What approach should be taken for the care of an adolescent patient?

Approach to Adolescent Patient Care

Adolescents should receive comprehensive, developmentally appropriate, and confidential primary care within a medical home model, with guaranteed private time during visits to address sensitive health issues. 1

Core Principles of Adolescent Care

Confidentiality as Foundation

• Establish confidentiality parameters at the beginning of every encounter, explaining what will and will not be shared with parents, as this directly impacts whether adolescents seek or continue care 2
• See adolescents alone for part of the interview to allow discussion of sensitive topics including sexual activity, substance use, mental health, and relationship violence 2
• Confidential billing remains a significant barrier, particularly for STI screening and contraception care in commercially insured patients 1

Developmentally Appropriate Communication

• Use motivational interviewing and tailor behavior-change counseling to the patient's stage of change rather than directive approaches 1
• Employ age-appropriate language and allow adolescents to describe experiences at their own pace and in their own words 1
• Maintain appropriate body language by orienting toward the patient and maintaining eye contact to demonstrate engagement 2
• Longer appointment times may be required compared to other age groups to accommodate developmental needs 1

Structured Assessment Approach

Mandatory Screening Topics

Screen routinely for high-risk behaviors at every visit: 1

• Sexual activity and violence: Ask direct questions about age of first sexual experience, unwanted or forced sexual acts, dating violence, and use of internet to find romantic/sexual partners 1
• Substance use: Screen all adolescents given that 8.5% meet criteria for substance use disorder and 32.6% report past-year use by 12th grade 1
• Mental health: Screen for anxiety, depression, mood disorders, and suicidality using standardized tools like the Pediatric Symptom Checklist 2
• Trauma exposure: Use direct questions such as "Has anything scary or concerning happened to you since the last visit?" 2

Essential History Components

Obtain these specific elements: 2

• Family context: Who lives in the home, recent family structure changes, financial stressors, housing stability, family conflicts 2
• Environmental risks: Exposure to violence, substance abuse, or mental illness in the home 2
• Academic functioning: School performance, attention span, ability to complete tasks, peer relationships 2
• Safety practices: Car restraint use, helmet use, gun safety, screen time habits, internet safety with parental monitoring 2

Substance Use Management

Treatment Framework

For adolescents with substance use disorders, implement these evidence-based practices: 1

• Medication-assisted treatment: Buprenorphine is FDA-approved for opioid use disorder in patients ≥16 years old and should be offered when indicated 1
• Continuing care: Use assertive approaches to link patients to ongoing support, including rapid service initiation post-discharge to prevent return to use 1
• Recovery support: Consider mutual support groups with caution—adolescent-focused meetings are rare, and adult-populated meetings may not be welcoming or align with youth beliefs (e.g., lifelong abstinence concepts) 1
• Virtual interventions: Expand use of automated mobile health interventions and remote treatment options for continuous assessment 1

Training Requirements

Primary care clinicians require specific training in medication for addiction treatment, including buprenorphine prescribing and virtual treatment delivery 1

Sexual Assault Care

Immediate Response Protocol

When sexual assault is disclosed or suspected: 1

• Emergency contraception: Offer to all female victims within 120 hours of assault; use 1.5 mg levonorgestrel as single dose (both tablets at once) 1
• STI prophylaxis: Treat with ceftriaxone 125 mg IM, metronidazole 2 g PO once, and either azithromycin 1 g PO once or doxycycline 100 mg PO twice daily for 1 week 1
• Baseline testing: Perform urine pregnancy test and document pregnancy status 1
• Forensic referral: Know when and where to refer for forensic medical examination in your community 1

Follow-Up Structure

• Week 1: Assess injury healing and ensure counseling arranged 1
• Week 2: Pregnancy testing, medication adherence assessment, emotional status evaluation 1
• Ongoing: Repeat syphilis and HIV testing at 6 weeks, 3 months, and 6 months if initial results negative 1
• Mental health: Refer for trauma-focused cognitive behavioral therapy, which has demonstrated efficacy for adolescent assault victims 1

Prevention and Anticipatory Guidance

Violence Prevention

Discuss these specific strategies at health supervision visits: 1

• Avoiding high-risk situations (parties with unknown people, meeting internet contacts, walking alone at night) 1
• "Buddying up" and not accepting drinks from strangers 1
• Not drinking from anything left unattended 1
• Abstaining from or moderating alcohol intake 1

Health Behavior Counseling

Understand adolescent health-behavior choices in context and help patients make the healthiest choices for themselves rather than using directive approaches 1

Quality Measurement

Use adolescent self-reported data rather than parental report to assess quality of preventive care, as adolescents are more valid and reliable sources for their own experiences 1

Common Pitfalls to Avoid

• Do not focus exclusively on biomedical aspects while ignoring psychosocial factors that profoundly impact adolescent health 2
• Do not rely on parental report for sensitive topics—adolescents must be queried directly 1
• Do not assume absence of physical injury means consent was given in sexual assault cases 1
• Do not refer to adult-focused 12-Step meetings without considering whether they are welcoming and appropriate for youth 1
• Do not rush through visits—adolescents require adequate time to build trust and disclose sensitive information 2