Lawrence S. Neinstein, M.D., F.A.C.P.
Professor of Pediatrics and Medicine
USC Keck School of Medicine
Executive Director
University Park Health Center
Associate Dean of Student Affairs
   

 

 

Health Screening (A8)

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Goal: To promote optimal physical and mental health, and to support healthy physical, psychological, and social growth and development.

As many of the common morbidities and moralities of adolescence are related to preventable health conditions associated with behavioral, environmental and social causes, it is important that preventive services for this age group reflect these issues. It is important to both reinforce positive health behaviors (e.g. exercise and good nutrition) while discouraging potentially health-risk behaviors (e.g. unsafe sexual practices, smoking, unsafe driving etc.). As lifetime habits may form during this age group, it is an important time to implement health promotion and preventive services.

Evidence based research on preventive services guidelines is only in its infancy. This is an important area of research given the limitation on health resources and the focus on evidence-based medicine.

COMPARISONS AMONG RECOMMENDATIONS FOR ADOLESCENT PREVENTIVE SERVICES
(Adapted from Elster AB. Comparison of recommendations for adolescent clinical preventive services developed by national organizations. Arch Pediatr Adolesc Med 1998;152:193. )

Subject
AAFP
AAP
AMA
BF
USPSTF

Immunizations          
  ACIP recommendations
Yes
Yes
Yes
Yes
Yes
Health guidance for teens          
  Normal development
Yes
Yes
Yes
Yes
No
  Injury prevention
Yes
Yes
Yes
Yes
Yes
  Nutrition
Yes
Yes
Yes
Yes
Yes
  Physical activity
Yes
Yes
Yes
Yes
Yes
  Dental health
Yes
Yes
No
Yes
Yes
  Breast or testicular self-exam
Yes
Yes
No
Yes
No
  Skin protection
Yes
Yes
Yes
Yes
Yes
  Health guidance for parents
Yes
Yes
Yes
Yes
No
Screening/counseling          
  Obesity
Yes
Yes
Yes
Yes
Yes
  Contraception
Yes
Yes
Yes
Yes
Yes
  Tobacco use
Yes
Yes
Yes
Yes
Yes
  Alcohol use
Yes
Yes
Yes
Yes
Yes
  Substance use
Yes
Yes
Yes
Yes
Yes
  Hypertension
Yes
Yes
Yes
Yes
Yes
  Depression/suicide
No
Yes
Yes
Yes
No
  Eating disorders
No
Yes
Yes
Yes
No
  School problems
No
Yes
Yes
Yes
No
  Abuse
No
Yes
Yes
Yes
No
  Hearing
Yes
Yes
No
Yes
No
  Vision
No
Yes
No
Yes
No
Tests          
  Tuberculosis
Yes
Yes
Yes
Yes
Yes
  Papanicolaou test
Yes
Yes
Yes
Yes
Yes
  HIV infection
Yes
Yes
Yes
Yes
Yes
  STDs
Yes
Yes
Yes
Yes
Yes
  Cholesterol
Yes
Yes
Yes
Yes
No
  Urinalysis
No
Yes
No
No
No
  Hematocrit
No
Yes
No
No
No
Periodicity of visits
Tailored
Annual
Annual
Annual
Tailored
Target age group (yr)
13-18
11-21
11-21
11-21
11-24

AAFP - American Academy of Family Physicians
AAP - American Academy of Pediatrics
AMA - American Medical Association
BF - Bright Futures
USPSTF - US Preventive Services Task Force

Overall, the guidelines of the various groups are more similar than different. One difference between the recommendations is the periodicity which for GAPS, BF, and the AAP are annual visits for preventive services versus the USPSTF and AAFP which recommend visits every 1-3 years based on the specific needs of the individual.

Blockades to preventive services to adolescents include:

  • The concept that adolescents are "generally healthy" and do not need services
  • The reluctance of adolescents to seek care
  • Low reimbursement rate
  • Lack of confidentiality
  • Transportation problems
  • Lack of health care providers trained and interested in caring for adolescents

Solutions include a broader base of health care settings including private physicians' offices, within health maintenance organizations (HMOs), in school-based health clinics, in family planning clinics and in public health clinics.

