What are the primary recommendations for a 13-year-old's well child visit, including vaccinations, screenings, and assessments?

13-Year-Old Well-Child Visit

A 13-year-old well-child visit should include annual depression screening, review and administration of adolescent vaccines (Tdap, HPV, meningococcal, and influenza), substance use assessment using the CRAFFT tool, and confidential time alone with the adolescent to address sensitive topics that directly impact mortality and morbidity in this age group. 1, 2

Mandatory Screenings and Assessments

Mental Health Screening

• Screen annually for depression starting at age 11 through 21 years, as suicide is a leading cause of death in adolescents. 1
• Screen for anxiety, suicidal ideation, and self-harm behaviors during the confidential portion of the visit. 2
• This screening must occur every year, not just at this visit. 1

Substance Use Assessment

• Use the CRAFFT screening questionnaire (Car, Relax, Alone, Forget, Friends, Trouble) to screen for drug and alcohol use. 1
• Screen specifically for tobacco, alcohol, marijuana, and other substances, as substance abuse is a leading cause of adolescent morbidity and mortality. 2

Immunizations

• Administer Tdap, HPV vaccine series (if not already started), meningococcal conjugate vaccine (MenACWY), and annual influenza vaccine. 1
• HPV vaccine should be normalized and coadministered with other vaccines, with a strong recommendation emphasizing cancer prevention. 1
• Review hepatitis B series completion status. 1
• Consider varicella vaccine if no reliable history of chickenpox and not previously vaccinated. 1

Physical Examination Components

Growth and Vital Signs

• Measure and plot height, weight, and body mass index (BMI) on appropriate growth charts. 3, 4
• Measure blood pressure annually using proper technique, with follow-up based on percentile rankings (≥90th percentile requires lifestyle interventions and recheck in 6 months). 2, 4

Comprehensive Physical Assessment

• Perform complete head-to-toe examination including skin assessment, cardiovascular examination, and assessment for signs of physical abuse or neglect. 2
• Assess pubertal development using Tanner staging. 2

Confidential Interview Structure

Visit Format

• Begin with parent/guardian present for medical history review, then provide mandatory private time alone with the adolescent. 2
• Almost 1 in 4 adolescent boys report being too embarrassed to discuss important health issues when parents are present. 2

Sexual Health Screening

• Screen for sexual activity, number of partners, contraception use, and history of sexually transmitted infections. 2
• Discuss consent, healthy relationships, and STI/pregnancy prevention. 2
• For sexually active adolescents, perform STI screening (though routine HIV screening is recommended at ages 16-18, not yet at 13). 1, 2

Psychosocial Assessment

• Screen for involvement in or victimization from violence or abuse. 2
• Assess school performance and learning difficulties. 2
• Evaluate peer relationships and social functioning. 2

Laboratory Screening

Lipid Screening

• Screen for dyslipidemia between ages 9-11 years due to the growing obesity epidemic. 1
• This is particularly important if there is family history of hyperlipidemia or cardiovascular disease. 2

Anemia Screening

• Perform hemoglobin/hematocrit screening based on risk assessment. 2

Anticipatory Guidance

Safety Counseling

• Emphasize seatbelt use, helmet use for sports/cycling, avoidance of distracted and drunk driving, and firearm safety, as unintentional injuries are the leading cause of adolescent death. 2

Nutrition and Physical Activity

• Discuss healthy eating patterns, limiting sugar-sweetened beverages, and appropriate portion sizes. 2
• Recommend at least 60 minutes of moderate to vigorous physical activity daily. 2
• Screen for eating disorders and body image concerns. 2

Sleep Assessment

• Assess sleep patterns and screen for obstructive sleep apnea if indicated. 2

Screen Time

• Address media screen time and its impact on health and development. 4

Critical Pitfalls to Avoid

• Do not conduct brief "sports physicals" instead of comprehensive examinations—this lacks psychosocial screening and confidentiality, missing opportunities for early diagnosis of conditions causing significant morbidity and mortality. 2
• Failing to provide confidential time alone with the adolescent results in missed screening opportunities for risky behaviors. 2
• Do not skip depression screening—it must be performed annually starting at age 11. 1
• Do not defer HPV vaccination—give a strong recommendation and normalize it by coadministering with other vaccines. 1