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Guidelines for adolescent preventive services

Guidelines for adolescent preventive services
Literature review current through: Jan 2024.
This topic last updated: Nov 29, 2023.

INTRODUCTION — The health status and health behaviors of adolescents have been monitored closely for many years [1,2]. Although improvement has been noted in certain indicators, compared with other age groups, adolescent health has failed to respond to the range of interventions developed for schools, communities, and the health system.

Unintentional injuries such as automobile crashes, intentional injuries such as homicide and suicide, and reproductive health issues such as unintended pregnancy and sexually transmitted infections remain the leading causes of adolescent morbidity and mortality. Alcohol and drug use contribute to many of these injuries and deaths. Obesity has become a major cause of adolescent morbidity and is a contributor to a dramatic increase in the number of youth with type 2 diabetes mellitus. Tobacco use causes harm during the teen years and can lead to nicotine addiction that results in major morbidity and mortality later in life. The common denominator in this list is that most adolescent morbidity and mortality is related to personal behavior and, as such, is preventable.

The preventable nature of all of these conditions provides a clear mandate to pediatric health care providers. The challenge is to integrate preventive services into routine medical care. Practitioners can use clinic visits for routine examinations, such as preparticipation athletic evaluations and chronic disease management, to provide a range of preventive services. These clinical encounters offer an opportunity for early identification of risk behavior and disease, updating immunizations, and offering health guidance. Clinical preventive services are an adjunct to preventive interventions provided through schools and in the community.

PREVENTIVE SERVICE RECOMMENDATIONS FOR ADOLESCENTS — The purpose of preventive services is to reduce serious morbidity and premature mortality both during adolescence and in later years. Preventive services typically fall into four categories: screening, counseling to reduce risk, providing immunizations, and giving general health guidance. In addition, a recommendation for how frequently routine visits should occur usually is included. Various organizations have developed or revised guidelines that are designed to enable practitioners to identify and address specific health problems and behaviors that cause the greatest burden of suffering among adolescents:

The United States Preventive Services Task Force (USPSTF) – Guide to Clinical Preventive Services [3]

American Medical Association (AMA) – Guidelines for Adolescent Preventive Services 1994 [4]

American Academy of Family Physicians (AAFP) [5]

Maternal and Child Health Bureau, United States Public Health Services, and American Academy of Pediatrics (AAP) – Bright Futures: Guidelines for Health Care Supervision of Infants, Children, and Adolescents [6]

Bright Futures/AAP – Recommendations for Pediatric Preventive Health Care 2022 [7]

Advisory Committee on Immunization Practices (ACIP) – Annual adolescent immunization schedules (figure 1); these recommendations include vaccines for preventing pertussis, human papillomavirus, influenza, and meningococcal disease (see "Human papillomavirus vaccination" and "Meningococcal vaccination in children and adults", section on 'Routine immunization of adolescents and young adults')

The organizations use different methods to arrive at their guidelines. The USPSTF guidelines, for example, are based upon the proven ability of screening procedures and interventions to improve clinical outcomes. Because data from preventive service studies using adolescent subjects in clinical settings are sparse, the AMA and Bright Futures guidelines also incorporate expert opinion.

An analysis of the recommendations reveals the following [8,9]:

General agreement is that primary care clinicians should provide the basic set of immunizations identified by the ACIP of the Centers for Disease Control and Prevention (figure 1). (See "Standard immunizations for children and adolescents: Overview", section on 'Adolescents' and "Meningococcal vaccination in children and adults", section on 'Routine immunization of adolescents and young adults'.)

Data provide strong support that clinical services should include screening and counseling to prevent injuries from violence and accidents, reduce risk for future cardiovascular disease (eg, smoking cessation, management of obesity, early treatment of hypertension and hyperlipidemia), reduce involvement in health-risk behaviors (eg, alcohol and drug use, unsafe sexual practices), and promote dental health.

Less agreement exists for teaching self-breast and self-testicular examinations, providing routine health guidance to caregivers, offering routine hearing and vision testing, and conducting routine testing for hematocrit and urinalysis.

Disagreement exists regarding the recommended periodicity for routine health evaluations. Although the AMA, Bright Futures, and AAP recommend annual preventive service visits for adolescents, the AAFP and USPSTF recommend that these visits occur every one to three years as necessary. The National Commission on Quality Assurance includes in its recommended set of performance measures for managed care organizations (Health Employer Data and Information Set) that adolescents between 13 and 18 years of age should be seen annually for a routine health visit [10].

