What education should be provided during a well‑child visit for an 18‑year‑old adolescent?

Education for 18-Year-Old Well-Child Visit

Education during an 18-year-old well-child visit must prioritize confidential screening and counseling for risky behaviors that directly impact mortality and morbidity, including substance use, sexual health, mental health, injury prevention, and healthy lifestyle habits. 1, 2

Mandatory Confidential Time and Framework

• Confidential time alone with the adolescent is non-negotiable, as 58% of high school students report health concerns they want to keep private from parents, and fear of disclosure causes adolescents to delay or avoid needed care. 2
• Explain confidentiality limits upfront (harm to self/others, abuse) to build trust before beginning sensitive screening. 1
• Use structured screening tools like the CRAFFT questionnaire for substance use assessment, as this systematically improves detection of risky behaviors. 1, 3

Mental Health and Substance Use Education

• Screen and counsel for depression, anxiety, suicidal ideation, and self-harm behaviors, as suicide is a leading cause of adolescent death and 80% of adolescents needing mental health treatment are not receiving care. 4, 1, 2
• Screen for tobacco, alcohol, marijuana, and other substance use, as substance abuse is a leading cause of adolescent morbidity and mortality. 4, 1, 2
• Counsel specifically against tobacco/nicotine use, electronic cigarettes, vaping, and recreational cannabis use in any form. 2
• Discuss risks of alcohol use and strategies to minimize harm. 2

Sexual Health and Reproductive Education

• Provide comprehensive sexual health education including consent, healthy relationships, STI/pregnancy prevention, and contraception options. 4, 2, 3
• Discuss availability and access to confidential sexual and reproductive health services and emergency contraception. 4
• Screen for sexual activity, number of partners, contraception use, and history of STIs. 2, 3
• Screen for sexual violence, dating violence, and nonconsensual sexual encounters, as 11% of 18-24 year-olds report unwanted first sexual encounters. 4
• For individuals of childbearing potential, incorporate preconception counseling into routine visits starting at puberty. 2

Injury Prevention and Safety Education

• Emphasize seatbelt use, dangers of distracted and drunk driving, and helmet use for sports and cycling, as unintentional injuries are the leading cause of adolescent death. 4, 1, 2, 3
• Discuss firearm safety and access issues with both adolescent and parents. 4, 2
• Screen for involvement in or victimization from violence, interpersonal violence, weapons, and bullying. 4, 2

Nutrition and Physical Activity Education

• Recommend at least 60 minutes of moderate to vigorous physical activity daily, including resistance and flexibility training. 1, 2, 3
• Discuss healthy eating patterns, limiting sugar-sweetened beverages, and appropriate portion sizes. 4, 1, 2, 3
• Screen for eating disorders and body image concerns using validated tools. 3

Sleep and Screen Time Education

• Assess sleep patterns and recommend 8-10 hours of sleep nightly with limited screen time before bedtime. 1
• Screen for obstructive sleep apnea if indicated by history or examination. 2, 3

School Performance and Social Functioning

• Assess school performance, learning difficulties, peer relationships, and social functioning. 4, 2, 3
• Screen for truancy and academic problems, as comprehensive sexuality education has been shown to reduce truancy and improve academic performance. 4

Immunization Education

• Provide strong recommendation for HPV vaccine series completion (if not completed), emphasizing cancer prevention and normalizing by coadministering with other vaccines. 1, 2
• Ensure Tdap booster, meningococcal conjugate vaccine, and annual influenza vaccine are up to date. 1, 2
• Review and catch up any missed childhood vaccinations. 1, 2

Media and Technology Education

• Address the influence of media imagery on sexuality as portrayed in music, videos, movies, pornography, television, print, and internet content. 4
• Discuss effects of social media and sexting on relationships and safety. 4

Critical Pitfalls to Avoid

• Never conduct brief "sports physicals" instead of comprehensive well-child visits, as these lack psychosocial screening and confidentiality, missing opportunities for early diagnosis and treatment of conditions causing significant morbidity and mortality. 1, 2, 3
• Never skip confidential time alone with the adolescent, as this results in missed screening opportunities for risky behaviors that cause significant morbidity and mortality. 1, 2, 3
• Never skip depression screening, as it is crucial for identifying the 80% of adolescents who need mental health treatment but are not receiving care. 4, 1
• Never defer HPV vaccination—give a strong recommendation emphasizing cancer prevention. 1
• Never focus only on physical health while neglecting behavioral and developmental aspects. 3