1. Adolescent Friendly Health Services

2. Outline Barriers to healthcare faced by adolescents
Adolescent-friendly health services
Essentials of communication
“HEEADSSS”
Cases

3. Objectives
By the end of this presentation, participants will be able to:
Identify three key barriers to healthcare access faced by adolescents.
Describe three elements of adolescent-friendly health services.
Utilize the HEEADSSS model of patient interviewing.

4. Adolescents For the most part, adolescents are: Adolescents are not:
Healthy.
Resilient.
Independent yet vulnerable.
Adolescents are not:
Big children.
Little adults.

5. The Culture of Adolescence
Peer dependent
Egocentric
Distinct language and dress
Popular culture influence
Ongoing search for identity

6. Why Focus on Adolescent Health?
Reduce death and disease, now and for the rest of their lives
Fulfill the rights of adolescents to healthcare, especially reproductive healthcare
Increase the chances for healthy adulthood
Lifelong health habits are formed in this time period, creating a unique window for healthcare providers and health educators.
Adolescents are at particular risk for behaviors that may lead to health conditions, including STIs and alcohol and drug use. During routine healthcare visits, providers have an opportunity to screen for risk and provide health education.

7. Early Adolescence 11–14 Characterized by a spurt of growth
Beginning of sexual maturation
Start to think abstractly
The early adolescent is usually considered 11–14 years old.
It is important for physicians to understand the different phases of adolescence in order to connect with the adolescent patient in a meaningful way.
For example, counseling a younger teenager about cigarette cessation must be accomplished in a concrete fashion (e.g., focus on bad breath, teeth staining, or the cost of cigarettes) and not with the distant threat of future cancer. As adolescents age and are capable of more abstract thoughts, counseling methods will change.
Sources:
Forman S, Emans S. Current Goals for Adolescent Health Care. Hospital Physician. 2000;27–42.
Adolescent Friendly Health Services: An Agenda for Change. The World Health Organization, Available at:

8. Middle Adolescence 15–17 Physical changes of puberty are complete
Develop a stronger sense of identity and relate more strongly to peer group
Thinking becomes more reflective
Mid-adolescents are usually 15–17 years old.

9. Late Adolescence 18 and older
The body continues to develop and takes adult form
Development of distinct identity and more settled ideas and opinions
18 and above

10. 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
Additionally, adolescents face many structural and external barriers that may limit access and willingness to utilize health services.
Primarily, confidentiality concerns can significantly limit healthcare utilization for adolescents. A recent study of girls younger than 18 years old attending family planning clinics found that 47% would no longer attend if their parents had to be notified that they were seeking prescription birth control pills or devices, and another 10% would delay or discontinue STI testing or treatment. [i]
Clinician-related barriers also exist, including insensitive attitudes on the part of providers, lack of knowledge and skills regarding reproductive and sexual health, insufficient or inadequate communication, and clinician discomfort with the discussion of sexual behavior with adolescents. [ii]
Since teenagers often rely on others for transportation, geographically inaccessible locales can be formidable structural barriers to care.
Sources:
[i] Reddy DM, Fleming R, Swain C. Effect of mandatory parental notification on adolescent girls’ use of sexual health care services. JAMA 2002;288:710–4.
[ii] Huppert JS, Adams Hillard PK. Sexually transmitted disease screening in teens. Curr Womens Health Rep 2003;2:451–8.

11. External Barriers: Lack of Insurance
75,040 children under the age of 18 lack health insurance.
29,313 youths ages 18–24 are uninsured.
The risk of being uninsured historically doubled when a teen turned 19.
Affordable Care Act allows young adults to stay on parent’s health care plan until age 26.
Lack of money and insurance is a significant external barrier to reproductive and sexual healthcare.
Providers should be aware of referral resources (county STD clinic, immunization health fairs, slide-scale fee services) in their communities.
Bullets 1 and 2: U.S. Census Bureau, Current Population Survey, 2009 and 2010 Annual Social and Economic Supplements. Table 8: People Without Health Insurance Coverage by Selected Characteristics: 2008 and Accessed: November 3, 2010:
Bullet 3:Source: Quinn K, Schoen C, Buatti L. On Their Own: Young Adults Living Without Health Insurance. New York, NY: Commonwealth Fund; 2000
Bullet 4: Young Adults and the Affordable Care Act: Protecting Young Adults and Eliminating Burdens on Families and Businesses. Regulations and Guidelines, U.S. Department of Health and Human Services. Accessed November 3, 2010:

12. Lack of Insurance = Lack of Care
Insured adolescents visit a physician’s office twice as often as uninsured teens.
In a 1997 survey of adolescent girls:
50% of uninsured girls reported foregoing needed care.
More than twice the rate of insured girls
Bullet 1 – Source: Adolescent Health Care and Health Services Research. Role of Partnerships: Second Annual Meeting of Child Health Services Researchers. June 27, Agency for Healthcare Research and Quality, Rockville, MD.
Bullet 2 – Source: Klein JD, Wilson K, McNulty M, Kaplan C, Collins K. Access to medical care for adolescents: results from the 1997 Commonwealth Fund survey of the health of adolescent girls. J Adol Health. 1999;25:120–130
Note: More recent research has found that adolescents who were poor and uninsured were less likely to get a preventative care visit than those who had insurance. Source: Preventive Care for Adolescents: Few Get Visits and Fewer Get Services. Charles Irwin, Jr., Sally Adams, M. Jane Park and Paul Newacheck. Pediatrics 2009; 123; e565–e572. DOI: /peds.2008–2601. Accessed November 3,2010:

