Adolescents and Young Adults

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[edit] Adolescents and Young Adults

Elizabeth A. Alexander

Unlike other age groups in the population, adolescents (ages 13 to 21 years) are the only subgroup for whom mortality has not declined significantly in the past 30 years and for whom significant morbidity has increased. Also unlike other age groups, the major causes of morbidity and mortality are usually preventable (Fig. 7-1).^[1] Rather than purely organic processes impairing health, as in other age groups, most preventable illnesses and deaths in adolescents are related to intersecting behavioral and developmental issues, or “pubertal hazards” that do not occur at other points in the life cycle. Health-related behavioral patterns established in adolescence also affect lifetime health patterns of many adults and thus have a secondary impact on morbidity and mortality as persons age.

Figure 7-1 Causes of child and adolescent mortality. HIV, Human immunodeficiency virus. (From Ventura SJ, Peters KD, Martin JA, et al: Monthly Vital Statistics Report 46 [suppl 2]:32-33, 1997.)

Theoretically, 75% of the deaths in adolescents and young adults are preventable, and the cumulative impact of many adolescent behaviors on health into adulthood is modifiable. Many behavioral issues that cause mortality and morbidity in adolescence, however, are deeply rooted in complex social issues and cannot be resolved only in the health care setting. In addition to physicians' care, public policy change, community interventions, and protective factors that impact the health of adolescents and young adults are critical in addressing “behavioral epidemics” that impair health in these age groups and later in life.

[edit] DEVELOPMENTAL CONTEXT

Any approach to the care of adolescents and young adults requires an understanding of the developmental context in which this care occurs (Fig. 7-2). Struggling with and progressing toward mastery of these tasks often help explain risk-taking behavior in young people who previously have not engaged in unhealthy behaviors. For example, when a young adult rides in a car with an alcohol-impaired driver, the desire to be accepted by peers (task 2) may be more critical at that point in life than distantly perceived risks, such as death or impairment from an accident. Adolescents, in struggling with both developmental tasks 1 and 2, adopt a relative-risk model. This view is generally short term rather than long range, and the “data” in the risk assessment areoften either exaggerated or underestimated. Primary care physicians should therefore help young people assess whether they are making decisions based on good data, with consideration of the long-range view.

Figure 7-2 Erikson's model of developmental tasks for adolescents and young adults.

A second model describing the interface between developmental issues and risk-taking behaviors divides adolescence into three consecutive stages: early, middle, and late (Fig. 7-3).

Figure 7-3 Developmental issues in early, middle, and late adolescence into young adulthood, with parental concerns, corresponding Tanner stages, and counseling recommendations.

[edit] HEALTH SCREENING AND PREVENTION

[edit] Settings

Adolescents may seek health care in a variety of settings, including primary care offices, school-based clinics, community clinics, and athletic “batch” screening programs. Unfortunately, some adolescents (12%) do not have access to any regular source of health care. Furthermore, although adolescents (ages 11 to 20) constitute about 17% of the population, they account for only 11% of health care visits.^[2] Common barriers to care for this age group include discomfort with the setting (e.g., pediatrician's offices, offices that allow little privacy), inefficiency of clinical care, inconvenient hours, and problems with transportation. Many young people also do not know how to negotiate appointment systems in provider offices and simply forego care rather than persist with a scheduling system that puts their needs “on hold.” To reach this group for preventive and long-term care, office-based providers might consider (1) special time blocks on Saturdays or after school reserved for adolescents, (2) special training of receptionists in dealing with adolescents who call directly, (3) artwork on walls that is inviting and relevant to this age group, and (4) alternate mechanisms for billing when confidentiality is requested.

[edit] Confidentiality

Several studies have shown that adolescents will not discuss personal health concerns without clear assurance of confidentiality. Although the laws vary from state to state, most states protect confidentiality for adolescents in the health care setting, unless there is a serious threat to life or long-term health. Minimally, providers must be clear about the issues and agreements regarding confidentiality with both adolescents and their parents. The discussion about confidentiality preferably should occur with both youth and parents together, before the need for privacy arises. Part of this discussion also involves explicitly identifying issues that are exempt from confidentiality, as well as care issues exempt from consent of either parents or adolescents. Finally, discussion about issues of payment when confidentiality is expected can prevent inadvertent disclosure of information through billings sent to parents. Box 7-1 provides an example form that may help to clarify for parents and youth the boundaries of confidentiality with their physicians.^[3]

[edit] Risk Factors

The health care of adolescents should be guided primarily by factors that impair their health and development. The three guidelines for justification of screening in the health care setting require that (1) the screening occur for conditions that have significant burden in terms of morbidity or mortality; (2) an effective means of screening is available; and (3) effective interventions are available to reduce risk when screening is positive. When these screening guidelines are applied to the health care of adolescents, the first and second requirements are straightforward, with the third more challenging. In the last decade, however, research has improved on the effectiveness of programs that protect the health of young people. This knowledge likely will increase over the next few years, making this third guideline more readily attainable.