COMPREHENSIVE GUIDELINES FOR ADOLESCENTS — The Society for Adolescent Health and Medicine focuses on the similarities between the guidelines and calls for the widespread acceptance and implementation of clinical preventive services for adolescents [11]. The American Medical Association's Guidelines for Adolescent Preventive Services paradigm provides a framework for the content and delivery of comprehensive preventive services for adolescents [4]. The recommendations target screening, anticipatory guidance, and immunizations.

Inexpensive technologies, such as handheld computers or tablets, may enhance clinician screening and counseling and improve adolescents' perceptions that their visit was confidential and that they were listened to carefully [12]. Social networking, including cell phones, may also provide new opportunities to reach adolescents with health messages [13].

Screening — Adolescents should be screened for the following conditions during clinical preventive services visits:

Hypertension (table 1A-B) (see "Evaluation of hypertension in children and adolescents", section on 'Definition')

Obesity and eating disorders (calculator 1 and calculator 2) (see "Eating disorders: Overview of epidemiology, clinical features, and diagnosis", section on 'Screening' and "Clinical evaluation of the child or adolescent with obesity", section on 'Body mass index')

Hyperlipidemia – For children without any risk factors for premature cardiovascular disease, such as obesity or family history of a lipid disorder, routine screening for dyslipidemia should be done periodically; this is discussed further in a separate topic (see "Dyslipidemia in children and adolescents: Definition, screening, and diagnosis")

Tuberculosis, if at risk (see "Tuberculosis infection (latent tuberculosis) in children", section on 'Whom to test')

Physical, sexual, and emotional abuse (see "Physical child abuse: Diagnostic evaluation and management" and "Evaluation of sexual abuse in children and adolescents")

Learning or school problems (see "Specific learning disorders in children: Clinical features", section on 'Risk factors' and "Specific learning disorders in children: Role of the primary care provider", section on 'Early identification')

Substance use (both tobacco and alcohol) (see "Prevention of smoking and vaping initiation in children and adolescents", section on 'Smoking and vaping prevention in the primary care office' and "Screening tests in children and adolescents", section on 'Nicotine, alcohol, and substance use')

Behaviors or emotions that indicate recurrent or severe depression, anxiety, or risk of suicide (see "Screening tests in children and adolescents", section on 'Depression and suicide risk screening' and "Suicidal ideation and behavior in children and adolescents: Evaluation and management", section on 'Prevention' and "Pediatric unipolar depression: Epidemiology, clinical features, assessment, and diagnosis", section on 'Assessment')

Gender identity concerns (see "Gender development and clinical presentation of gender diversity in children and adolescents", section on 'Identification')

Sexual behavior that may result in unintended pregnancy or sexually transmitted infections (STIs), including indications for pre-exposure prophylaxis for youth at risk for human immunodeficiency virus (HIV) infection (see "Sexual development and sexuality in children and adolescents", section on 'Ask specific questions to assess risks and strengths')

STIs, if sexually active (see "Screening for sexually transmitted infections")

HIV infection; 2006 Centers for Disease Control and Prevention recommendations call for all adolescents seen in health care settings to be tested for HIV infection unless they specifically "opt out" [14,15] (see "Screening and diagnostic testing for HIV infection", section on 'Testing algorithm')

Cervical cancer (as indicated) (see "Screening for cervical cancer in resource-rich settings")

Anticipatory guidance for adolescents — Through anticipatory guidance, providers can help teens have a better understanding of their physical growth, psychosocial and psychosexual development, and the importance of becoming actively involved in decisions regarding their health care. In addition, adolescents should receive counseling regarding healthy habits and risk reduction in the following areas [16]:

Healthy dietary habits, including ways to achieve a healthy diet and safe weight management (see "Dietary recommendations for toddlers and preschool and school-age children", section on 'General guidance')

Reduction of injuries through use of use of bicycle and motorcycle helmets and car seatbelts (see "Bicycle injuries in children: Prevention", section on 'Bicycle helmets')

Regular exercise (see "The benefits and risks of aerobic exercise")

Optimal sleep duration (8 to 10 hours per day) and healthy sleep habits [17-19] (see "Behavioral sleep problems in children", section on 'Older children and adolescents' and "Drowsy driving: Risks, evaluation, and management", section on 'Teenage and young adult drivers')

Sun protection (see "Primary prevention of melanoma", section on 'Sun protection')

Responsible sexual behaviors, including abstinence (see "Sexual development and sexuality in children and adolescents", section on 'Risk and resiliency-based anticipatory guidance')

Avoidance of tobacco, alcohol, other abusable substances, and anabolic steroids (see "Prevention of smoking and vaping initiation in children and adolescents", section on 'Smoking and vaping prevention in the primary care office')