Other useful information regarding prevention strategies in adolescents include:

Some of these include:

  • Consistent use of seat belts while driving
  • Never driving while drinking or using drugs
  • Consistent use of condoms if sexually active
  • Never smoking
  • Eating a prudent diet
  • Getting regular aerobic exercise

QUESTIONNAIRES AND OTHER HEALTH SCREENING TOOLS

There are several ways to obtain screening health information from teens

  • Interview during the routine examination. Use of the HEADS psychosocial intake profile is helpful as outlined in section: A4
  • Screening forms - These can often complement the personal interview. The GAPS screening forms are available at the AMA web site
  • Computer Aided Screening and Assessment: There has been increased interest in this technology for assisting in screening. Further work needs to be done on the best programs and ways to implement this technology.

The history should include

  • Past Medical history including
  • Childhood infections and illnesses
  • Prior hospitalizations and surgery
  • Significant injuries
  • Disabilities
  • Medications, including prescription medications, over-the-counter medications, complementary or alternative medications, vitamins, and nutritional supplements.
  • Allergies
  • Immunization history
  • Prior developmental history and mental health history
  • Family history including
  • Health status and age of family members
  • Significant physical or mental illnesses in the family
  • Psychosocial profile - See A4
  • Review of systems

The physical examination should include:

  • Height, Weight, Vital Signs - Body mass should be calculated.
  • Vision Screening
  • Hearing Screening
  • Sexual Maturity Rating
  • Skin exam
  • Teeth and Gums
  • Neck exam for thyromegaly or adenopathy
  • Cardiopulmonary
  • Abdominal exam
  • Musculoskeletal
  • Breast exam
  • Neurologic: Cursory unless specific neurologic problem
  • Genitalia in males and pelvic exam as indicated in females

LABORATORY TESTS

Few laboratory tests are needed to screen adolescents. These might include:

  • Hemoglobin: Recommended at first encounter or at the end of puberty.
  • Routine urinalysis recommended at first encounter with an adolescent however up to 1/3 rd of healthy adolescents will have small amounts of proteinuria.
  • Sickle cell screening in African American youth should be done if the individual has not previously tested.
  • Targeted or routine cholesterol screening should be done.
  • Sexually active adolescents should be screened for gonorrhea and chlamydia. If indicated by risk profile, syphilis serology and/or HIV screening should be offered.
  • Tuberculosis screening with PPD should be done based on assessment of individual risk factors and recommendations of the local health department.

IMMUNIZATIONS

An immunization history should be obtained and immunizations should be updated. This age group still has significant rates for non-immunization. Schedules are available from the Advisory Committee on Immunization Practices (ACIP) of the CDC. Specific countries and areas should examine the recommendations of their area as these vary from country to country and even state to state. The current U.S. recommended immunization schedule is available at www.cdc.gov. In addition, international travel information is available at: http://www.cdc.gov/travel

Potential needs in adolescents include dT booster, MMR, hepatitis A and B, and varicella.

Part of the GAPS project has been to develop both methods of assessment and interventions. GAPS recommends the use of the mnemonic G-A-P-S -

Gather information - Screen for problems

Assess further - If a problem identified then assess level and nature of risk

Problem Identification - Work with teen toward agreement on the problem and to make changes

Specific Solutions. - This involves helping the teen with self-efficacy, giving the teen support, solving problems in working toward a solution and shaking on a contract.

A publication from the AMA, GAPS: Clinical Evaluation and Management Handbook, includes fully developed algorithms for each of the GAPS recommendations ( http://www.ama-assn.org/adolhlth/ama/pub/category/1947.html).

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Web Sites

Available websites with preventive health guidelines include:

Department of Health and Human Services:
http://odphp.osophs.dhhs.gov
Recommendations on periodic health examinations based on the health risks of specific age groups. The recommendations are evidence based or expert opinion based.

