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Adolescent Well Care: Making Every Opportunity Count

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1 Adolescent Well Care: Making Every Opportunity Count
Michele Dritz, MD, MS Adolescent Medicine Clinic Wright-Patterson AFB Medical Center

2 Overview Background data on adolescent preventive care provision
Adolescent preventive care guidelines Ohio and national statistics Current guidelines Setting the stage for providing quality care to adolescents

3 The rewards of caring for Adolescents
Many adult chronic diseases have origins in childhood and adolescence Most adolescent morbidity and mortality is preventable and related to personal health behavior – unintentional injuries, reproductive health issues, co-morbidities related to obesity Adolescence is a time of developing independence and establishment of long-term health behaviors Preventable problems related to personal behaviors where providers can help make a difference! 2005 CDC data (Leading causes of death ages 10-24yo) – 30% MVA, 15% homicide, 15% other intentional injury, 12% suicide, 28% other causes

4 Preventive Care Services
Only 38% of adolescents had a preventive care visit in the past year Only 35% of adolescents receive the recommended preventive care services On average, adolescents have non-preventive care visits times per year, versus times per year for preventive care visits Only 40% of adolescents had time alone with their provider at their last preventive care visit Recommended preventive care - RAND study from 2007 Annual preventive care visit & time alone– Irwin Pediatrics study – 2009 Preventive vs non-preventive care rates – Nordin 2010 study

5 Adolescent Preventive Care Guidelines
Lots of opinions… Guideline for Adolescent Preventive Services (GAPS) American Medical Association (AMA) Bright Futures (BF) American Academy of Pediatrics (AAP), Maternal & Child Health Bureau (MCHB), US Public Health Services Guide to Clinical Preventive Services United States Preventive Services Task Force (USPSTF) Recommendations for Pediatric Preventive Health Care American Academy of Pediatrics (AAP) Age Charts for Periodic Health Examinations American Academy of Family Physicians (AAFP) Adolescent Immunization updates Advisory Committee on Immunization Practices (ACIP) Different organizations use diff methods to arrive at their guidelines – UPSTF is based upon proven data, AMA (GAPS) & Bright Futures (AAP with other) also incorporates expert opinion b/c of lack of studies.

6 Not always a lot of consensus
Elster, AB, “Comparison for Recommendations for Adolescent Clinical Preventive Services Developed by National Organizations”, Arch Pediatr Adolesc Med, 1998, 152:

7 What’s a doctor to do?

8 Making the most of the visit
Medical history Psychosocial history with screening and counseling for high risk behaviors Adolescent exam and pelvic exam Screening and labs Immunizations Health guidance “We do that by making the most of the visits – in whatever form it comes in (acute care visit, preventive care visit)”

9 Medical History

10 Medical History Chronic medical conditions Medications and supplements
Prescription, Over-the-counter, nutritional supplements Past hospitalizations Medical, Psychiatric Surgical history Injury history Concussions, Sports injuries Family medical history Cardiovascular risk Psychiatric illnesses Substance abuse Mental health history Hospitalizations, counseling, suicide attempts, medications Review of systems Current concerns

11 Gynecological History
Last Menstrual Period – An adolescent vital sign Age of menarche Median = 12.4 years Cycle length Mean length = days Menstrual flow Normal length ≤7 days Typical menstrual products = 3-6 pads/tampons per day Ovulatory cycle symptoms Dysmenorrhea, headaches, PMS, PMDD Pregnancies and/or abortions

12 Psychosocial History and High Risk Behaviors

13 Taking a Psychosocial History
H: Home E: Education and Employment E: Eating A: Activities D: Drugs S: Sexuality S: Suicide and Depression S: Safety from Injury and Violence Handout: An essential update on HEEADSS – Contemporary Pediatrics Jan 2004 - “If you don’t ask, they usually won’t tell” - Psychosocial screening tool - HEADSS: developed by Cohen, et al – 1985; revised now to HEEADSSS (added Eating and Safety) HEADS in no way competes with the formal adolescent preventive care guidelines – rather it complements it as a strategy that physicians can use to gather necessary patient information in a busy clinical setting The order of the acronym is meant to allow a natural flow on conversation from less threatening questions (who do you live with, what school do you go to) to more personal and intrusive questions (questions about substance use, sex, depression and violence)