Avoiding online behaviors that can have negative consequences, such as "sexting" and sharing of personal information and pictures with strangers [20]; resources are available through the American Academy of Pediatrics

Strategies to deal with bullying; resources are available through Bright Futures and stopbullying.gov

Although inconsistent, there is evidence that provision of anticipatory guidance improves some adolescent health behaviors [21,22]. Targeted preventive interventions have been associated with increased condom use and safer sexual behaviors [23,24], improved diet and physical activity [25], and decreased drug use [26]. General interventions that include screening followed by motivational interviewing (table 2) or brief counseling also have some evidence of success in safer sexual behaviors [27,28], increasing bicycle helmet and seatbelt use [29-31], improved diet and physical activity [32,33], improved sleep habits [32], decreased alcohol and drug use [27,34], and reducing drinking and driving [32].

Anticipatory guidance for parents or caregivers — Health guidance for parents or caregivers includes advice to assist them in making appropriate decisions and in adapting their parenting practices to meet the changing needs of their adolescent children [8]. Caregivers should receive health guidance at least once during their child's early, middle, and late adolescence [4].

Caregiver involvement and attitudes affect adolescent behavior and health outcome [35-39]. As an example, the 2021 Youth Risk Behavior Survey found that higher levels of parental monitoring were associated with higher rates of sexual abstinence and condom use and also were protective against adverse experiences (forced sex and electronic bullying), poor mental health (depressed mood and attempted suicide), and health-risk behaviors (multiple sexual partners, prescription opioid misuse, marijuana use) [39]. Similarly, a cross-sectional analysis of interview data from more than 12,000 7th- through 12th-grade students found that caregiver-family connectedness (eg, feelings of warmth, love, and caring from the caregivers) was protective against every health-risk behavior measure (emotional distress, suicidality, violence, cigarette use, alcohol use, and marijuana use) except history of pregnancy [35]. In another prospective study of 10,000 adolescents in the Longitudinal Study of Adolescent Health, adolescent perception of maternal attitudes toward the adolescent's engaging in sexual intercourse and adolescent satisfaction with the maternal relationship were predictive of the occurrence of the onset of sexual intercourse in the ensuing 12 months [36].

Caregivers should also be counseled to monitor their teen's use of online social media. Specific attention should be directed at helping caregivers understand the hazards associated with sharing personal information with strangers.

Firearms are a leading cause of adolescent deaths due to suicide, homicide, and accidental discharge. Providers should counsel caregivers to: remove guns from the home; contact police if the caregiver is concerned a child may use a firearm to harm others (red flag laws authorize police to temporarily remove firearms from a home if there is concern for harm to others); and, if guns remain in the home, ensure the safety of firearms by having them securely stored and equipped with trigger locks. (See "Firearm injuries in children: Prevention".)

Lastly, caregivers should be counseled to take seriously any comments or indications of bullying of their teen. If bullying is suspected, caregivers should discuss with school personnel the nature of the problem and interventions that will be taken.

Immunizations — Adolescents should have their immunizations reviewed and updated as necessary (figure 1) (see "Standard immunizations for children and adolescents: Overview", section on 'Adolescents'). Special attention should be given to those students who are matriculating to college and to those who are incarcerated or in detention facilities. By age 11 to 12 years, they should have received [16]:

Hepatitis B vaccine (see "Hepatitis B virus immunization in adults")

Hepatitis A vaccine (see "Hepatitis A virus infection: Treatment and prevention")

Measles, mumps, and rubella vaccine (see "Measles, mumps, and rubella immunization in infants, children, and adolescents")

Varicella vaccine if they have not had varicella infection (see "Vaccination for the prevention of chickenpox (primary varicella infection)", section on 'Adolescents and adults')

A booster dose of tetanus if ≥5 years have elapsed since their last dose; ideally, this booster should include the acellular pertussis vaccine (if not acellular pertussis-containing vaccine not previously administered) (see "Diphtheria, tetanus, and pertussis immunization in children 7 through 18 years of age", section on 'Indications')

Meningococcal vaccine (see "Meningococcal vaccination in children and adults", section on 'Routine immunization of adolescents and young adults')

Human papillomavirus vaccine (see "Human papillomavirus vaccination")

Annual influenza vaccine (see "Seasonal influenza in children: Prevention with vaccines", section on 'Target groups')

Pneumococcal vaccine if they are at high risk for infection (see "Pneumococcal vaccination in children", section on 'Immunization of high-risk children and adolescents')

STRATEGY FOR PROVISION OF ADOLESCENT PREVENTIVE SERVICES — Most medical education prepares practitioners to identify and manage biomedical disease but may not prepare them to manage preventable disorders related to personal behavior, especially in adolescents [40]. When seeing adolescents for routine health evaluation, practitioners tend to focus on diseases or conditions with which they are familiar, rather than on health-risk behaviors and problems [41-43].

