The Early Adolescent Visit: Accentuating the Positive

by Nancy Rudner Lugo, DrPH, NP

Expiration Date: December 31, 2008
No CE contact hours (CH) will be given after this date.


Table of Contents

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Acknowledgments

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.

Abstract

Early adolescence is a time of great physical and emotional transition and growth. An 11-12 year-old assessment has been on the immunization schedule since 1995 but underutilized. This important milestone assessment is not only an opportunity to assess immunization needs, but also a time to reinforce positive behaviors and to screen for and address problems. Nursing tools of anticipatory guidance, education, and counseling for health promotion and disease prevention can not only encourage the 11-12 year old, but also can make it successful for the teen, parent, and nurse. Adolescent behaviors, visit content, tips, tools, and resources are discussed. The purpose/goal of this independent study module is to help nurses develop skills and knowledge regarding early adolescence and the well child needs of this age group.

Objectives: On successful completion of this independent study module, the learner will be able to:

  1. Explain the rationale for the early adolescent visit.
  2. Recognize positive behaviors to be reinforced in encounters with early teens and their parents.
  3. Define roles for nurses in promoting adolescent health and the early adolescent visit.
  4. Identify key components of the early adolescent visit.

Key words: 11-12 year-old visit, adolescent preventive care, adolescent visit, adolescent anticipatory guidance, reinforcing positive behaviors

Introduction

The Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC) has recommended a health assessment for 11-12- year olds since 1996.1 It appears on the immunization schedule as “the purple line”. While the ACIP recommendation focuses on immunization assessment, the 11-12 year- old well child visit is also a time for nurses to encourage healthy behaviors, assess risks, and provide useful information to the emerging adolescent and family.

Youth are often practicing good health behaviors that can be encouraged and reinforced during the 11-12 year-old health visit. Nurses can be effective advocates for 11-12 year old visit by

  1. encouraging youth to have regularly scheduled physical exams,
  2. providing health assessments and care; and
  3. advocating for access to comprehensive services for this age group.

The purpose of this independent study module is to help nurses develop skills and knowledge regarding early adolescence and the well child needs of this age group. This module outlines some of the findings of the health status of this age group, tips and tools for the early adolescent visit, and the role of nurses. While this module is focused on the 11-12 year old visit, routine annual visits during adolescence are recommended.2 Some clinicians refer to this as the “early adolescent visit” although not all 11-12 year olds are developmentally in “early adolescence”. Hence, in this module, the visit will be referred to as the “11-12 year-old visit”. For increased readability, the 11-12 year old patient will be referred to as “youth”, “adolescent”, and “teen”.

Prevention is critical at this age

Adolescence is a transition time, with experimental behavior and associated risks and the establishment of life long healthy and unhealthy behaviors patterns. While preventing risks and discouraging unhealthy practices may be foremost on the clinician’s agenda, recognizing and building on the adolescent’s strengths and positive attributes may be more protective.

Positive youth development has been looked at from several perspectives. Resnick looked at protective and risk factors3 Benson and Scales focused on increasing youths’ developmental assets as an avenue to reduce high-risk behaviors.4 ,5 Hawkins and Catalano found programs that focused on positive youth development, developing resiliency and protective factors were associated with improved outcomes.6 All of these approaches have found success by building on the youth’s positive attributes. This requires a switch from focusing on deficits and risks to identifying strengths and potential. Family and community expectations of healthy behaviors can be more successful than expectations of unhealthy behaviors; nursing efforts can support these approaches.

The 11-12 year-old is on the threshold of dramatic change. The 2003 National Youth Risk Behavior Survey (YRBS) shows that most healthy behaviors are more common among 9 th graders (typically age 14) than 12 th graders (typically age 17), suggesting the need for positive reinforcement and prevention early in the teen years. 7 (Table 1) The YRBS data show 71 percent of deaths among 10-24 year olds are due to preventable causes (motor vehicle crashes, homicides, suicides, and other unintentional injuries).

Most adolescent health problems are rooted in environment and behaviors, including lack of physical activity, poor nutritional patterns, substance use and abuse, unsafe sexual behaviors, and risky vehicle use. 7 Longitudinal data from the National Study of Adolescent Health indicate that, for 15 of 20 indicators, health risk increased and access to health care decreased for the teen and adult years for most US race/ethnic groups.8

The National Initiative to Improve Adolescent Health identifies 21 critical health objectives from Healthy People 2010. These include mortality, violence and injuries, mental health and substance abuse, reproductive health, exercise and obesity objectives.

