The author gratefully acknowledges the inspiration and input from the Planning Task Force of the American Nurses’ Foundation Partners in Program Planning for Adolescent Health (PIPPAH). The PIPPAH project was made possible through a cooperative agreement of the American Nurses’ Foundation with the Health Resources and Services Administration /Maternal and Child Health Bureau Office of Adolescent Health.
In All Encounters With 11-12 Year-Olds and Adolescents
I. Seize the prevention and health promotion opportunity at every encounter
Sport and camp physicals bring young teens into health care with form in hand, but rather than just completing the form, assess the whole person, assess immunizations, and set appointments for follow up care as needed. School nurses can assess multiple risks when working with children. Parish nurses can encourage early teen visits and preventive practices. Emergency Department nurses may be the only nurses a child encounters; the opportunity to assess needs and provide preventive care and referrals should not be underestimated. Proactive nursing in an urgent care center visits and upper respiratory infection visits can also open the door to preventive care for a young teen.
Teens get care in a wide range of settings. Some seek health care at a pediatric or family practice office. Many others receive services in school-based health centers, family planning centers, health departments, and schools - settings where nurses are often key players. Nurses can give care and information wherever teens are and make every encounter a prevention encounter. It is possible that school nurses are the only health care provider some teens may see.
Nurses interacting with adolescents can encourage healthy choices, provide a confidential sounding board to young teen questions, assess health needs, educate and counsel. Teens develop the strengths and assets in their transition to adulthood that will serve them for a lifetime. Nurses can help adolescents identify the positive adults and other positive role models in their lives. Nurses can encourage and reinforce positive activity occurring in a young teen’s life.
II. Strive for Privacy and confidentiality
Visits for young teens - and all teens - should include private time with the clinician. However, not all jurisdictions have statutes that protect the adolescents’ confidentiality in health care.9 Teens who report having privacy in their visit were 1.6 times more likely to feel they can talk openly with their clinician. However, in that same survey, only 28 percent of teens in the study said they had had a private and confidential visit with their health care provider in the past 12 months.10 Structure the visits to allow confidential and private communication, but understand the legal rights of adolescents in your state before you promise your conversation is private. If your jurisdiction’s laws do not support the adolescents’ privacy, advocate for change.
III. Communicate your nursing openness to diverse teens and their diverse needs
Be open and non judgmental. Nursing care should always be nonjudgmental, and the early teen visit is no exception. The openness and acceptance the nurse and nurse practitioner communicate in the early teen visit can set the stage for a lifetime of health care relationships.
Cultural gaps between providers and patients have been cited as barriers to utilization and appropriate care.11 Cultural competence is a critical piece of care and builds on the nursing foundation of nonjudgmental care. Communicating openness and acceptance to the teen are critical to establishing a good relationship and helping the young teen feel comfortable and open to talking about health concerns that really matter.
Components of The Visit
The 11-12 year-old visit, like all well child visits, should include screening, anticipatory guidance, immunization and health assessment, and intervention for identified problems. Resources for the visit include the American Medical Association’s “Guidelines for Adolescent Preventive Services” (GAPS) and the multidisciplinary “Bright Futures. Depending on the clinical setting, many of the history and guidance questions can be addressed by the nurse prior to the clinician (physician, NP, PA) encounter.
The American Medical Association’s GAPS resources (available online at www.ama-assn.org) include a chart of recommended services as well as practice tools such as a young adolescent questionnaire and a parent questionnaire. 12 Health guidance on development, diet, physical activity, healthy lifestyles, and injury prevention are recommended. GAPS recommends that the screening history address eating disorders, substance use, school performance, depression and suicide risks. Physical assessment should include blood pressure and body mass index (BMI), as well as a complete physical if not done in three years. Cholesterol, tuberculosis, sexually transmitted infections, and Pap screenings should be done indicated by history.
“Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents” provides comprehensive guidelines for health supervision, immunizations, screenings, and anticipatory guidance with a multidisciplinary perspective.13. Georgetown University’s “Bright Futures” Web site (www.brightfutures.org) provides the full guidelines and pocket versions of the guidelines, as well as family materials in English and in Spanish. Family encounter forms tell the patient and family what to expect at the visit and lay the foundation for questions to be discussed at the visit. There are also handouts to reinforce preventive care messages and to prepare for the next visit. Tip sheets for the visit offer questions for the nurse or other health care provider to ask the parent and the child, components of the visit, recommended tests and screenings, counseling topics, and anticipatory guidance. Bright Futures also has multiple patient education materials which can be printed out to supplement the visit. The American Academy of Pediatrics is adding to the Bright Futures guidelines and materials (www.brightfutures.aap.org).
“Bright Futures” recommends:
I. History: Assess parents’ perception of the child and parental supervision. Ask the child/adolescent questions regarding social and emotional development, physical development, and health habits. Ask about relationships, sexuality, family functioning, and school performance. Observe parent-adolescent interaction during the visit. Discover the patient’s interests: “The Bright Futures” materials offer useful wording of questions to guide the history.
II. Exam: Height, weight, BMI for age, sexual maturity rating, scoliosis or kyphosis screening, neglect/abuse, eating disorders, sports injuries, orthopedic problems, teeth, acne, tattoos, piercings, external genital exam, vision, hearing, blood pressure, anemia (menstruating females), emotional health, risks for anemia, hyperlipidemia, and TB assessment and testing as indicated.
III. Anticipatory guidance: Include the promotion of healthy and safe habits, encompassing smoking, sleeping, physical activity, TV and computer time, seat belt use, sunscreen, helmet use, mental health, nutrition, oral health, and sexuality. The visit should also address prevention of substance use including sports enhancing drugs, promotion of social competence and responsibility, school achievement, and community interaction. Anticipatory guidance for the parents includes relationship building, modeling, and realistic expectations.
Advocate for access to care
Critical to health and well-being is access to care and having a regular primary care provider or other source of ongoing health care (a health care home). Communication between nurses and teens can be stronger when there can be continuity in the relationship.
Many teens do not have preventive care. A study of 12,000 adolescents, grades 7-12, found that 18.7 had no care in the past year. 13 percent had no insurance while another 6.5 percent had insurance for only part of the year. One third (33 percent) of all teens had no physical exam in the past year and many of those who had a physical exam did not have comprehensive assessment, education, and counseling addressing their developmental needs.23
State children’s health insurance programs provide health insurance to uninsured children and teens from families with incomes above the Medicaid eligibility limit and below 200 percent of federal poverty. However, in some states, families are on a waiting list for this program and, of course, many families above 200 percent of the poverty line still struggle without viable insurance options.
Nurses, as advocates for health and prevention, can support process, policies, and legislation that address the access issues above. The National Association of School Nurses (www.nasn.org/legislation/default.htm) and the National Assembly of School-based Health Centers’ Center for Advocacy and Public Policy (www.nasbhc.org/APP/APP_Intro.htm) are two resources for legislation and policy information for nurses working with adolescents. 24, 25
Conclusion
The early adolescent well child visit can be a wonderful opportunity for timely assessment, education, and intervention to facilitate successful adolescent development. It has also become an important immunization assessment visit. Nurses can promote health and wellness for teens at every encounter. Make every opportunity count!
Tips for the Nurse
- Communicate your nursing openness to diverse teens and their diverse needs
- Make every encounter a prevention encounter
- Partner with families
- Assess immunizations at every encounter
- Assess assets, strengths, and risk behaviors
- Reinforce the positive and provide tools for change of the risky behaviors
- Use resources to plan early adolescent visits, such as GAPS and Bright Futures
- Advocate for access
References
1. Centers for Disease Control and Prevention (2006). Childhood and Adolescent Immunization Schedule, 2006 and Provisional Recommendations, accessed www.cdc.gov/nip August 18, 2006.
2. Clinical preventive services of adolescents, A Position Paper of the Society of Adolescent Medicine, J or Adolescent Health 1997, 21: 203-214.
3. Resnick, MD, PS Bearman, et al (1997) “Protecting adolescent from harm. Findings from the National Longitudinal Study on Adolescent Health”, JAMA, September 10, 1997, 278 (10)
4. Scales, P. C. (1999). Reducing risks and building developmental assets: Essential actions for promoting adolescent health. Journal of School Health, 69, 113-119.
