Adolescent Health Decision-Making

Pediatrics I: Adolescents

• Adolescence is a gateway to adulthood, involving completing puberty, physical growth, developing social, emotional, and cognitive skills, establishing an independent identity separate from family, and preparing for a career.

Puberty

• Puberty is the stage of sexual maturation and fertility achievement.
• Boys typically start puberty between 10-12 years old and finish around 16-18 years old. Signs include testicular enlargement, pubic hair, axillary hair, muscle development, voice deepening, and body/facial hair.
• Girls typically start puberty between 8-11 years old, finishing around 14-16 years old. Signs include breast development, pubic hair, axillary hair, and menarche (first menstrual period).

Hormones

• Pituitary and gonadal hormones are low before puberty.
• During puberty, the hypothalamic-pituitary-gonadal axis is activated.
• Timing of puberty is related to genetics, ethnicity, and environment.

Tanner Stages

• Tanner stages are used to describe the sequence of pubertal development.
• Stages are visible and documented for both boys (genitals) and girls (breasts).

Physical Growth

• Weight nearly doubles during adolescence.
• Height increases by 15-20%.
• Major organs double in size.
• Lymph tissue decreases.
• Muscle mass in boys increases, but decreases in girls.
• Growth spurts start approximately 2 years earlier in girls than in boys.
• Growth spurts happen usually 1 year prior to the appearance of breast development or hair growth.
• Psychosocial development doesn't always mirror physical growth.

Psychosocial Development (Early Adolescence 11-14 years)

• Rapid physical growth and secondary sex characteristics.
• Self-image fluctuates significantly.
• Concerns about puberty development.
• May express curiosity about sex, but often prefer same-sex groups.
• Sexual orientation can start to develop.
• Still using concrete thinking, transitioning towards more abstract thought as the middle years approach.
• Difficulty with future planning.
• May have unrealistic goals for adulthood.

Psychosocial Development (Middle Adolescence 15-17 years)

• Rapid development slows.
• More comfortable with self.
• Often experience intense emotions.
• No longer rely on concrete thinking; using formal operational and abstract thought.
• Omnipotence, "it won't happen to me" attitude.
• Self-centered, identity experimentation.
• Dating, sex, peer pressure, conformity.
• Can be stressful for all parties.

Psychosocial Development (Late Adolescence 18-21 years)

• Less self-centered and more caring toward others.
• Shift from peer group relationships to individual relationships.
• Dating becomes more intimate.
• Abstract thinking develops, leading to more realistic future views.
• Idealistic and rigid thinking.
• Potential for strong moral or religious views.

Adolescent Care

• Put biases aside when handling adolescents.
• Understand that teens need care focused on emotional, cognitive, and psychosocial development.
• Identify at-risk teens early.
• Enrolled teens in primary care should get preventive care like immunizations and contraception.
• Social histories are important for teens and should include sex, drugs, tobacco, and alcohol use.

Stages of Adolescence

• Parents' role decreases from high to medium to low as the teen becomes older (11-14, 15-17, 18-21)
• Risk taking is high in early and mid-adolescence, lowering in late adolescence.
• Peer influence is low in the early adolescent age 11-14 years, increasing greatly in mid adolescent years 15-17, decreasing in late adolescent years as the teen becomes older and more autonomous (18-21).

Morbidity in Adolescents

• Social Determinants of Health (SDoH) significantly affect adolescent health.
• Poverty, ethnic/racial disparities, and single-mother households are concerning elements regarding adolescent morbidity.
• High morbidity correlates with low academic achievement and various behavioral/mental health issues.
• Psychosocial issues and poverty are major contributors to adolescent morbidity.
• Related concerns might include pregnancy, sexually transmitted infections (STIs), substance abuse, school dropout, depression, running away from home, violence, and delinquency.

Common Health Problems in Adolescents

• Acne
• Asthma
• Diabetes
• Gynecological and menstrual issues
• High blood pressure
• Infectious mononucleosis
• Mental illnesses
• Obesity
• Oral/dental health
• Osgood-Schlatter disease
• Scoliosis
• Slipped capital femoral epiphysis
• Sexually transmitted infections
• Sports injuries
• Substance abuse disorders
• Heat-related illnesses
• Road traffic injuries
• Early pregnancy
• Violence

Leading Causes of Death in Adolescents (15-19 years)

• Accidents (including motor vehicle accidents, MVAs)
• Suicide (often using firearms)
• Homicide (often using firearms)
• Poisoning
• Cancer
• Heart Disease

Confidentiality

• Confidentiality depends on level of maturity, intelligence, independence, and health conditions in the child/adolescent.
• Exceptions to confidentiality include suspected suicide, homicide, sexual abuse, and physical abuse (conditional confidentiality).
• Laws vary by state when parent requests to review child's medical record
• At some sites, patients 13-17 years old do not have access to portal unless they can consent and there is no parental consent needed.
• HIPAA laws generally state that parents can access minors' medical records, except when a minor gives consent to care that doesn't require parental consent.