13. Adolescent-Friendly Health Services Include:
Establishing a comfortable, confidential, safe space maintained by office staff and providers.
Communicating respectfully and appropriately.
Screening for high-risk behavior.
Awareness of how:
ability, age, culture, gender identity, sexual orientation, religion, socioeconomic status, can affect an adolescent’s reproductive health.

14. Adolescent Friendly Services:
Adolescent-specific
Multi- and interdisciplinary
Accessible
Financially affordable
Adolescent-focused materials on display
Peer educator component
Adequate space
Confidential
Flexible scheduling
Comprehensive services
Continuity of care
Help transitioning into the adult medical care system
Communication and flexibility are a vital part of adolescent care. Examination requirements and guidelines can be flexible, and providers should undertake the most appropriate steps to maximize the adolescent's health.

15. Preparing for Clinical Visits

16. Discuss Confidentiality in Advance
Inform parents about confidentiality policy before visit.
Letter home:
Detail when parent will be included in clinical visit and when not.
Discuss billing issues.
Display materials such as posters or brochures discussing importance of doctor/patient confidentiality (See packet for examples).

17. OUR POLICY ON CONFIDENTIALITY
Our discussions with you are private. We hope that you feel free to talk openly with us about yourself and your health. Information is not shared with other people unless we are concerned that someone is in danger.
Sample statement developed by URMC Department of Pediatrics

18. Develop Referral Network
Social worker
Nutritionist
Psychologist or counselor
Abortion, adoption, and prenatal care services
STD clinics
Department of Health clinics

19. The Clinical Interview

20. Comprehensive HEEADSSS
H: Home
E: Education/Employment
E: Exercise/Eating
A: Activities
D: Drugs
S: Suicidality/Depression
S: Sexuality
S: Safety
*Additional questions:
Strengths, Spirituality
The major causes of morbidity and mortality in the adolescent population are unintentional injuries, many of which are related to alcohol and drug use.
Other causes of morbidity include unintended pregnancy, sexually transmitted diseases, eating disorders, and depression.
These factors are not easily discernable from the traditional patient/physician model of health interviewing.
The healthcare provider who sees adolescents must be willing to take a developmentally appropriate psychosocial history.
The HEEADSSS Model was developed in 1972 by Dr. Harvey Berman of Seattle and refined by Dr. Eric Cohen and Dr. John M. Goldenring. Dr. Melanie Gold, DO, Associate Professor of Pediatrics, Division of Adolescent Medicine, University of Pittsburgh School of Medicine, is on the Adolescent Reproductive Health Education Committee and kindly developed the corresponding questions for this model.
The HEEADSSS questions should be asked without a parent in the room unless the adolescent specifically gives permission or asks for a parent’s presence. If the questions are asked and answered with other people in the room, document this in chart and that this was by patient request.
Some providers add additional categories to this tool. For example, assessing the role of spirituality in the patient’s life can bring greater understanding of the context of their home life and personal decisions. Adding an assessment of strengths gives clinicians an opportunity to assess resiliency and give positive reinforcement.
Source:
Goldenring, JM and Rosen DS (2004) Getting into adolescent heads: An essential update. Contemp Pediatr 2004; 21(1):64–90.

21. Utilizing HEEADSSS
Time limitations make model difficult
Can use written questionnaire in waiting room
Provider should follow up on answers drawing concern

22. Other Clinical Interview Tools
GAPS: AMA Guidelines for Adolescent Preventive Services
Bright Futures: Collaboration between AAP and Bureau of Maternal Child Health Care
Trigger Questionnaire: Developed by Office of Managed Care in the New York State Department of Health
ACOG Tool Kit: Designed by the ACOG Committee on Adolescent Health Care to help every office care for adolescent patients

23. Home

24. US Children: Home Demographics, 2007
27% live with families where no parent has full-time, year-round employment
34% live in single-parent households
20% live in poverty
24% of 18–24 year olds live in poverty
Source:
Annie E. Casey Foundation (2008). KIDS COUNTS Date Center. Accessed: November 3,
Annie E. Casey Foundation (2009). KIDS COUNTS Date Center. Accessed: November 3,
Annie E. Casey Foundation (2009). KIDS COUNTS Date Center. Accessed: November 3,
Annie E. Casey Foundation (2009). KIDS COUNTS Date Center. Accessed: November 3,

25. Home Who lives in the home with you?
How are your relationships with siblings, parents, other relatives?
Who do you go to for advice?
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?
It is important to begin the assessment with questions regarding the adolescent’s home life.
The first question: Who lives in the home with you? Is in bold because the answer to this will dictate the rest of the interview.
Keep questions specific, allowing the patient to expound when needed.
Adapted from the presentation "Interviewing the Adolescent: Tricks of the Trade" by Melanie A. Gold, D.O., Associate Professor of Pediatrics, Division of Adolescent Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA.