14 Eating Behaviors and Weight: Ohio & National Statistics
33% of Ohio teens are overweight or obese Over ½ of female teens and ⅓ of male teens use unhealthy weight control behaviors such as skipping meals, fasting, smoking, vomiting or using laxatives Eating disorders have the highest mortality rate of any other mental illness Obesity – Kaiser Family Foundation data – 2007 Other obesity facts: Youth Risk Behavior Surveillance (YRBS) – 2007 – Ohio Executive Summary Eating Disorder facts – South Carolina Dept of Mental Health – National statistics

15 Eating Behaviors and Weight
Important to screen both girls and boys Be cognizant of high risk categories for eating disorders: Involvement in weight-specific sports (wrestling, gymnastics, dance) and competitive athletes Frequent dieters Recent or significant weight loss; or being overweight Diabetes and other chronic illnesses Co-morbid psychiatric and personality disorders Family history (eating disorder, obesity) Ask about typical meal intake, exercise, body image and diets/other weight loss behaviors Plot BMI on a growth chart Ask about their weight goals and help develop with them healthy weight plans Opportunity to engage in motivational interviewing

16 Drugs & Substance Use: Ohio Statistics
29% report binge drinking (5 or more alcoholic drinks within a few hours) 20% report having their first drink before the age of 13 34% report using marijuana one or more times in their life 22% report smoking in the past month Youth Risk Behavior Surveillance (YRBS) – 2007 – Ohio Executive Summary (8% report using cocaine and 6% report “huffing”)

17 Drugs & Substance Use Increased risk-taking behavior is developmentally appropriate in adolescence, but can still be dangerous and lead to negative long-term consequences Screening tools developed to help providers assess risk category CRAFFT (alcohol and drugs) Know your local resources - CRAFFT – Knight et al – screening tool for adolescents ETOH & drug abuse or dependence risk C= driven in car, R= Do to relax, A= do when alone, F= do to forget, F= family/friends say quit, T= get in trouble when using Score of 2 or higher identifies abuse or dependence risk – need for advanced resources

18 Sex and Sexuality: Ohio Statistics
45% of Ohio teens have had sexual intercourse 40% did not use a condom during their last sexual encounter 5 to 6% of US students identify themselves as gay, lesbian, bisexual or transgender

19 Sex and Sexuality Importance of asking questions and not assuming anything In order to determine STD risk, you need to know what and where to screen May need to be specific in your questions: kissing, touching, oral sex, anal sex, penile-vaginal intercourse? When was the last time they had sex? Asking about safe sex: Did they use a condom? Have they ever had an STD? Have they ever been tested? Contraception: Have they ever been pregnant or had an abortion? Are they trying to get pregnant?

20 Suicide & Depression: Ohio Statistics
25% of teens report feeling depressed 13% of teens had suicidal ideations in the past year 7% attempted suicide in the past year 91% of parents were unaware of their teen’s suicide attempts

21 Suicide & Depression 2009 USPSTF recommendation for routine depression screening if systems in place for treatment Use screening tools such as PHQ-9, SIGECAPS or BDI to adequately assess risk Other important questions to ask: History of counseling? Psychiatric hospitalizations? Recent suicidal ideation? History of suicide attempt in past? Non-suicidal self-injurious behaviors If concern, assess current safety, presence of reliable adult support, if there are guns in the home Know your local resources PHQ-9 – “patient health questionnaire” – 9 questions (same idea as SIGECAPS – DSM IV criteria) but with Likert scale, recently validated in adolescents – score of 11 or higher suggested for adolescents to dx MDD SIGECAPS = sleep disturbance, interest/pleasure reduction, guilty/worthless feelings, energy changes/fatigue, concentration impairment, appetite/weight changes, psychomotor disturbances, suicidal thoughts For dx of depression = depressed mood plus 4 SIGECAPS BDI = becks depression invetory – 21 questions

22 Safety, Violence and Injury: Ohio Statistics
30% of teens said they were in a physical fight in the past year 28% reported being harassed or bullied on school grounds In Ohio, there were 47,444 confirmed cases of child abuse or neglect – 26% higher than the national average 23% of teen reporting riding in a vehicle driven by someone who had been drinking Weapon – knife, gun or club 90% of adolescents in Ohio are wearing their seatbelt while in the car

23 Violence and Injury Important to screen both boys and girls
Either can be victim or perpetrator Screening tools available: FISTS Ask about history of physical or sexual abuse, dating violence or witnessing domestic violence MVAs are the leading cause of morbidity in adolescents and young adults ages 10 to 24 Discuss use of seatbelts Discuss risks of drinking and driving or getting into car with driver that has been drinking Violence screening – FISTS – Fights (how many, last one), Injured or caused injury in a fight?, Sexual Violence (perp or victim), Threats (have you received), Self-defense strategies (how do you defend yourself) – assess resiliency to threats of violence