The other dilemma in health screening for youth is that with so many preventable causes of disease and death, deciding which issues deserve attention within the constraints of limited contacts and time requires careful judgment. Because adolescents do not seek health care frequently, “premium” clinical time must focus on the most likely risks for a particular patient. For example, with inner-city youth, screening for alcohol-related driving behavior might yield fewer positive responses than screening for weapon availability or use. Finally, as in assessing risk factors, the physician also must assess protective factors that may balance the hazards of risk factors for many adolescents and young adults. Fig. 7-4 offers a paradigm for such assessment.

Figure 7-4 Assessment on health of multiple risks and safeguards in lives of adolescents. (Adapted from Jessor R: J Adolesc Health 12:602, 1991.)

[edit] Outcomes

Although good research is limited on outcome markers for health care screening and preventive guidance for adolescents and young adults, some studies suggest that certain interventions make a positive difference on their health status (Table 7-1).

Table 7-1 Health Care Interventions for Adolescents and Young Adults with Degree of Supportive Evidence

An equally important consideration in the use of health care resources involves what is not effective for youth. This information is also included, although even less research has been done in this area. Generally, preaching, scolding, threatening, withholding of information, and denial of care based on moral beliefs are not effective means of influencing the behavior of adolescents or young adults. Education, accurate information, and developmentally relevant information increase the chances of successfully partnering with youth in efforts to protect and preserve their health.

[edit] SPECIAL ISSUES

[edit] Sexuality and Reproductive Health

Data confirm that adolescents and young adults of the last decade continue to initiate intercourse earlier than did youth of previous generations. A synopsis of data✢✢Because research on youth uses heterosexual intercourse as the marker for sexual activity, these data reflect that research. Clinicians should be aware that some youth engage in sexual behaviors that would not be reflected in this definition. relevant to the sexual health of youth indicates the following^[4][5]:

• The number of years of sexual intercourse (i.e., age at onset of coitus) correlates with increased numbers of sexual partners and with all sexual health risks, including human immunodeficiency virus (HIV) infection, sexually transmitted diseases (STDs), and unintended pregnancy. Therefore, knowing the age at first onset of coitus provides a proxy for estimation of risk.
  
• The median age of onset of coitus for youth is about 16, with a great increase in those who begin coitus between 14 and 16. About 7.2% of youth begin coitus before age 13.
  
• About 70% to 80% of youth have experienced intercourse by age 18.
  
• By grade 12, one fourth of all students have had intercourse with four or more partners.
  
• Sexually active youth have a 10% to 26% positive rate for some STDs (Chlamydia, gonorrhea, herpes,Trichomonas), depending on the study.
  
• HIV seroprevalence of homeless youth in areas of high HIV prevalence is 11%.
  
• About 16% to 20% of all diagnosed STDs infect adolescents.
  

Despite these data, clinicians often avoid screening youth for sexual risk-taking behaviors. Reasons for this avoidance include the pressure of time, poor reimbursement for preventive health, and a belief that the physician's patients are at lower risk than the general adolescent population. Millstein et al^[6] reported that primary care physicians provide gynecologic and STD services to youth far below the recommended guidelines, with 31% providing STD/HIV education and only 40% regularly screening for sexual activity, 17% for numbers of sexual partners, 12% for sexual orientation, and 10% for casual sex. Because risk-taking behavior in sexuality and reproductive health has a wide range, the physician is faced with how best to assess risk efficiently, how often to screen, and the best screening methods. Fig. 7-5 presents a paradigm based on data and recommendations from several national groups, including the Adolescent Health Division of the American Medical Association (AMA) and the Centers for Disease Control and Prevention (CDC).^[7]

Figure 7-5 Clinical decision-making approach to sexually transmitted disease (STD) screening for adolescents. HIV, Human immunodeficiency virus.