26. Education and Employment
Healthcare providers need to be aware of the risk factors associated with poor academic performance.
Poor attendance and grades have been shown to be a risk factor for early sexual initiation and teenage pregnancy.
Source: Santelli JS, Kaiser J, Hirsch L, Radosh A, Simkin L, Middlestadt S. Initiation of sexual intercourse among middle school adolescents: the influence of psychosocial factors. J Adolesc Health. 2004;34(3):200–8.
Additionally, poor academic performance and truancy have been linked with alcohol abuse.
Source: Ellickson SL, Tucker JS, Klein DJ, McGuigan KA. Prospective risk factors for alcohol misuse in late adolescence. J Stud Alcohol 2001;62(6):773–82

27. Education and Employment
In 2009, of U.S. eighth graders:
29% scored below basic math level
26% scored below basic reading level
Since 2008:
9% of teens not attending school and not working
14% of 18–24 year olds not attending school, not working, a high school degree
Source of statistics:
Annie E. Casey Foundation (2009). KIDS COUNTS Date Center. Accessed: November 3, 2010.
Annie E. Casey Foundation (2009). KIDS COUNTS Date Center. Accessed: November 3,
Annie E. Casey Foundation (2008). KIDS COUNTS Date Center. Accessed: November 3,

28. Education What is the name of your school and what grade are you in?
What kind of student are you?
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?
Adapted from the presentation "Interviewing the Adolescent: Tricks of the Trade" by Melanie A. Gold, DO, Associate Professor of Pediatrics, Division of Adolescent Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA.

29. Employment Do you work after school? 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?
Adolescents are often employed part-time during the school year.
Frequently by their senior year, they are working more than 20 hours a week.
A review of the literature reveals that adolescent employment has both positive and negative effects.
Positive effects of adolescent employment include a stronger sense of personal efficacy and orientation to occupational achievement.
Working has also been associated with negative aspects of adolescents’ psychological, behavioral, and social well-being. For example, working adolescents, especially girls, have been found to be notably more depressed.
Working adolescents have also been noted to experience inferior relationships with their parents, which may be related to spending less time with their families.
In addition to less family time, they have less time to spend on homework, which may result in a lower grade point average.
It is important for the healthcare provider to assess the impact that employment is having on the adolescent’s development, including ability to handle stress, mood, and relationships.
Sources:
Bachman J, Schulenberg J. How part-time work intensity relates to drug use, problem behavior, time use and satisfaction among high school seniors: Are these consequences or merely correlates? Developmental Psychology 2003;29:220–235.
Mael , Morath R, McLellan J. Dimensions of adolescent employment. Career Development Quarterly 1997;45:351–368.
Sayfer A, Leahy B, Colan N. The impact of work on adolescent development. Journal of Contemporary Human Services 1995;1:38–45.
Steinberg L, Dornbusch S. Negative correlates of part-time employment during adolescence: Replication and elaboration. Developmental Psychology 1991;27:304–313.

30. Exercise and Eating
Adolescence is a critical juncture in adoption of health behaviors.
The early formation of health behaviors, such as eating fruits and vegetables and engaging in regular exercise, contributes to the delay of major morbidity and mortality later in life.
It is important to assess the adolescent’s diet and exercise regimen and to screen for eating disorders and body image distortion.
Two of the main eating disorders are:
Anorexia nervosa
A disorder that involves a distorted body image and the pursuit of thinness through drastic means including starvation and excessive exercise.
Bulimia nervosa
This disorder involves a cycle of binge eating followed by purging in the form of vomiting, laxatives, or exercise.

31. US High School Students: Weight, 2011 YRBS
Source: Centers for Disease Control and Prevention. Youth Risk Behavior Surveillance – United States, Surveillance Summaries, August 2, MMWR 2012;61(No. 4).

32. Controlling Weight, 2009 and 2011 YRBS
“Took Diet Pills,” and “Vomited or Took Laxatives,” Source: Centers for Disease Control and Prevention. Youth Risk Behavior Surveillance – United States, Surveillance Summaries, August 2, MMWR 2012;61(No. 4).
“Were Trying to Lose Weight,” and “Went 24 hours without Eating,” from 2009 YRSB Data. Source: Centers for Disease Control and Prevention. Youth Risk Behavior Surveillance – United States, Surveillance Summaries, June 4, MMWR 2010;59(No. SS-5).

33. Exercise Behaviors, 2011 YRBS
28.7% met recommended levels of physical activity
48.2% attended physical education less than once per week
Nationwide, 28.7% of students had been physically active doing any kind of physical activity that increased their heart rate and made them breathe hard some of the time for a total of at least 60 minutes per day during the 7 days before the survey (i.e., physically active at least 60 minutes per day on 5 or more days)
Nationwide, 51.8% of students went to physical education (PE) classes on 1 or more days in an average week when they were in school (i.e., attended PE classes).
Source: Centers for Disease Control and Prevention. Youth Risk Behavior Surveillance – United States, Surveillance Summaries, August 2, MMWR 2012;61(No. 4).