24 High Risk Behaviors Most risks are taken by “multiple-risk” teens who have many points of contact and therefore many possible intervention sites Nearly all teens, even multiple risk-taking adolescents participate in positive behaviors So what should a physician do? Celebrate and praise teens who are avoiding high-risk behaviors Encourage and support participation in positive behaviors, especially in risk-taking teens Target the risk-taking behaviors as a whole and work with the teen to minimize negative outcomes - The Urban Institute Publication – 2000 – “Teen Risk-Taking: A statistical Portrait” - 10 Risk Behaviors studied: regular ETOH use, binge drinking, regular tob use, MJ use, illicit drug use, fighting, weapon carrying, suicidal thoughts, suicide attempts, risky sexual activity - Risk behaviors are down 29% from - Positive behaviors – 92% of HS students were involved in at least one positive behavior

25 Adolescent Exam

26 Physical Exam Vitals, including last menstrual period (LMP)
Height, weight, BMI Plot height, weight & BMI Overweight = BMI 85th – 95th percentile Obese = BMI ≥ 95th percentile Underweight = BMI <5th percentile Comprehensive physical Importance of having teen change into a gown to be able to do thorough skin and genitourinary (GU) exam Vision Screening guidelines – GAPS (AMA)

27 Male GU Exam Determine Sexual Maturity Rating (SMR)
Look for signs of STIs Penile discharge, warts, vesicles Examine testicles Hydrocele, hernia, varicocele, mass

28 Female GU Exam Determine Sexual Maturity Rating (SMR) – breast and genitals Look for signs of STIs Vaginal discharge, warts, vesicles Is a pelvic exam necessary? AAP: All sexually active females ACOG: Not necessarily at 1st visit, but with annual STD screen GAPS: No, can do STD screening via vaginal or urine sample for females, urine sample for males Bright Futures: If “clinically warranted” Do a pelvic exam if: Symptomatic Vaginal symptoms, abdominal or pelvic pain, abnormal bleeding Question about pubertal development or primary amenorrhea Due for a pap smear Current ACOG recommendations, 21 years or older Pelvic exam includes external exam, speculum and bimanual

29 Screening and Labs

30 Screening and Labs: Ohio Statistics
26% of US female adolescents had at least one of the most common STIs (HPV, Chlamydia, Trichomonas, HSV) Syphilis rates in Ohio teens have more than tripled since 2005 Approximately 10% of US teens have elevated cholesterol levels The incidence rate of Type II Diabetes in Cincinnati children has increased 10-fold STDs – National Health & Nutrition Examination Survey – Syphilis – Ohio dept of health DM II – CCHMC article

31 Screening and Labs Sexually Transmitted Infections:
Gonorrhea (Females) Chlamydia (Females) Trichomonas (Females) HIV Syphilis Pap smear4 (HPV) Pharyngeal & Rectal Gonorrhea5 Rectal Chlamydia5 Abstinent Once At age 21 Sexually active Yearly (Males) (Yearly) (prn) High Risk1 (q 3-6 mo) MSM2 (anal pap) WSW3 yearly (yearly) prn Table above is based upon 2010 CDC guidelines (all STDs) and 2009 ACOG recommendation (pap) Things in parenthesis are not recommended by CDC or ACOG, but general consensus in AM community All guidelines from CDC Pap guidelines from ACOG 3) HIV recs – 2006 CDC – all patients ages 13-64yo, regardless of risk status (risk-based testing not sufficient in identifying HIV positive patients); AAP recommendation states all patients should receive HIV counseling, but only “high risk” get screened 4) No specific syphilis guidelines, but our practice given the syphilis epidemic in Cincinnati & Ohio 1High Risk = >1 sex partner in past 6 months, history of STI, IV drug use, sex for money, homeless, sex with high risk partner 2MSM = men who have sex with men 3WSW = women who have sex with women 4Pap Smear = ACOG: 21 yo; American Cancer Society: 3 years after sex or by 21 yo 5Based on risk due to sexual practices