Adolescent Consent

• Adolescents can provide consent for certain medical services and care.
• Minor is anyone under 18 years old and consent is from a parent/guardian.
• Emancipated minor is when a minor has attained legal adulthood.
• There is medical emancipation for minors in some states, so that they can consent for care independently.
• Mature minor doctrine gives minors the right to consent to care without parental consent; there are rules involved as to which care falls under this category.
• An emancipated minor is someone who is legally able to make decisions for themselves, such as a minor who is sixteen or older and is married or in the armed services, or has received a declaration from a court.

NM Statutes (NMSA)

• In New Mexico, certain minors are allowed to consent to their treatment for certain health conditions and care without parental/guardian consent.
• Relevant issues include treatment of STIs, pregnancy, contraception, mental health concerns, and substance abuse.
• Homeless youth or parent of a child have similar considerations to the above.
• Consideration of all health conditions that are not determined emergency may have specific regulations depending on the individual circumstance.

Adolescent Decision Making: Case Study - Jamie

• 14-year-old Jamie was diagnosed with renal failure.
• Her condition was complicated by repeated infections.
• Was put on peritoneal dialysis.
• Several hospitalizations.
• 2 years later, Jamie had a kidney transplant; however, issues of rejection occurred.
• Jamie and her parents disagreed regarding treatment decision, involving return to hemodialysis.
• Jamie does not want hemodialysis; she is not an emancipated minor, her parents are not neglectful nor abusive; these factors do not limit the parents' authority in the medical decisions.

Respect for Jamie's Autonomy

• Understanding Jamie's current decision, while it may have future ramifications, is crucial.
• Respecting her right to future autonomy may involve exercising limited paternalism, allowing her to exercise choices when she is older.
• Parental decision makers need to protect kids' future rights until full decision making capacity is attained.

Preserving Jamie's Future Autonomy

• Educational efforts about "informed consent" are important, including in this case understanding the treatment options.
• Understand and respect Jamie's viewpoint; be truthful.
• Negotiation is necessary regarding treatment options and persuading her of the benefits of continued treatment.

Possible Outcomes for Jamie

• Persuasion of Jamie succeeds, leading to continued treatment.
• Persuasion succeeds, but eventual future treatment fails.
• Persuasion fails, resulting in the treatment plan being unsuccessful and stopping the treatment.

Conclusions: Jamie's Case

• Parents are usually decision-makers for their children.
• Involving children as they mature in medical decisions is essential.
• When adolescent preferences differ from parents, the clinician must ensure the adolescent understands the condition and consequences and try to negotiate treatments and respect their autonomy when treatment fails.

Adolescent Well Visit

• Use of Bright Futures Pocket Guides for Early (11-14), Middle (15-17), and Late (18-21) Adolescent Visits.
• Include annual visits.
• Include Health supervision related to development and Parent-youth interaction.
• Perform physical exam with Vitals, screenings, and immunizations and provide anticipatory guidance.

HEADSS: Adolescent Psychosocial History

• HEADSS is a tool for evaluating adolescents.
• HEADSSS (HOME, EDUCATION, ACTIVITIES, DRUGS, SEXUALITY, SUICIDE/DEPRESSION).
• Collect relevant information from H to S to better understand the adolescent.

11 Year Old Visit: Example Data Collection

• Include history including vitals (weight, height, BMI, blood pressure)
• Hearing test
• Developmental Surveillance
• Psychosocial/Behavioral Assessment
• Physical exam that includes a symptom review from the SMR (systemic review of past medical history)
• Vaccinations (including Covid, Influenza, Tdap, and HPV)
• Meningococcal vaccination
• Fasting lipid panel and anticipatory guidance.

Transitioning to Adult Care

• The adolescent visits will transition to adult health care, involving policy discussion, tracking progress, assessment of skills, development of plans, and follow up with confirm transfer completion, and eliciting consumer feedback.

Transitioning to Adult Care: Challenges

• Fear of new health system
• Anxiety
• Change of treatment therapies
• Family fears
• Negative beliefs regarding adult health.
• Inadequate planning which includes insufficient preparation and support
• Youth and young adults may be less focused on health
• Socioeconomic status based on adolescents' age, sex, and race/ethnicity, compared to their parents

Pre-participation Sports Physical Exam

• Identify medical issues with risks of life-threatening complications, like cardiomyopathy.
• Conditions requiring treatment plans beforehand (e.g., hypertension), as well as identifying and rehabilitating old musculoskeletal injuries are necessary.
• Identify conditions interfering with performance (e.g., exercise-induced bronchospasm).
• Removing unnecessary participation restrictions.

Sports Physical Examination

• Thorough medical and family history is essential, including menstrual history if female.
• Cardiovascular risk factors and all previous injuries/surgeries must be documented.
• General physical exam.
• Heart, lung, vision, and hearing assessment, including murmurs, wheezing, and deficits.
• Thorough musculoskeletal exam to consider for diagnosis, weakness, and limited range of motion.

Example of a Sport's Physical Form

• Includes patient medical history questions about stress, anxiety, safety at home, tobacco use, alcohol use, and performance-enhancing supplements.
• The form would also include specific questions about cardiovascular issues.
• Height, weight, pulse, vision, and blood pressure would be recorded.
• Detailed physical examination data for eyes, ears, nose, and throat would be collected.