34. Exercise/Eating Body image: What is your ideal weight?
What do you like about yourself?
Calcium, iron, fiber in diet?
How many meals do you eat per day?
Bowel movement pattern and problems?
Thin: Do you exercise, ever vomited, used diuretics, laxatives?
Overweight: Do you drink soda/juice, whole milk? Exercise? TV?
Adapted from the presentation "Interviewing the Adolescent: Tricks of the Trade" by Melanie A. Gold, DO, Associate Professor of Pediatrics, Division of Adolescent Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA.

35. Activities
An estimated 8 million school-age children are home alone after school. [i]
These are the hours when violent juvenile crime peaks and when youth are most likely to experiment with alcohol, tobacco, drugs, and sex. [ii]
After-school programs help to reduce juvenile crime and violence because they offer alternative activities for children and youth during their out-of-school time. [iii]
Sources:
[i] U.S. Department of Education. (2001). 21st Century Community Learning Centers [Online]. Available:
[ii] Snyder, H. N., & Sickmund, M. JUVENILE OFFENDERS AND VICTIMS: 1999 NATIONAL REPORT. Washington, DC: Office of Juvenile Justice and Delinquency Programs, 1999.
[iii] Roth J, Brooks-Gunn J, Murray L, Foster W. Promoting healthy adolescents: Synthesis of youth development program evaluations. Journal of Adolescence 1998;8(4), 423–459.

36. 58.4% reported having played on a sports teams in the past 12 months
Activities, 2011 YRBS:
58.4% reported having played on a sports teams in the past 12 months
32.4% reported watching 3 or more hours of television per day
31.1% reported using a computer 3 or more hours/ day
Source: Centers for Disease Control and Prevention. Youth Risk Behavior Surveillance – United States, Surveillance Summaries, August 2, MMWR 2012;61(No. 4).

37. Activities 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?
Adapted from the presentation "Interviewing the Adolescent: Tricks of the Trade" by Melanie A. Gold, DO, Associate Professor of Pediatrics, Division of Adolescent Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA.

38. Drug and Alcohol Use
In shifting from the non-sensitive, more general questions (home, activities, etc.) to questions regarding drugs, alcohol, and sex, it is important to acknowledge that a shift has taken place, explain to patients why you are asking about these behaviors, and once again secure confidentiality.
Most adolescents experiment with drugs at some point in their development, whether limited to alcohol, caffeine, and cigarettes or extended to marijuana, cocaine, and hard drugs. The United States has the highest rate of adolescent drug use of any industrialized nation. [i]
Adolescents who use drugs to manage stress are of particular concern as this can interfere with coping skills and responsible decision-making, and can lead to life long addiction. [ii]
Sources:
[i] Johnston L, O’Malley, P, and Bachman J. National survey results on drug use from the Monitoring the Future Study, Vol.1: Secondary school students. Ann Arbor: University of Michigan, Institute of Social Research, 1999.
[ii] Santrock, J. Child Development. University of Texas: Dallas, 2001.

39. Substance Use, 2011 YRBS: Ever Used: 70.8% drank alcohol
21.9% reported episodic heavy drinking
39.9% used marijuana
11.4% inhalants
8.2% ecstasy
6.8% cocaine
3.8% methamphetamines
During 1991–2011, a significant linear decrease occurred in the percentage of students who ever drank alcohol (81.6%–70.8%). The percentage of students who reported current alcohol use did not change significantly during 1991–1999 (50.8%–50.0%) and then decreased during 1999–2009 (50.0%–41.8%). The percentage of students who reported current alcohol use also decreased during 2007–2009 (44.7%–41.8%). The percentage of students who reported binge drinking did not change significantly during 1991–1997 (31.3%–33.4%) and then decreased during 1997–2011 (33.4%–21.9%). The percentage of students who ever used marijuana increased during 1991–1999 (31.3%–47.2%) and then decreased during 1999–2009 (47.2%–39.9%). The percentage of students who reported current marijuana use increased during 1991–1999 (14.7%–26.7%) and then decreased during 1999–2009 (26.7%–20.8%).
The percentage of students who ever used cocaine increased during 1991–1999 (5.9%–9.5%) and then decreased during 1999–2011 (9.5%–6.8%), and the percentage of students who reported current cocaine use increased during 1991–2001 (1.7%–4.2%) and then decreased during 2001–2009 (4.2%–2.8%). The percentage of students who ever used inhalants decreased during 1995–2003 (20.3%–12.1%) and then did not change significantly during 2003–2011 (12.1%–11.4%). The percentage of students who ever used inhalants also decreased during
2007–2011(13.3%–11.4%). During 2001–2009, a significant linear decrease occurred in the percentage of students who ever used ecstasy (11.1%–6.7%). The percentage of students who ever used methamphetamines did not change significantly during 1999–2001 (9.1%–9.8%) and then decreased during 2001–2011(9.8%–3.8%).
Source: Centers for Disease Control and Prevention. Youth Risk Behavior Surveillance – United States, Surveillance Summaries, August 2, MMWR 2012;61(No. 4).