32 Screening and Labs Sexually Transmitted Infections: If asymptomatic:
Males: Urine GC/CT NAAT (“1st catch” urine) Females: Vaginal GC/CT NAAT (self-obtained) – preferred method urine GC/CT NAAT also option (“1st catch” urine) Trichomonas vaginal swab (can be self obtained) If symptomatic: Male: Female: Endocervical, Vaginal or urine GC/CT NAAT Trichomonas vaginal swab (physician obtained) Pelvic exam with bimanual NAAT – Nucleic Acid amplification test – “dirty” urine catch, keep to 60ml or less (to not dilute sample) 2005 study – Schachter at UCSF– self obtained vaginal swab NAAT for CT & GC– same sensitivity as endocervical physician sample (95-99% for both), slightly higher than urine (missed ~1-4% - better sensitivity for GC) - whether patient asymptomatic or symptomatic Early evidence that NAAT is comparable to culture (previous gold standard) for rectal and pharyngeal testing 2002 study in the Archives of Pediatric & Adol Med – adolescents prefer urine sample 1st, self-obtained vaginal 2nd and physician obtained swab 3rd One drawback of NAAT specimen is inability to perform antibiotic susceptability testing (esp with growing abx resistance to gonorrhea) Trichomonas still potential STD in males, just not as easy to detect with current testing methods, therefore, not usually tested for – instead automatically treated if partner known to be positive.

33 Screening and Labs Tuberculosis: PPD
Recommendation: Selective screening based upon risk factors Suspected contact with TB Clinical or radiographic findings suspicious for TB Emigration from TB endemic area Travel to TB endemic countries or close contact with travel to those areas Live in high prevalance TB area as determined by local health department HIV positive Live with someone who is HIV positive Incarcerated adolescents Exposure to HIV positive individuals, homeless persons or nursing home residents Institutionalized adolescents Illicit drug use Migrant farm worker Exposure to high-risk adult

34 Screening and Labs Dyslipidemia: Fasting lipid panel
No recommendation for universal screening, but selective screening by most guidelines Concern is that targeted screening misses up to ½ of all affected teens, but recommended intervention is typically only diet and exercise Selective screening if any of the following: Family history of premature CHD (<55 yo) Parent with total cholesterol of > 240 mg/dl Family history unknown Obesity High blood pressure Diabetes Heart disease If results normal, repeat every 3-5 years Dyslipidemia screening – 2008 AAP policy statement based on NHLBI’s National Cholesterol Education Program (NCEP)

35 Screening and Labs Diabetes: Fasting plasma glucose:
No recommendation for universal screening and no pediatric specific recommendations by any of the adolescent guidelines Concern is due to increasing rates of adolescent obesity and associated co-morbidities and insulin resistance American Diabetes Association “consensus statement” for screening adolescents: Overweight/Obese PLUS 2 OF THE FOLLOWING: 1st or 2nd degree relative with Type 2 DM Native American, African American, Hispanic American, Asian/South Pacific Islander Signs or conditions associated with insulin resistance (PCOS, acanthosis nigricans, HTN, dyslipidemia) Retest every 2 years ADA “consensus statement”

36 Screening and Labs Anemia: Vision Screen: Hearing Screen:
High prevalence of iron deficiency anemia due to poor diet, rapid growth and menstrual losses Only recommended by AAP Hemoglobin or Hematocrit With 1st visit, end of puberty or both Vision Screen: Mixed opinions Recommendation: At initial visit, and then every 2-3 years Hearing Screen: At least once during adolescence

37 Immunizations

38 Immunizations 2011 Advisory Committee on Immunization Practice (ACIP) update:

39 Immunizations Adolescent Specific: Tdap: MCV4: HPV:
Recommendation: years Catch-up: years Booster: Td booster every 10 years MCV4: Booster: at age 16 years Catch-up: 1 dose at age years Dose 1 at years, booster at years 1 dose if previously unvaccinated college freshman living in dorm HPV: HPV4 (Gardasil) – HPV 16, 18, 6, 11 – females and males HPV 2 (Cervarix) – HPV 16, 18 – females only Recommendation: 3 shot series at years

40 Immunizations Childhood Catch-up: Continuous: Varicella Hepatitis B:
Recommendation: 2 dose series if no clinical immunity and no previous immunization 1 dose due for catch-up if previously received only single dose Hepatitis B: Recommendation: 3 dose series if not previously vaccinated Hepatitis A: Recommendation: 2 dose series if MSM or other high risk group Catch-up for any other recommended childhood vaccines IPV, MMR Continuous: Influenza: Recommendation: Yearly

41 Health Guidance

42 Health Guidance Guidance for parents: Normative adolescent development
Physical, emotional and sexual development Discussing health-related behaviors with their teens Acting as positive role models Methods to help teens avoid potential injuries: Safe driving Avoiding weapons at home Monitoring their teen’s activities Maintaining open communication with their teen