5. Benson P and Scales PC , 1998, A fragile foundation: The State of Developmental Assets Among American Youth. Minneapolis, MN; The Search Institute.
6. Catalano, R. F.;Berglund, M. L.;Ryan, J. A. M.;Lonczak, H. S.;Hawkins, D. J. (1998), Technical Report : Positive Youth Development in the United States: Research Findings on Evaluations of Positive Youth Development Programs, Office of the Assistant Secretary for Planning and Evaluation, Department of Health and Human Services;200 Independence Ave., SW, Washington, DC 20201, 877-696-67, available online http://aspe.hhs.gov/hsp/PositiveYouthDev99/
7. Centers for Disease Control and Prevention (2004a). Surveillance Summaries: Youth Risk Behavior Surveillance--United States, 2003. Morbidity and Mortality Weekly Report, May 21, 2004, 53(SS-2) p 1-96
8. Kathleen Mullan Harris, PhD; Penny Gordon-Larsen, PhD; Kim Chantala, MS; J. Richard Udry, PhD, Longitudinal Trends in Race/Ethnic Disparities in Leading Health Indicators From Adolescence to Young Adulthood, Arch Pediatric Adolescent Med. 2006;160:74-81. number 1 Jan 06
9. Brooke, Penny, Consent and Confidentiality When Caring For Adolescents, Continuing Education module, American Nurses Association, 2005 http://nursingworld.org/mods/mod845/consentfull.htm
10. Foundation for Accountability and the Robert Wood Johnson Foundation (2001). Portrait of Adolescents in America 2001, http://www.facct.org/facct/doclibFiles/documentFile_522.pdf, accessed December 21, 2004
11. U.S. Department of Health and Human Services (2000). Healthy People 2010, 2nd edition. Washington, D.C.: U.S. Government Printing Office
12. American Medical Association, Guidelines for Adolescent Preventive Services, www.ama-assn.org, March 8, 2006
13. American Academy of Pediatrics (2004). Retrieved August 3, 2004, from www.brightfutures.aap.org/web/aboutBrightFutures.asp
14. Cohall, AT, et al More than heights and weights: what parents of urban adolescents want from health care providers. J Adolescent Health, April 2004 Vol 34 (4)
15. Fisher, M, “Parents' views of adolescent health issues” Pediatrics, Vol 90(3):335-341, Sept 1992
16. Cavanaugh, R. M., Jr, Hastings-Tolsma, M., Keenan, D., Buser, B., & Henneberger, P. K. (1993). Anticipatory guidance for the adolescent. Parents' concerns. Clinical Pediatrics, 32(9), 542-545
17. Mays, Rose; Lynne Sturn; and Gregory Zimet. (2004). Parental perspectives on vaccination children against sexually transmitted infections. Social Science and Medicine, 58, 1405-1413.
18. Steinberg, L and P Duncan, “Work Group IV: Increasing the Capacity of Parents, Families, and Adults Living with Adolescents to Improve Adolescent Health Outcomes” J of Adolescent Health 2002: 31: 261-263
19. National Committee for Quality Assurance (2003) The State of Health Care Quality: 2003.
20. Centers for Disease Control and Prevention (2005), Prevention and Control of Meningococcal Disease, Morbidity and Mortality Weekly Report, May 27, 2005, 54 (RR7) p 13.
21. Hedberg VA, Klein JD, Andersen E, Health Counseling in adolescent preventive visits: effectiveness, current practices, and quality measurement J Adol Health, Dec 1998 vol 23, 6: 344-353)
22. Whitcock P, Orleans Ct, Pender N, Allan J Evaluating Primary Care Behavior counseling Interventions: an evidenced-based approach, American Journal of Preventive Medicine 2002:22:267-84
23. Ford CA, B. P., Moody J.(1991) Foregone health care among adolescents. JAMA, 282(23), 2227-2234.
24. National Association of School Nurses (2004) ( www.nasn.org/legislation/default.htm), accessed August 13, 2004
25. National Assembly of School-based Health Centers’ Center for Advocacy and Public Policy (2004) (www.nasbhc.org/APP/APP_Intro.htm), accessed August 13, 2004
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