40. Drugs and Alcohol
Does anyone you hang out with smoke, drink, or use drugs? Do you?
How frequently and how much?
Do you smoke or chew tobacco?
Do you use anabolic steroids?
Do you drink alcohol?
What kind: beer, wine, hard liquor?
Any blackouts? Ever pass out? Vomit?

41. Drugs and Alcohol Do you use any illicit drugs?
Marijuana, inhalants, cocaine, crack, heroin, pills, LSD, ecstasy, crystal meth, other drugs?
Ever do anything you have regretted while high?
Context of use: socially, alone, how often?
Attitudes toward cutting back and/or quitting?
Ever received drug treatment or counseling?
How is your drug use supported?
Have you ever had any arrests?

42. 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?
“Yes” to 2 or more suggest high risk of substance use disorder. This instrument was developed by John Knight, M.D., Children's Hospital Boston.
Copyright © Children's Hospital Boston. All rights reserved

43. Depression and Suicidality
It is important to screen all teenagers for depression, not just those who may look depressed. Suicide is now the third leading cause of death in 15–24 year olds. [i]
Though females are more likely to attempt suicide, males are about three times as likely to succeed. This may be because of their choice of more lethal methods for attempting suicide. [ii]
Estimates indicate that for every successful suicide in the adolescent population 50 attempts are made. Suicidal adolescents often have depressive symptoms. [iii]
A sense of hopelessness, low self-esteem, and high self-blame are also associated with adolescent suicide. [iv]
Sources:
[i] Bell C, Clark D. Adolescent Suicide. Pediatric Clinics of North America. 1998;45:365–370.
[ii] Centers for Disease Control and Prevention. WISQARS (Web-based Injury Statistics Query and Reporting System), 2006.
[iii] Gadpille W. Adolescent suicide. Washington, DC: American Psychological Association, 1996.
[iv] Harter S, Marold D. Psychological risk factors contributing to adolescent suicide ideation. In G, Noam and St. Borst (Eds.), Child and adolescent suicide. San Francisco: Jossey Bass, 1992.

44. Depression and Suicidality, 2011 YRBS:
Source: Centers for Disease Control and Prevention. Youth Risk Behavior Surveillance – United States, Surveillance Summaries, August 2, MMWR 2012;61(No. 4).

45. Depression/Suicidality
What is your usual mood: happy, sad, both?
What do you do to cope with or relieve stress?
Have you ever received counseling and/or therapy?
Have you ever been in a psychiatric hospital?
What was the reason?
How long did you stay?
Have you ever thought of hurting yourself?
Have you ever tried to hurt or kill yourself?
Whom did you tell?
Adapted from the presentation "Interviewing the Adolescent: Tricks of the Trade" by Melanie A. Gold, DO, Associate Professor of Pediatrics, Division of Adolescent Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA.

46. Sexuality
As children and adolescents develop, many will have questions regarding their bodies, sex, pregnancy, and STIs, and the majority will begin to experiment sexually.
Discussing sex with adolescent patients in a clinic or office setting provides opportunities for personalized information, for confidential screening of risk status, and for health promotion and counseling.
Prevention and counseling can be targeted to the needs of youth who are and who are not yet sexually active and to groups at high risk for early or unsafe sexual activity.
However, the majority of physicians are not offering this necessary care. Less than half of primary physicians routinely discuss sex, condoms, STIs, contraception, and sexual orientation with their adolescent patients.
Source: American Academy of Pediatrics, Committee on Psychosocial Aspects of Child and Family Health and Committee on Adolescence. Sexuality Education for Children and Adolescents. Pediatrics 2001;108:498–502.

47. Paradigm of Sexuality Sexual Orientation Gender Identity
Sexual Behavior
Sexual Attraction
Biological Sex
Adolescence is characterized as a time between the asexual child and the sexual adult.
It is also a time of sexual exploration and experimentation, of sexual fantasies and realities, of incorporating sexuality into one’s identity.
During adolescence, young people solidify their gender identification by observing the gender roles of their parents and other adults.
Gender identification includes understanding one's existence as male or female, and the roles and responsibilities of being a man or a woman.
A young person’s sexual orientation also often emerges in adolescence.
Healthcare professionals should be aware that a large number of adolescents have questions about their sexual feelings.
Some are attracted to and may have sexual relations with people of the same gender, and a small number may identify themselves as being gay or lesbian.
Remember that sexual identification does not always match behavior—i.e. homosexual-identified patients should still be asked about heterosexual activity and vice-versa.

48. Sexual/Reproductive Health History
Number of lifetime sexual partners
Number of partners in last 3–6 months
History of STIs
Sexual satisfaction
History of survival sex, sexual victimization, unwanted or coerced sex
Menstrual history
Sexual orientation
Gender identity
Age at first intercourse
Vaginal, oral, anal sex history
Contraceptive history
Pregnancy history
Timing of childbearing plans
There are several components of a sexual reproductive health history.

