or intimate with
another person: kissing, hugging, touching, having
oral sex, anal sex, or vaginal sex.
 Have you ever had any of these
experiences?
 Which ones?
 With males, females, both or other genders?

 What kind of protection did you use at last sex?

 Condoms? Pills? Something else?


 US High School Students: Ever Had Sex

100

80

58.1
60
49.6 48.5
Percent

41.2 43.2 42.5 39.9

39.2
40 35.7
24.1
20

National Youth Risk Behavior Survey, 2015

 US High School Students: Currently Having
Sex
100

80

60
46.0
Percent

40 35.5 33.1 30.3 30.3

30.1 30.3 29.8
25.5
20 15.7

National Youth Risk Behavior Survey, 2015

 Suicide and Depression


 Suicide and Depression

 Is the 3rd cause of death among adolescents.

 It is important to screen teenagers for depression not
only those who look depress.
 Females are most likely to attempt suicide.
 Males are 3x more likely to succeed.
 Most suicidal adolescents have depressive symptoms
low self esteem, a feeling of hopelessness and high self
blame.
17% Deaths Among Young People From
Suicide

MMWR / June 10, 2016 / Vol. 65 / No. 6

 Suicide and Depression
 Do you feel “stressed” or anxious more than
usual?

 Do you feel sad or down more than usual?

 Have you ever received counseling and/or therapy?
 Are you having trouble getting to sleep?
 Tell me about a time when you felt sad while using
social media sites like Facebook.
 Have you ever thought of hurting yourself or
someone else?


 US High School Students: Felt Sad or
Hopeless
100

80

60
Percent

39.8
40 35.3
29.9 28.4 29.8 31.4 30.0 25.2
28.6
20.3
20

National Youth Risk Behavior Survey, 2015

 Sexual Behavior Questions
 There are many ways of being sexual or intimate with
another person: kissing, hugging, touching, having
oral sex, anal sex, or vaginal sex.
 Have you ever had any of these
experiences?
 Which ones?
 With males, females, both or other genders?

 What kind of protection did you use at last sex?

 Condoms? Pills? Something else?


US High School Students: Contraceptive
Use
YRBS Question US

Percentage of students who used a

condom at last sex 56.9%

Percentage of students who used birth

control pills at last sex 18.2%

Percentage of students who used

Depo-Provera, NuvaRing®, 8.6%
Implanon®, or any IUD before last sex


 Safety


 Safety

 Have you ever been seriously injured? (How?)

How about anyone else you know?

 Do you always wear a seatbelt in the car?

 When was the last time you sent a text message

while driving?

 Tell me about a time when you have ridden with a

driver who was drunk or high. When? How often?

23% Deaths Among Young People From Car
Crashes

MMWR / June 10, 2016 / Vol. 65 / No. 6

 Sexual and Physical Abuse

 Have you ever been forced to have sex or been

touched in a way against your will?
By whom and is this still going on?
Who did you tell?
How does it affect your day-to-day life?
In what ways does that experience affect your
sexual relationships now?

 Has anyone ever hurt you on a repeated basis? At

home, in school, or in your neighborhood?


 Interpersonal Violence includes

 Child abuse
 Battering
 Domestic violence
 Partner violence
 School, peer, community violence
 Sexual harassment
 Sexual abuse
 Sexual assault
 Hate crime


 US High School Students:
Ever Physically Forced to Have Sex
100

80

60
Percent

40

20
10.3 7.6 7.6 7.3 7.0
6.7 5.6 5.9 6.0
3.1
0

National Youth Risk Behavior Survey, 2015

 US High School Students:
Experienced Physical Dating Violence
100

80

60
Percent

40

20
9.6 11.7 9.6 10.1 10.5 10.5 9.7 9.0
7.4 8.1

National Youth Risk Behavior Survey, 2015

 US High School Students:
Experienced Sexual Dating Violence
100

80

60
Percent

40

20 15.6
10.6 10.8 11.8 10.3 9.2 10.0 10.6 10.1
5.4
0

National Youth Risk Behavior Survey, 2015

 Strengths-Based Approach
 Identify strengths early and Praise

 Look for examples of past difficulties that your patient

has successfully overcome

 Use reflective listening and pause

 Create a comfortable, trusting, nonjudgmental setting

 Share your concerns


 Strength Based Approach
 Emphasize the positive
 Assess resiliency and health risk behavior
 Identify past difficulties that have been overcome
 Praise the adolescent when you find positive in the
history
 Positive reinforcement to improve self esteem and
cementing a positive and long lasting trusting
relationship.


 Spirituality*

 How do your beliefs influence your health and

attitudes about sex and contraception?

 How important are your spiritual beliefs in your day-

to-day life?

 How often do you participate in religious activities?

 What do you consider to be your religion?


 Wrap Up
 Emphasize that your approach is nonjudgmental and
that you welcome future visits

 “I’m here for you, and I want you to feel comfortable

confiding in me. If you have something personal to
talk about, I’ll try to give you my best advice and
answer your questions”


THANK YOU