GAPS - Guide to Adolescent Preventive Services - American Medical Association
These are the comprehensive guidelines puts in place by the AMA's Division of Adolescent Health. The recommendations are called GAPS - Guide to Adolescent Preventive Services. GAPS recommendations cover both the content and delivery of health care to adolescents. Several web sites are available:

For survey questionnaires: http://www.ama-assn.org/ama/pub/physician-resources/public-health/promoting-healthy-lifestyles/adolescent-health/guidelines-adolescent-preventive-services/screening-health-guidance-suicide-depression.shtml
For actual recommendations http://www.ama-assn.org/ama/pub/physician-resources/public-health/promoting-healthy-lifestyles/adolescent-health/guidelines-adolescent-preventive-services/suicide-depression-resources.shtml

Other useful links are available at the adolescent health section of AMA at
http://www.ama-assn.org/ama/pub/category/1947.html including

  • healthy people 2010 recommendations for adolescents
  • Adolescent health resources and links

Bright Futures
The Bright Futures (BF) guidelines for the health care supervision of infants, children, and adolescents were published in 1994 and represent the work of expert panels convened through a collaboration of the Maternal and Child Health Bureau of the Health Resources and Services Administration, and the Medicaid Bureau of the Health Care Financing Administration. The guidelines are both evidence-based and based on expert opinion. They are available at:
www.brightfutures.org/

American Academy of Pediatrics

The AAP has also reviewed the preventive care for children and adolescents and published revised recommendations in 1995. These recommendations represent a consensus by the Committee on Practice and Ambulatory Medicine in consultation with national committees and sections of the American Academy of Pediatrics. In 1996, the AAP also released Guidelines for Health Supervision III which more comprehensively describes the elements of health supervision visits for children and adolescents.

However, currently the AAP is working with Bright Futures through two cooperative MCHB grants to help facilitate usage of Bright Futures among child health professionals and the public. The new web site starting in June 2003 will be:
http://brightfutures.aap.org

The American Academy of Pediatrics recent guidelines are posted at
http://aappolicy.aappublications.org/practice_guidelines/index.dtl

These are from March 2000.

American Academy of Family Physicians (AAFP)
AAFP offers age-specific recommendations for periodic health examinations for healthy patients. The AAFP recommendations are derived from the USPSTF report by the Commission on Public Health and Scientific Affairs of the AAFP. The website is at:
http://www.aafp.org

Also available are:

Canadian Task Force on Preventive Health Care
http://www.ctfphc.org

World Health Organization
http://www.who.int/child-adolescent-health/prevention/adolescent.htm

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References

American Academy of Pediatrics, Committee on Practice and Ambulatory Medicine. Recommendations for Pediatric and Preventive Health Care. Pediatrics 1995; 96:373.

American Academy of Pediatrics, Committee on Psychosocial Aspects of Child and Family Health. Guidelines for Health Supervision III. Elk Grove Village , IL : American Academy of Pediatrics, 1996.

American Medical Association: AMA guidelines for adolescent preventive services (GAPS): recommendations and rationale. Baltimore : Williams & Wilkins, 1994.

Elster AB , Levenberg P. Integrating Comprehensive Adolescent Preventive Services into Routine Medical Care: Rationale and Approaches. Pediatr Clinics N Am 1997; 44:1365.

Elster AB. Comparison of Recommendations for Adolescent Clinical Preventive Services Developed by National Organizations. Arch Pediatr and Adolesc Med 1998; 152:193.

US Preventive Services Task Force. Guide to Clinical Preventive Services: An Assessment of the Effectiveness of 169 Interventions, 2 nd Edition. Baltimore : Williams and Wilkins; 1996.

Zimmerman RK, Clover RD. Adult immunizations-a practical approach for clinicians: part II. Am Fam Physician 1995;51:1139.

 
Copyright (©) 2004-2013 Lawrence S. Neinstein, University of Southern California . All rights reserved. Republication or redistribution of the text, table, graphs and photos is expressly prohibited. The University of Southern California shall not be liable for any errors or delays in the content, or for any actions taken in reliance thereon.