In addition to guidelines, therefore, practitioners need a strategy to help them integrate preventive services into routine medical care. The scheme presented in the algorithm (algorithm 1) can help providers screen for a large number of potential health risks, identify those that need further assessment, and focus on those that are of immediate concern [44].

Step 1: Gather information and identify problems — The goal of this step is to identify indicators for all or a subset of the specific health risks and problems listed above. Data that are easy to obtain and have a high sensitivity for the issues of greatest concern are collected. Height, weight, and blood pressure are measured; questionnaires to assess health risks, habits, and behaviors can be completed in the waiting area. The use of questionnaires (including electronic questionnaires) can save time and improve identification of problems [45-47].

The data that are gathered are used to guide the clinical interview and for further assessment. If no areas of concern are elicited, the practitioner can offer support and reinforcement for healthy behaviors. If, however, the indications are that the teen has a problem, such as being overweight or engaging in a health-risk behavior, then the practitioner goes to Step 2.

Step 2: Further assess — The goal of this step is to determine, for each potential problem identified in Step 1, whether the teen is at high, moderate, or low risk for adverse consequences. The problems identified by the screening information are further assessed with a complete history and physical examination. If the problem presents an imminent and serious risk, then referral for specialty evaluation and management is appropriate. To illustrate the assignment of risk category, consider three 16-year-old females who, during a routine health examination, indicate they use alcohol:

The first patient discloses during the interview that she has tried alcohol at a few parties. She does not particularly like the taste, but she continues to sip on her drink throughout the evening so that she will not stand out in the crowd. Her friends drink more than she does. She makes sure not to be driven home by someone who appears to have had too much to drink at the party. The clinician would assess the patient's alcohol use as relatively low risk for adverse health outcomes and consistent with experimentation that is common during adolescence. The clinician might encourage her to continue making responsible decisions and schedule her for a return visit in six months.

The second patient reports that she has several drinks when she attends parties, which is every one to two weeks, and she only drinks when at parties. She and her friends usually drink a fruity punch with hard liquor. She has been drunk and, on a few occasions, vomited. She stops herself from drinking too much when she starts to feel overly dizzy. She knows that her parents will pick her up "no questions asked" if she cannot find a sober ride home. She does not think she has ever driven home with a drunk driver. She has not had sex while drinking. The clinician would have a moderate degree of concern for this patient. Her alcohol use warrants harm reduction counseling, such as always attending parties with a friend group that designates one member that will not drink. The clinician might schedule her back for more frequent visits (eg, every three months) to reassess her risk for alcohol use disorder, unintended pregnancy, and sexually transmitted infection (STI).

The third patient enjoys drinking at parties. She does not think that she displays signs of intoxication when at parties and believes that she is fine to drive herself home. She will often drink her parents' alcohol when she is at home alone. She indicates that drinking calms her nerves and makes her feel better. There have been a couple of times that she does not remember what has happened after drinking more alcohol than usual. She is pretty sure that she has not had sex when passed out, but a friend told her that there was a rumor she had had sex with a person who drove her home from one of the parties. This patient is at high risk for unintended pregnancy, STI, and alcohol use disorder and should be referred for specialty care by a physician with expertise in adolescent care to help her address her substance use and reproductive health risks. Due to her high risk for unintended harm to self, the clinician might decide to involve her caregivers in the follow-up plans.

Step 3: Identify and prioritize problems together — Once the practitioner has determined the risk category for each of the problems, they should have a discussion with the adolescent to acknowledge the problems and prioritize the problem list. The existence of a therapeutic relationship between the practitioner and the adolescent will facilitate this discussion. Adolescents tend to respond to an approach that enlists their cooperation and involvement in the decision-making process. The practitioner can foster a therapeutic alliance by:

Assuring the adolescent the information shared with the practitioner will remain confidential [47], unless the information indicates that they are at risk for harming other or themselves (see "Confidentiality in adolescent health care")

Listening to and valuing the adolescent's perspective

Not responding to information regarding personal behaviors in a derogatory or punitive manner

The practitioner and the adolescent must come to an agreement regarding the type and severity of each problem. Although the practitioner might believe that smoking, monthly use of alcohol, and skipping breakfast are the top issues of concern, the adolescent may rank these behaviors in a different order or may not even view them as problems. Without the teenager's acceptance of the problem list and its prioritization, chances of compliance with the management plan are nil. Unless the behavior is life-threatening in the immediate future, the practitioner and the adolescent must negotiate what they will work on together. The negotiation process provides the occasion to determine whether the adolescent is ready to change their behavior and to identify opportunities for and barriers to change. This information is necessary to proceed to the development of a management plan.