TABLE 1

Changing Health Behaviors: 9 th and 12 th grade,
Source: YRBSS, 2003 7

Behavior Prevalence 9 th grade Prevalence 12 th grade
Wear seat belts 79.6 83.8
Have sufficient vigorous physical activity 68.5 55
Have five fruits and vegetables a day 23.3 19.5
Never had sexual intercourse 67.2 38.4
Used a condom last time had intercourse 69 57.4
Not currently sexually active in past 3 months 78.8 51.1
Has had fewer than 4 partners 89.6 79.7
Never tried marijuana 70 51
Never tried alcohol 35 27
Not engaged in episodic drinking (5 or more drinks in a few hours) in past 30 days 80 63
Never tried cocaine 93 90
Never smoked a cigarette 48 34.6
Not currently smoking (in past 30 days) 82.6 73.8
Has not felt sad or hopeless in past 12 months 72 72.6

 

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.

Parents want the health care providers to address sensitive issues

Cohall et al found that urban parents wanted health care providers to counsel their adolescents on issues of risks, sexuality, substance abuse, and other sensitive topics.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) Fisher found suburban parents had similar perspectives.15 Cavanagh also found parents wanted sensitive issues addressed.16 Rose Mays17 found that parents did not want their children to be sexually active, but felt that their young teens should be immunized and protected from sexually transmitted diseases whenever possible.

Parents and teens want to prevent problems. The nurse can facilitate this and strengthen the role of parents and care givers by addressing the information needs of the family. Steinberg and Duncan18 (2002), reporting from a Society for Adolescent Medicine workgroup, identify four things parents and other primary care givers need to help their teen’s healthy development: 1) information on normal growth and development, 2) basic information on effective parenting during the teen years, 3) understanding of changes in the family during the adolescent years, and 4) support of other social institutions in the face of the challenges of this period. Skillfully placed questions can open doors for important discussion on health risks and behaviors. Nurses can balance the needs of parents and adolescents by ensuring both parent and teen get private time with the clinician.

Immunizations

Immunizations are the most effective intervention in preventive care. Every encounter is an opportunity to assess vaccine status and identify needed immunization protection. Thinking of immunizations as a young pediatric concern only is a disservice to adolescents and contributes to the underimmunization and vulnerability of teens to vaccine-preventable hepatitis and other vaccine preventable diseases. The 11-12 year old needs not only the age-specific immunizations, but also an immunization review to identify the need for any immunizations which may have been missed in their earlier years. The National Committee on Quality Assurance reports that only 43-50 percent of 11-12 year-olds in Medicaid and commercial managed care plans were up-to-date for the adolescent immunizations (using the required immunizations at the time of the study: the booster MMR, chicken pox immunization or disease, and three hepatitis B), according to the HEDIS results.19 In 2005, the ACIP added the meningococcal vaccination to the early adolescent visit20 and a tetanus/diphtheria/acellular pertussis booster (Tdap) for adolescents (to replace the tetanus-diphtheria, Td). In 2006, ACIP recommended routing immunization for the human papilloma virus (HPV) for females ages 11-12 years, to prevent cervical cancer. Influenza and pneumonia may also be indicated. 1We can expect other vaccinations to be added to the adolescent immunization schedule.

Encouraging behavior change when needed

More research is needed on the effectiveness of counseling early adolescents regarding both risky and positive behaviors.21 When appropriate, nurses can use behavior change tools that have shown promise. One such tool is the “Five As” (Table 2) to counsel a patient on multiple health issues, adapting specific content to the targeted behaviors.22

TABLE 2

The Five "A"s for Behavioral Change

  1. Assess- Ask about and assess behavior health risk and factors affecting choice of behavior change goals and methods
  2. Advise- Give clear, specific and personalized behavior change advice
  3. Agree-Collaboratively select appropriate goals and methods based on the patient’s interest and willingness to change the behavior
  4. Assist-Using self-help resources and/or counseling, help the patient achieve goals by acquiring skills, confidence, and social and environmental supports for behavior change
  5. Arrange for follow up

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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