43 Health Guidance Guidance for adolescents: Normative development
Physical, emotional and sexual development Importance of becoming actively involved in their health care and medical decisions How to avoid potential injury: Safe driving Use of safety devices (helmets, seatbelts, etc) Healthy interpersonal relationships Avoiding weapons Promotion of physical activity and healthy dietary habits Responsible sexual behavior including abstinence, condom use, contraception, and STI screening. Avoidance of tobacco, alcohol, drugs and anabolic steroids

44 Health Guidance Mixed Opinions: Breast self-exam (BSE)
USPSTF recommended against routine BSE (2009) ACOG still recommends Still recommended in all adolescent preventive services guidelines except GAPS (AMA) Testicular self-exam (TSE) USPSTF recommended against routine TSE and physician testicular exam for testicular cancer screening (2004) American Cancer Society does not recommend USPSTF – US Preventive Services Task force Against BSE b/c no yield with increased risk of emotional trauma and bx Against TSE b/c low yield, low incidence of testicular cancer and favorable outcomes when discovered – even among high risk populations (h/o undescended testes or testicular atrophy)

45 So how do we go from here…
to there?

46 Setting the Stage

47 Setting the Stage Capturing every opportunity at every visit
Honoring confidentiality Asking the right questions to gather a thorough psychosocial history Fostering behavior change through motivational interviewing Recommended preventive care - RAND study from 2007 Annual preventive care visit & time alone– Irwin Pediatrics study – 2009 Preventive vs non-preventive care rates – Nordin 2010 study

48 Capturing Every Opportunity
Develop processes that automatically allow the right thing to happen every time Immunization standing orders “Best Practice” reminders Consider the use of screening tools to optimize both the reliability of care and use of time Risk behaviors, depression, substance use Have health education tools readily accessible for patients and create a teen-friendly environment Take a team approach and consider developing a quality improvement team Track your practices performance over time Screening tools: Depression: PHQ-9, BDI, SIGECAPS Substance Use: CRAFFT Violence: FISTS General risk profile: GAPS

49 Honoring Confidentiality
Recognize an adolescent’s legal right to confidential services Ohio law: Can consent: STI counseling & treatment, HIV testing, substance abuse evaluation and treatment, limited mental health evaluation and treatment, emergency treatment, sexual assault services, adoption Cannot consent: abortion, psychiatric medication, inpatient psychiatric hospitalization, HIV treatment No law either way: contraception including emergency contraception, pregnancy testing, prenatal care Making confidentiality a part of the discussion from the beginning “New Patient” letter Website Initial and subsequent visits - Physicians for Reproductive Rights & Health – PRCH – publishes resource card for physicians on minors’ consent laws for each state - For some of these services, even though Ohio may not have a law, minors are afforded the right to consent in federally-funded clinics through Title X (pregnancy testing, contraception,

50 Honoring Confidentiality
Discussing confidentiality with both teens and parents Stressing importance of open communication Data showing importance of confidentiality in adolescents seeking care Stress that both you and parent have the same interest – to keep their teen healthy and safe Discussing the limits of confidentiality Concern for harm to self or others, or harm done to them Areas of possible disclosure (i.e. insurance billing, mental health records) Acting on that promise Seeing the teen alone for part of the visit Getting alternative contact info for teen in case necessary (i.e. cell phone) Advice on confidential billing options available on the Society for Adolescent Health & Medicine’s website

51 Asking the Right Questions
Don’t be afraid to ask…but realize it is up to you to create a safe environment for them to be able answer honestly Small talk matters in building a relationship of trust Consider using screening tools to stream line data collection GAPS Initial Adolescent Preventive Services Form, GAPS Parent/Guardian Questionnaire, topic-specific screening tools If time is short, focus on high risk behaviors that need to be addressed immediately and then have them follow-up If you feel you are out of your element, ask for help GAPS teen & parent questionnaires – extremely thorough (medical hx, past hx, family hx, psychosocial hx), several pages long Earning trust with teens – 2005 – J of Family Practice - asking for adolescent's opinion, keeping private information confidential, not withholding information, and engaging in small talk to show concern.