Step 4: Solutions — Developing a management plan for the set of problems involves five steps:

Negotiate the intervention – Discuss management options with the teen and determine, together, the best course of action. If the adolescent views the ultimate outcome to be too difficult, then negotiating more immediate, attainable objectives is reasonable. As an example, losing 2 pounds per month for six months may be more acceptable to a teen than losing 12 pounds as the long-term goal.

Promote the teen's confidence that the management plan can work – Motivation to work on a behavioral change plan is key to success.

Discuss strategies with the teen to overcome barriers to the management plan – Have the teenager identify a list of the barriers that they believe will interfere with the strategy for changing the behavior. Help plan ways to overcome the barriers.

Develop a contract or verbal agreement with the teen regarding joint expectations.

Follow up with the actions identified – The patient can make contact through electronic mail, telephone calls to office staff, and postcards prior to future office visits.

INTEGRATING PREVENTIVE SERVICES INTO ROUTINE MEDICAL CARE — Although most health systems for pediatric care have well-established procedures for health maintenance visits, they are less likely to be set up to provide comprehensive preventive services for adolescents [48,49]. Establishing systematic changes facilitates the ability of practitioners to deliver preventive services [50-52]. National programs and materials can be modified to meet local needs and directions, as the local clinic must take ownership of the preventive services that are delivered. Objectives should be clear and protocols well delineated before broad changes are instituted. The integration process requires time and the complicity of each staff member. Experience with the Guidelines for Adolescent Preventive Services (GAPS) program and information from the clinical literature on services for adult patients provide a set of steps for successful integration of comprehensive adolescent preventive services into routine medical care (table 3) [53-57].

The efficacy of the GAPS recommendations to improve preventive health care service to adolescents was analyzed before and after implementation of the GAPS program in five community and migrant health centers [50]. The percentage of adolescents who reported having received preventive screening or counseling increased after implementation in 19 of 31 content areas including:

Physical or sexual abuse (22 versus 10 percent)

Sexual orientation (27 versus 13 percent)

Fighting (21 versus 6 percent)

Weapons (22 versus 5 percent)

Depression (34 versus 16 percent)

Suicide (22 versus 7 percent)

Eating disorders (29 versus 11 percent)

In an additional study, researchers found that with appropriate skill-based training, clinicians can successfully implement preventive services in routine outpatient visits [51]. Thus, following an educational intervention, the proportion of adolescents screened by their primary care providers for seat belt use, helmet use, tobacco use, alcohol use, and sexual behavior increased from 38 to 56 percent, 27 to 45 percent, 64 to 76 percent, 59 to 76 percent, and 61 to 75 percent, respectively.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Adolescent sexual health and pregnancy".)

SUMMARY

Most adolescent morbidity and mortality is related to personal behavior and, as such, is preventable. Clinicians have an important role in early identification of risk (screening), counseling to reduce risk and provide general health guidance (anticipatory guidance), and provision of immunizations. (See 'Introduction' above and 'Preventive service recommendations for adolescents' above.)

We suggest that adolescent patients be screened for hypertension; obesity and eating disorders; hyperlipidemia (if indicated); tuberculosis (if at risk); physical, sexual, and emotional abuse; learning or school problems; substance use; gender identity concerns; depression, anxiety, and suicide; sexual behavior that may result in unintended pregnancy and sexually transmitted infections, including HIV infection; and cervical cancer (as indicated). (See 'Screening' above.)

We suggest that adolescents receive counseling about healthy eating habits, reduction of injuries, regular exercise, responsible sexual behaviors, avoidance of sharing personal information and pictures on the internet, and avoidance of tobacco, alcohol, and other abusable substances. (See 'Anticipatory guidance for adolescents' above.)

Caregiver involvement and attitudes affect adolescent behavior and health outcomes. We suggest that caregivers receive anticipatory guidance at least once during their child's early, middle, and late adolescence. (See 'Anticipatory guidance for parents or caregivers' above.)

We recommend that adolescents have their immunizations reviewed and updated as necessary (figure 1). (See 'Immunizations' above.)

A strategy for integrating preventive services into routine medical care is provided in the algorithm (algorithm 1). Such a strategy can help providers screen for a range of potential health risks, identify those that need further assessment, and focus on those that are of immediate concern. (See 'Strategy for provision of adolescent preventive services' above.)

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