For all adolescents, topics necessary for adequate screening and education for STDs include how they make decisions about their sexual health, when they consider initiating intercourse, how they determine if a potential partner is safe, and how they insist on condom use if they choose to become sexually active. Predictors of STDs in teens include socioeconomic status, contraceptive method, frequency of intercourse, multiple partners, age at first intercourse, and sex with a partner who has symptoms of an STD. Of these, age of first coitus and lifetime number of partners have the highest positive predictability for STD and HIV risk.

New advances in STD testing for both men and women now permit screening and follow-up for gonorrhea, Chlamydia, and Trichomonas infection based on urine tests; a swab specimen from the cervix is not required in women. This laboratory option allows for easy follow-up of treated patients and more frequent testing than the annual gynecologic examination in youth with risk factors. Routine screening for Chlamydia infection and gonorrhea has been determined to be cost-effective when the prevalence of disease in the population is greater than 2%. Even in sexually active adolescents at lowest risk, the prevalence is 6%, so the cost-effectiveness of routine screening is well documented.^[8]

[edit] Contraception.

When a young person is sexually active and requests a prescription method of contraception in addition to condoms, the physician's options include the diaphragm, oral contraceptives, depot progesterone preparations, and intrauterine device (IUD). Each has advantages and disadvantages, which must be individualized to the patient. Regardless of the prescription contraceptive, the physician still must reinforce the importance of condoms as a method of minimizing the risk of STDs if a young person engages in coitus. Table 7-2 lists the options for contraception, their effectiveness, side effects, benefits, and costs.

Table 7-2 Options for Contraception

[edit] Gay, Lesbian, and Bisexual Youth.

Little good research is available on gay, lesbian, and bisexual youth. Some adolescents and young adults struggle with the issue of sexual orientation, with some ultimately self-identifying as gay, lesbian, or bisexual. Health risks that occur more frequently for this group than for heterosexual youth should guide their screening and care. These known risks, with available supporting data, include the following^[9][10]:

• Depression and suicide: 33% of adolescents who self-identify as gay or lesbian attempt suicide during adolescence, and 30% of all adolescent suicides are committed by gay or lesbian youth.
  
• Homelessness: many homeless youth are gay, lesbian, or bisexual and have left or been forced to leave their homes because of conflict over this issue.
  
• Sexual victimization: a significant number of gay or lesbian youth, particularly the homeless population, are victimized sexually in exchange for food, money, or shelter. More gay and lesbian youth have a history of sexual abuse as children than do heterosexual youth.
  
• Substance abuse: 9% to 14% of gay, lesbian, and bisexual youth have histories of problematic substance use that involves risk to health; half of gay youth report alcohol misuse.
  
• Violence: 40% of gay youth report being victims of violence related to their sexual orientation; most (75%) of these incidents are not reported to adults because of fear.
  
• School dropout: 28% of gay youth withdraw from school because of harassment.
  

Although uncomfortable for some, it is important to consider and ask about the issue of sexual orientation of youth with a screening question such as, “Do you find yourself romantically attracted to boys, girls, or both?” If screening yields questions or concerns in this area, follow-up with attention to the more prevalent risk factors is critical. In caring for gay, lesbian, or bisexual youth, a safe physician confidant can be protective for young people who feel isolated without adult support.

[edit] Disordered Eating

The number of youth with disordered eating continues to rise in the United States. Asking youth how they feel about their weight or doing a 24-hour recall on dietary intake frequently yields positive results in screening. Obesity, defined as a body mass index greater than 95% for age and gender norms, affects 12% of all adolescents.^[11] Data also indicate that less than 5% of obese teenagers manage to lose weight and maintain weight loss for 2 years. Many more youth perceive themselves as overweight, with 61.5% of adolescent girls and 21.5% of adolescent boys attempting weight loss at any one time. Caucasian girls are more likely to perceive themselves as overweight than other racial groups and subsequently engage more often in unhealthy eating patterns.^[12] Accompanying the data on weight is a corresponding drop in physical activity, with the steepest decline between midchildhood and adolescence.