49. Sexual Behavior QuestionsDo
Assure confidentiality
Explain why you are asking sensitive questions
Ask patient to describe specific sexual behaviors
Add “second tier” questions to assess comfort with behaviors
Don’t
Ask “Are you sexually active?”
Use gendered-biased pronouns when referring to sexual partners
Use judgmental language
Use slang unless patient offers it first

50. Identifying Sexual Minority Youth
Actual prevalence of gay, lesbian, bisexual (GLB), transgender, and questioning is unknown
Because many gay, lesbian, bisexual, transgender, and questioning youth are often at high risk for depression, dropping out of school, homelessness, and substance abuse, it is important to discuss sexual orientation and its impact on the adolescents mental, physical, and social health.
It is hard to quantify how many youth experiment with same-sex sexual behavior or identify as gay, lesbian, bisexual, or questioning.
Each state can decide whether they want sexual orientation questions to be included in the YRBS. For 2005, Vermont was the only state that included these questions.
Source: Vermont Department of Health. Vermont Youth Risk Behavior Survey Results. Burlington, VT: 2005.

51. 2011 Vermont Youth Risk Behavior Survey
Few states assess same sex sexual behavior or GLBT identity using their YRBS surveys. Vermont is one state that does ask students if they identify as heterosexual, homosexual, bisexual, or unsure. Overall, 9% identified as homosexual, bisexual, or unsure. Of course, asking about identity does not always capture all same-sex sexual behaviors as students engaging in this behavior may still identify as heterosexual. The opposite is true as well.
Source: 2011 Vermont YRBS, available at:

52. Sexual Orientation & Adolescents: Growing Up Today Study (’97–’03)
A 2008 community-based prospective cohort study was conducted to compare sexual orientation group differences in the longitudinal development of alcohol use behaviors during adolescence. Participants included a total of 13,450 Growing Up Today Study participants (79.7% of the original cohort). The Growing Up Today Study is a US community-based longitudinal cohort study of 9,039 female and 7,843 male children of women participating in the Nurses' Health Study II. Approximately 93% of the cohort self-identified as non-Hispanic white. After maternal consent was obtained, baseline questionnaires were mailed in 1996 to potential participants between ages 9 and 14 years. The children were invited to return a completed questionnaire if they agreed to participate in the study. Follow-up data collection occurred annually from 1997 through 2001 and in 2003.
Overall, 8.5% of males and 16.1% of females reported a minority sexual orientation (i.e., mostly heterosexual, bisexual, or gay/lesbian). When gender differences in the distribution of sexual orientation based on hierarchical coding were compared, females were significantly more likely to have identified themselves as bisexual, mostly heterosexual, or unsure, whereas males were more likely to have identified themselves as gay (P < .001).
Source: Corliss H, Rosario M, et al. Sexual Orientation Disparities in Longitudinal Alcohol Use Patterns Among Adolescents Arch Pediatr Adolesc Med. 2008;162(11):1071–1078.
Corliss H, et al. Arch Pediatr Adolesc Med. 2008;162(11):1071–1078.

53. Assessing Gender Identity
Do you think of yourself as male, female, neither, or both?
What pronoun do you use (she, he, they, sie*)?
Are you comfortable with your feelings?
How do you think your parents/teachers/friends would react (have reacted) to your gender identity?
Gender identification includes understanding one's existence as male or female, and the roles and responsibilities of being a man or a woman.
Transgender is an umbrella term to describe the full range of individuals who have a strong belief, often from childhood onwards, that they were born into a body with the wrong physical gender and incorporate one or more aspects, traits, social roles, or characteristics of the other gender.
Transgenderism includes:
transsexuals (individuals who have had sex-reassignment surgery),
androgynes (those with an androgynous presentation and whose behavior combines both genders or is gender-neutral),
intersexuals (those who are born with sex chromosomes, external genitalia, or an internal reproductive system that is not considered standard for either male or female), and
cross-dressers (clinically known as transvestism).
Transgendered individuals can live full or part-time as members of the opposite gender.
Regardless, all transgendered individuals should be consistently referred to by the pronouns of their self-identified gender.
Prevalence rates of transgendered populations are not clearly established.
Source: American college of Obstetricians and Gynecologists. Health care for transgendered individuals. In: Special issues in women’s health. Washington, DC: ACOG; 2005 p. 75–88.
*Sie is a gender neutral pronoun sometimes used by members of the transgender community

54. Assessing Sexual Orientation
Are you romantically interested in men, women, or both?
Are you comfortable with your feelings?
Have you ever had sex with someone of your same gender?
For younger teens: when you imagine yourself in a relationship in the future is it with a man, a woman, or both?
Adapted from the presentation "Interviewing the Adolescent: Tricks of the Trade" by Melanie A. Gold, DO, Associate Professor of Pediatrics, Division of Adolescent Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA.