52 Fostering Behavior Change
Strong evidence regarding using motivational interviewing to facilitate positive behavior changes Motivational interviewing techniques natural fit for adolescent developmental stages: Collaborative approach to health priorities Gives adolescents a voice in the decision process Allows for proactive problem solving Helps build self-efficacy and self-esteem Creates opportunity for frequent follow-up Motivation is the driver of behavior change – so understanding what motivates your patient is key Consider behavior changes for your clinic as well Utilizing newer technologies to better serve adolescents needs “Meeting teens where they are” Handout: Motivational Interviewing 2 part article – Contemporary Pediatrics (Dec 2010, Jan 2011) - People are more likely to change a behavior if they view the alternative behavior as positive - Utilizing newer technologies to help implement preventive care strategies – PDAs for screening & improving sense of confidentiality - “Meeting teens where they are” to provide important health messages – cell phones, social networking sites

53 In the end… The majority of adolescents move successfully from childhood to adulthood with the help and support of: Families, Friends, Communities, Social institutions, Physicians More than ¾ volunteered in the past year Nearly ½ feel they can make a difference in their communities Over ⅓ say religion plays a large role in their life More than 90% of teens are enrolled in school or employed 87% of young adults completed high school More than ¾ felt they could go to their parents for advice and guidance in time of need There has been a 29% increase in the proportion of teens choosing healthy behaviors over health-risk behavior US Dept of Health & Human Services – “Celebrating America’s Youth”

54 You play a key role in helping teens navigate adolescence successfully… And that creates a solid foundation not just for their health today, but for their tomorrows to come

55 Bibliography Youth Risk & Behavior Surveillance, Ohio Executive Summary, Ohio Department of Health, 2007. National Longitudinal Study of Adolescent Health, 2001, National Health and Nutrition Examination Survey (NHANES), , . Ohio Department of Health, South Carolina Department of Mental Health, Eating Disorder Statistics, Neinstein, LS, Adolescent Health Care: A Practical Guide, 4th Edition, Lippincott Williams & Wilkins, 2002. Mangione-Smith, R et al, “The Quality of Ambulatory Care Delivered to Children in the United States”, NEJM, 2007, 357(15): Irwin, CE et al, “Preventive Care for Adolescents: Few Get Visits and Fewer Get Services”, Pediatrics, 2009, 123:e565-e572. Nordin, JD et al, “Adolescent Primary Care Visit Patterns”, Ann Fam Med, 2010, 8: Elster, AB, “Comparison for Recommendations for Adolescent Clinical Preventive Services Developed by National Organizations”, Arch Pediatr Adolesc Med, 1998, 152:

56 Bibliography Elster, A., “Guidelines for Adolescent Preventive Services”, UpToDate, Sept 2010 , Goldenring, J, Rosen, D, “Getting into Adolescents Heads: An Essential Update”, Contemp Pediatr, 2004, 21:64. Bloomgarden, ZT, “Type 2 Diabetes in the Young: The evolving epidemic”, Diabetes Care, 2004, 27(4): Stephen R. Daniels, Frank R. Greer and the Committee on Nutrition , “Lipid Screening and Cardiovascular Health in Childhood,” Pediatrics, 2008; 122: American Diabetes Association, “Screening for Diabetes”, Diabetes Care, 2002, 25(1supplement): s21-s24. Center for Disease Control and Prevention, 2010 STD Treatment Guidelines, Schachter, J et al, “Vaginal Swabs Are the Specimens of Choice When Screening for Chlamydia trachomatis and Neisseria gonorrhoeae: Results From a Multicenter Evaluation of the APTIMA Assays for Both Infections”, Sex Transm Dis, 2005, 32(12):725-8. Center for Disease Control and Prevention, 2011 Advisory Committee on Immunization Practices,

57 Bibliography US Preventive Services Task Force, “Screening for Testicular Cancer Recommendation Statement”, 2004. American Congress of Obstetricians and Gynecologists, “Response of The American College of Obstetricians and Gynecologists to New Breast Cancer Screening Recommendations from the U.S. Preventive Services Task Force”, 2009. Physcians for Reproductive Choice and Health, “Minors ‘Access to Reproductive Healthcare in Ohio”, Klostermann, B et al, “Earning trust and losing it: Adolescents’ views on trusting physicians”, J of Family Practice, 2005, 54(8): US Department of Health and Human Services, National Clearinghouse on Families and Youth, “Celebrating America’s Youth: The Facts are Positive”, Tellerman K. Catalyst for change: motivational interviewing can help parents to help their kids. Part 1. Contemp Pediatr. 2010;27(12):26-38. Tellerman K. Catalyst for change: motivational interviewing can help parents to help their kids. Part 2. Contemp Pediatr, 2011, 28(1):47-54.

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