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Jessica Alper
Components of an annual exam for an adolescent patient
Having an adolescent as a patient may be difficult, as generally, the adolescent is not the one to initiate or agree to have the consultation. While that is true, “delineating signs and symptoms through detailed clinical history and examination help ascertain key areas of concern and presence or absence of a mental health disorder” (Srinath et al., 2019). Because communicating with a teenager may be challenging, a therapeutic alliance between the two parties is crucial. If good rapport is built, facts become more meaningful and become more useful, which will then lead to shared intervention goals.
Srinath et al. (2019) state that there are five goals in the evaluation of clinical history and examination. The first one is to evaluate the developmental trajectories and attainments of the patient, to present behavioral and emotional problems, to assess the current functioning in different settings, to evaluate the strengths of the adolescent and the family, and to reach the highest level of functioning before the onset of current concerns. These goals are achieved by obtaining a detailed medical history along with a physical examination. Laboratory investigations may be needed in complement to the history and physical examination. Additionally, “a history of similar or other behavioral concerns and history of medical issues must be asked for” (Srinath et al., 2019). Developmental history across different domains may help determine the source of the behavioral concerns along with the pharmacological and psychotherapeutic management. The developmental profile includes information about the age of acquisition of milestones, as well as the current developmental level. Temperamental history should also be assessed as well as schooling history. The child’s interests, skills and talents must also be assessed to get an accurate understanding of the child.
It is vital for the practitioner to assess the behaviors of the teenagers, as substance abuse use, high-risk sexual behaviors and risky driving may lead to poor health outcomes and high mortality rate. Bright Futures, as part of the American Academy of Pediatrics, has set guidelines on what type of preventative care to perform depending on each age group. For this 14-year-old patient, personal history, all measurements including a blood pressure and BMI should be obtained, and vision and hearing should be examined. As previously stated, developmental surveillance, behavioral/social/emotional screening, tobacco/alcohol/drug assessment, depression and suicide risk screening should be assessed. Immunizations should be kept up-to-date, and anticipatory guidance should be provided. Laboratory findings should be obtained to screen for anemia, tuberculosis, dyslipidemia, sexually transmitted diseases, and HIV as well as fluoride supplementation (Recommendations for Preventive, 2022).
Presence of parent during examination of teenager
Having the teenager’s parent present during the examination can be a clinical judgment call. There are times where patients and children must be talked to separately. Some of the situations include “older children or adolescents, history suggestive of parent-child discord, peer relationship issues, history of trauma/abuse, and children staying in child care institutions” (Srinath et al., 2019). One way this could be done would be to speak with the parents before or after seeing the child together with the parents in order to observe the interaction between the two. If the child is an adolescent however, they are recommended to be present during the initial interviews and to then be spoken to separately before interviewing the parent. Srinath et al. (2019) states that “it is important to interview the adolescent alone, since a developing self-awareness and self-consciousness may make them feel inhibited in front of family”.
Health promotion for teenagers
During adolescent years, many changes take place, such as social, physical, physiological and psychological, which can have adverse consequences on risk-taking behaviors. One of the risky behaviors that should be mentioned during this visit is alcohol use. The term “early alcohol consumption” is defined as a child having drunk alcohol before the age of 15 years old. Drinking from an early age can have negative impacts affecting the child’s health risks, especially the development of the brain. When comparing early alcohol use to later use in adolescence, the frequency and quantity of the alcohol consumed is elevated, along with the alcohol-related troubles going into adulthood. Some factors playing into early alcohol consumption includes family and peers. Pedroni et al. (2021) state that “parents’ and friends’ alcohol use, peer encouragement towards consumption, or low parental monitoring have been identified as risk factors for early alcohol use”.
The patient’s mother in this case study states that the child’s grades have declined, and that he engages with other teenagers that she is concerned about. Research shows that children aged 11-15 years of age who enjoy school have a negative relationship with alcohol and are less likely to drink (Pedroni et al., 2021). However, this patient’s grades are declining, which could insinuate that he may possibly be involved in risky behaviors outside of school, especially with questionable friends. Additional research shows that “10-17-year-olds with ‘low’ life satisfaction were also more likely to consume alcohol in conjunction with tobacco and/or marijuana” (Pedroni et al., 2021). This topic is important to address as alcohol, tobacco along with marijuana can have negative effects on the health outcomes of each child. The practitioner should assess the behavior to make sure the child is not depressed, have anxiety, which could all lead to unhealthy behaviors.
Important screening tools
In order to assess for anxiety and/or depression, the practitioner should provide the teenager with a questionnaire called PHQ-9: Modified for Teens. This screening tool allows the practitioner to determine if the patient is experiencing any mental health disorders. The questionnaire includes 9 questions that have answers varying from “not at all” to “nearly every day” additionally to 4 “yes” or “no” questions. Depending on the score that is obtained, the practitioner will be able to know if the teenager is experiencing any, mild, moderate, or severe depression.
Additionally to the PHQ-9 screening tool, another important tool should be used during this visit. CRAFFT is an excellent and well-validated substance use screening tool for teenagers aged 12-21. This tool is recommended by the American Academy of Pediatrics’ Bright Futures Guidelines for preventive care and well-visits. Appendix A is made of two parts, consisting of yes or no questions. Appendix B is a contract for life for both the parent and the child which can help facilitate a foundation for trust and caring, and promotes open communication. Lastly, appendix C is an abstinence challenge, which is when the patient makes a promise to himself or herself to not use drugs, alcohol and or non-prescribed medications (Use The CRAFFT, 2018).
References
Pedroni, C., Dujeu, M., Lebacq, T., Desnouck, V., Holmberg, E., & Castetbon, K. (2021). Alcohol consumption in early adolescence: Associations with sociodemographic and psychosocial factors according to gender. PLoS ONE, 16(1), 1-13. https://doi.org/10.1371/journal.pone.0245597
Recommendations for preventive pediatric health care. (2022). Bright Futures – American Academy of Pediatrics. https://downloads.aap.org/AAP/PDF/periodicity_schedule.pdf
Srinath, S., Jacob, P., Sharma, E., & Gautam, A. (2019). Clinical practice guidelines for assessment of children and adolescents. Indian Journal of Psychiatry, 61(Suppl 2), 158–175. https://doi.org/10.4103/psychiatry.IndianJPsychiatry_580_18
Use the CRAFFT. (2018). CRAFFT. https://crafft.org/use-the-crafft/#how-to
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