55. Discussing Sexual and Romantic Relationships
Have you ever had a crush on a boy or girl? What was that like?
Have you ever had a romantic relationship with someone?
How would you describe it?

56. Assessing the Health of the Relationship
What does a healthy relationship look like to you?
Disagreements and arguments are a normal part of any intimate relationship. What is it like when you and your partner get into an argument? How do you usually resolve it?
How often are you and your partner together? How does you partner feel about you hanging out with other friends?
(If sexually active) Who makes the decisions about when to have sex and if or what kind of contraceptives you should use?

57. Characteristics of a Healthy Relationship
Non-violent conflict resolution
Open and honest communication
Right to autonomy for both people
Shared decision-making
Trust
Mutual respect
Individuality
Empathy
Healthy relationships have open and honest communication. No relationship is conflict free, but the key to a healthy relationship is knowing how to resolve those conflicts.
Belief in non-violent conflict resolution/anger control – how we express anger is what makes the difference between healthy and unhealthy relationships
Ability to negotiate and adjust to stress
Open and honest communication – each partner needs to say exactly what they mean without interruption
Partners work together to make decisions – about the relationship or their own interests
Belief in partner’s right to autonomy – individuals in a relationship need to be free to pursue their own interests, make their own decisions and take their own actions
Individuality – not choosing who you are or what you do to please your partner
Shared decision making
Trust – partners are able to rely on one another
Mutual Respect – each person values the other and understands personal boundaries
Honesty – when someone says something, it’s actually what they mean
Compromise
Fighting fair – when disagreeing, partners stick to the subject of the argument without getting emotional or insulting
Empathy – taking time to figure out a partner’s feelings
Sources:
Catallozzi et al. (2011). Understanding control in adolescent and young adult relationships. Arch Pediatr Adolesc Med, 165 (4),
Glass et al. (2011) Adolescent dating violence: prevalence, risk factors, health outcomes, and implications for clinical practice. Curr Opin Pediatr, 23(4):
Adapted from, “Hanging out or Hooking Up: Clinical Guidelines on responding to Adolescent Relationship Abuse” by Elizabeth Miller, MD, PhD and Rebecca Levenson, MA.

58. Risk factors for unhealthy relationships
Partner is 3-5 years older
Exposure to violence in the household or community
Early sexual activity
Low education level
Sexual risk taking
Substance abuse
Sources:
Catallozzi et al. (2011). Understanding control in adolescent and young adult relationships. Arch Pediatr Adolesc Med, 165 (4),
Glass et al. (2011) Adolescent dating violence: prevalence, risk factors, health outcomes, and implications for clinical practice. Curr Opin Pediatr, 23(4):

59. Assessing Sexual Behavior
How old were you when you first had sex? (Include anal, oral, and vaginal.)
What was the date of your last intercourse?
What kind of protection did you use at last sex?
Condoms? Hormonal contraception?
Do you have a current partner?
How long have you been with your partner?
How many sexual partners have you had?
How many sexual partners have you had in the past three months? Six months? Lifetime?
Adapted from the presentation "Interviewing the Adolescent: Tricks of the Trade" by Melanie A. Gold, D.O., Associate Professor of Pediatrics, Division of Adolescent Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA.

60. Sexual Satisfaction
How often do you have pain during sexual intercourse or other sexual activities?
Are you satisfied with how often you have sexual relations and with what you do with your sexual partner?
Any problems becoming aroused, getting an erection, getting lubricated (wet), or having an orgasm?

61. Sexual Health Have you ever had any STIs?
Do you know what the symptoms of STIs are? Tell me.
Have you ever been tested for an STI?
Have you ever been pregnant or gotten anyone pregnant? What were the outcomes?
Do you have any concerns about fertility?
When (if ever) would you like to have children?
Adapted from the presentation "Interviewing the Adolescent: Tricks of the Trade" by Melanie A. Gold, D.O., Associate Professor of Pediatrics, Division of Adolescent Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA.

62. Safety

63. Sexual/Dating Violence 2011 YRBS:
Many adolescents and young adult women experience physical or sexual violence perpetrated by someone close. Knowledge of risk factors and sequelae associated with interpersonal violence and of screening methods to detect it can help the healthcare provider identify potential victims of assault.
Dating Violence:
Source: Centers for Disease Control and Prevention. Youth Risk Behavior Surveillance – United States, Surveillance Summaries, June 4, MMWR 2010;59(No. SS-5).
Forced to Have Sex:
Source: Centers for Disease Control and Prevention. Youth Risk Behavior Surveillance – United States, Surveillance Summaries, August 2, MMWR 2012;61(No. 4).

64. Drunk Driving, 2011 YRBS:
Source: Centers for Disease Control and Prevention. Youth Risk Behavior Surveillance – United States, Surveillance Summaries, August 2, MMWR 2012;61(No. 4).

65. 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?
Adapted from the presentation "Interviewing the Adolescent: Tricks of the Trade" by Melanie A. Gold, DO, Associate Professor of Pediatrics, Division of Adolescent Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA.