[edit] Cardiovascular Disease

A significant number (30%) of youth have at least one modifiable risk factor for coronary artery disease (elevated cholesterol, hypertension, smoking, or obesity), and 5% to 10% of youth have two or more risk factors. Long-term cardiovascular health should become a consideration before diet and exercise habits are firmly established or before disease has progressed. Thus screening for and discussing cardiovascular health are appropriate in adolescence. The National Cholesterol Education Project recommends that adolescents with a family history of hyperlipidemia or premature cardiovascular disease be screened earlier and that all adolescents have lipid screening by age 21. For low-density lipoprotein (LDL) cholesterol in adolescents, below 110 is normal, 110 to 129 is borderline, and above 130 is elevated. As with adults, the recommendation for initial treatment is diet and exercise.^[13]

[edit] Skin Care

Acne is one of adolescents' most common health-related concerns. Skin care evaluation and treatment provide an opportunity for additional education related to smoking and sun exposure prevention and for access to youth on other health issues. When youth have acne, explaining the physiologic mechanisms, the principles of treatment, and regular follow-up is important (Table 7-3) (see Chapter 84 ).

Table 7-3 Medications for Acne

✢Patient must be using effective method of birth control, have written and oral informed consent, and be monitored for lipids while taking isotretinoin.

[edit] Substance Use

Many physicians underestimate the age of onset of substance and their ability to detect problematic use through screening. They also are bereft of strategies for effective intervention when they do uncover a problem. The following principles should guide the conversation about this topic with youth^[14][15]:

• Theaverage age of onset of alcohol use is 14 years, so beginning the conversation about substance use early (age 11 to 12) is appropriate.
  
• The problematic use of substances has covariance with other behavioral clusters, including accidents, school underperformance, delinquency, and sexual risk taking. These other clinical presentations should prompt questions about substance use.
  
• The best screening technique for substance use may be to ask a young person about friends' alcohol use (assuming use), then proceeding with more specific and personal questions regarding binge drinking and associated risk behaviors when using substances.
  
• The progression from casual or binge drinking to physiologic addiction occurs more rapidly with young people; thus the earlier the onset of drinking, the more likely drinking proceeds to addiction in youth.
  
• The biologic and laboratory markers for alcohol misuse are γ-glutamyltransferase (GGT), probably the most sensitive marker; serum iron; and mean corpuscular volume (MCV). The combined use of carbohydrate-deficient transferrin (CDT) with GGT to screen for excessive alcohol intake has a sensitivity of 75% and specificity of 85%.
  

The use of inhaled and smokeless tobacco often precedes alcohol misuse; thus tobacco is considered a “gateway drug,” or early marker for subsequent problematic substance use (see Chapters 51 and 57 ).

[edit] Mood Disorders

Suicide is the third leading cause of death among adolescents and has tripled in the last 20 years. Firearm suicides have increased dramatically, and the availability of guns in the home is an independent risk factor for adolescent suicide. Across all ages, suicides increase in the spring, and with youth, most suicides (70%) occur in the home, where the primary means of attempt is kept. Sixty percent of all youth report having some suicidal ideation, and 8% to 9% report having made some attempt. Estimates of attempts among youth range from 50,000 to 500,000 a year, with the attempt-to-completion ratio about 100 to 1. Prior suicide attempts, male gender, history of substance abuse, family dysfunction, and access to weapons all are risk factors that increase the likelihood of suicide in youth.

The connection between suicide and psychologic diagnoses, including depressive disorders, is more complex. The diagnoses with the most positive predictive weight for suicide in adolescence are conduct disorder and substance abuse; mood disorders are correlated less strongly with suicide. Compared with depressed adults, adolescents with depression have less melancholia, less impairment of functioning, less likelihood of psychotic disorder, fewer suicide attempts connected to depression, and a lower lethality with attempts. Depressed adolescents describe more anxiety, phobias, somatic complaints, and behavioral problems than depressed adults. Other predictors and comorbid factors for depression include a family history of mood disorders and family conflict. Depression in adolescents typically resolves within 12 to 18 months of onset, with 70% of these youth having another episode within 5 years of the initial presentation. Selective serotonin reuptake inhibitors (SSRIs) are the most effective antidepressant choice for adolescents. Tricyclics have not been shown to be as efficacious in treating depression in adolescents as SSRIs and carry a higher risk for lethality if used in a suicide attempt.^[16][17]

Health care providers fail to identify depression and suicide risk in youth often because of the belief that adolescents are normally in turmoil, they are normally healthy, and their worries are inconsequential. Time and training also constrain many providers. Effective screening for depression is direct, often with questions such as “Do you ever feel down?” “What usually causes that?” and “How do you handle your down feelings?” Predictive life events with a positive correlation for depression and suicide in youth include the recent death of a close friend or relative, parental divorce, sexual assault, and relocation.

[edit] REFERENCES