66. Interpersonal Violence includes
Child abuse
Battering
Domestic violence
Partner violence
School, peer, community violence
Sexual harassment
Sexual abuse
Sexual assault
Hate crime
The overwhelming proportion of violence is perpetrated by men against women, although partner violence also occurs in LGBT relationships and by women against men.
There is a high prevalence of abuse histories among women seeking medical attention. Physicians must recognize and address the symptoms of interpersonal violence.
Healthcare providers seeing adolescents should maintain a referral network in the event that one of their patients has been a victim of interpersonal violence.

67. Additional Safety Concerns
Recreational safety: bicycle helmets, protective sports gear, sunscreen use
Auto safety: riding in stolen car, in car with drunk driver, in car late at night, seatbelt use
If you are presenting in an area where many families have guns in their homes, it is important to discuss how to handle this question with the session’s participants. Do they ask where the gun is stored? Do they ask if the adolescent has access to it?
Adapted from the presentation "Interviewing the Adolescent: Tricks of the Trade" by Melanie A. Gold, DO, Associate Professor of Pediatrics, Division of Adolescent Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA.

68. Spirituality

69. What do you consider to be your religion?
Spirituality*
What do you consider to be your religion?
How often do you participate in religious activities?
How important are your spiritual beliefs in your day-to-day life?
How do your beliefs influence your health and attitudes about sex and contraception?
*An individual’s religious and/or spiritual beliefs can have an impact on his/her health behaviors and outcomes. Healthcare professionals should let the patient take the initiative when approaching the discussion of religion.

70. Strengths*
Assess healthy behaviors and resiliency throughout the interview
Identify past difficulties that have been overcome
Provide positive feedback and balance to the interview
Be sure to praise the adolescent when you find such a positive in the history.
A little bit of positive reinforcement goes a long way toward improving self-esteem and cementing a positive,
trusting relationship with the young person. Some examples of strengths in each of the HEADDSSS categories are below:
Home
Connected, caring parents or family members
Care of siblings or other relatives
Education and employment
Better than average school performance
Strong participation in extracurricular school-related
activities, including sports
Activities
Leadership among peers
Drugs
Refusal skills
Sexuality
Consistently responsible sexual behavior
Suicidality
Access to a confidant
Successful coping skills
Safety
Conflict resolution skills
Substance-free
Source:
Goldenring, JM and Rosen DS (2004) Getting into adolescent heads: An essential update. Contemp Pediatr 2004; 21(1):64-90.

71. Case 1:
A 15-year-old female patient comes to your office. You notice that she has gained a bit of weight. When you ask her to stand on the scale, she begins to cry.
What questions do you ask her regarding her health and body weight?
How do you approach the subject sensitively?
Explain that during puberty many girls gain weight in specific areas of their bodies.
Review “Exercise/Eating” slide of HEEADSSS
Body image:
Are you happy with your weight?
What do you think your ideal weight should be?
How many meals do you eat per day?
Do you ever skip meals?
Has there been any change in your eating patterns in the past three months?
What do you do for exercise?
How are things at home? (Assess for possible abuse)
Refer patient for nutritional counseling.
Schedule follow-up.

72. Case 2:
A 14-year-old female enters your office with her mother. To every question you ask the young woman, the mother offers a response. Your patient seems shy and rather uncomfortable.
How do you proceed with this visit?
Explain to the mother that though you commend her for her interest in her daughter’s healthcare, in your office, a patient’s confidentiality must be assured.
Invite the mother to wait outside in the waiting room until you have finished interviewing her daughter.

73. Case 3:
You have recently accepted a new position as practitioner at a pediatric office. The clinic sees a small population of adolescents but wishes to expand its efforts with this population.
What are some initial steps that you take to ensure that your office is adolescent friendly?
Is the clinic accessible? Financially affordable?
Are there adolescent focused materials on display such as magazines, posters, etc.?
Does the clinic offer flexible scheduling?
Has the staff been trained to be sensitive to adolescents’ needs?
Does the clinic offer comprehensive services?
Is a minor’s right to confidential healthcare respected, and has the staff been trained to ensure confidentiality?
Does the clinic have a method of helping youth transition into the adult medical care system?

74. Please Complete Your Evaluations Now

75. Provider Resources
for Reproductive Choice and Health
American Academy of Pediatrics
American College of Obstetricians and Gynecologists
Society for Adolescent Health and Medicine
Reproductive Freedom Project of the American Civil Liberties Union
for Youth
Institute
for Adolescent Health and the Law
Jane Fonda Center of Emory University
Sexuality Information and Education Council of the United States
Association of Reproductive Health Professionals

76. Provider Resources
PRCH’s Minors’ Access to Confidential Reproductive Healthcare Cards and Emergency Contraception: A Practitioner’s Guide
ARHP’s Reproductive Health Model Curriculum
AMA Guidelines for Adolescent Preventive Services (GAPS)
The American College of Obstetricians and Gynecologists:
Confidentiality in Adolescent Health Care
Primary and Preventive Health Care for Female Adolescents
Tool Kit for Teen Care—available at:
For emergency contraception: