Overview

Source: Heather Collette and Jaideep Talwalkar; Yale School of Medicine 

The adolescent module will focus on techniques to promote a trusting provider-patient relationship and foster healthcare autonomy as teenagers approach adulthood. While most of the basic components of the physical exam in adolescents are similar to those in adults, there is added focus on pubertal development through the use of the Sexual Maturity Rating scale. Discussion of physical changes is accompanied by important adolescent psychosocial screening questions, including environmental safety, mental health, sexual activity, and drug/alcohol use. 

Adolescence is a time of significant physical changes as surges of hormones, such as estrogen and testosterone, cause growth in stature and the development of secondary sexual characteristics. These secondary characteristics at puberty include new hair growth, breast, and penile maturation that happen in a predictable series.

Adolescence is also a time of marked physical and emotional changes, which can be distressing and uncomfortable for adolescents. Pediatric providers can play a key role in relieving some distress by normalizing feelings and physical changes. To build a trusting provider-patient relationship, the provider needs to create an environment where the adolescent feels safe to disclose personal information and concerns. Adolescents should be treated as unique individuals, respectfully and without preconceived notions about their concerns or goals.

An eventual goal in the care of adolescents is to prepare them for navigating their health and healthcare as adults. The transfer to an adult-oriented care system typically occurs sometime after age 18, though the transition process for a successful transfer starts years before that.

Procedure

 1. Promoting a trusting provider-patient relationship and fostering autonomy

1. First, set expectations at the beginning of the visit by explaining the provider's role as a source of confidential information and support. Explain that all adolescents are provided with opportunities to discuss their health privately with the clinician, which serves a dual purpose. In the short term, adolescents can bring up concerns they may be uncomfortable discussing in front of their parents. In the long term, adolescents learn to interface directly with the healthcare provider, setting the stage for navigating care as an adult.
2. If a parent or caregiver accompanies the adolescent, ask them to provide historical or contextual information about the patient's concerns. However, the adolescent should have a chance to speak privately with the provider to bring up concerns they may be uncomfortable discussing in front of the parent. For this reason, as a matter of routine, ask the caregiver to step out to speak one-on-one with the adolescent. This private time with the adolescent can range from a small portion of the visit to the entire visit depending on the clinical situation. 
3. Before starting a private conversation with the patient, let them know that the discussion will remain confidential within the healthcare team — unless there are concerns about the patient hurting themselves or someone else, a concept called conditional confidentiality. This line will establish an honest trust and set a boundary that the provider can honor.
4.  Actively consider the promotion of an adolescent's healthcare autonomy to prepare them for the eventual transition to an adult model of care.
   1. Starting as early as 11 or 12 years of age, address the patient primarily throughout the visit, eliciting their concerns and directing responses directly to them rather than the parent.
   2. Work with the adolescent and the parent to develop ideas about how the child can take more responsibility regarding their health. Ask the adolescent to participate in healthy meal planning, take ownership of their medication schedule, keep a journal of symptoms, or think about questions for the clinician before visits.
   3. Allowing adolescents to make medical appointments under supervision will help them learn how to navigate the medical system.
   4. As adolescents age, the provider should continuously promote understanding of their health history – as they won't always have a parent present to fill in the gaps.
   5. The provider can also promote autonomy by educating the adolescent about lifestyle choices, promoting health, and praising them when they report making these choices.  

2. Pubertal development assessment

1. Pediatric providers play a major role in addressing adolescents' concerns about pubertal development and should provide education and support.
2. Assess a patient's comfort with their bodily changes by asking, "Do you have any concerns about how your body is developing?"
3. As they express any changes or concerns, try normalizing these while not offering reassurance until your assessment is complete.
4. Offer the patient a chaperone before starting the physical exam. Some adolescents will be comfortable with a family member or friend who has accompanied them to the visit, while others will prefer another medical professional from your team. Be aware of institutional policies before accepting an adolescent's request to be examined without a chaperone in the room. There are some circumstances where this might be appropriate and preferable regarding patient comfort and privacy.
5. During the physical exam, perform routine checks such as breathing rate, blood pressure, temperature, pulse rate, eyes, ears, and throat.
6. Next, include an external genital exam – documenting the patient's sexual maturity stage for pubic hair and genitals and any external lesions, vaginal or penile discharge, or masses.
7. If an adolescent is particularly reluctant to be examined, use the opportunity to understand their concerns and negotiate an acceptable solution if the exam is not urgent (e.g., another day, a different provider). Adolescents can be praised for exerting ownership and control over their bodies, though this must be balanced against the need for appropriate and timely healthcare services.
8. The sexual maturity staging system utilized most frequently is that published by Marshall and Tanner — commonly referred to as the "Tanner stages."
9. The Tanner stages show the expected progression of testicular and penile growth in males and the distribution of pubic hair and breast enlargement in females.
10. If the patient's development does not align with the timing and expected progression of pubertal stages, hormonal testing may be indicated to establish the etiology of potential delayed (late) or precocious (early) puberty.
11. This part of the exam is an opportunity to teach the patient about normal and abnormal breast and genital findings — helping them learn about their own body and changes they can expect as they progress through puberty.
12. For example, with a young girl starting puberty — let her know that she will notice hair growing under her arms and in her pubic region, which is expected and normal. She will also start menstruating — indicating that her body is ready to support a child. Her breasts will get larger and firmer, and she should let her doctor know of any nipple discharge or lumps in her breasts.
13. A boy starting puberty should be alerted that his penis and testicles will get larger and he will have erections when aroused, which is also a normal and expected part of his development.
14. Internal examinations (e.g., bimanual, speculum) and clinical breast examinations are not done as part of routine puberty assessment in adolescents. Still, they may be indicated in specific clinical circumstances (e.g., pelvic pain, vaginal discharge, breast lump). These will not be covered here.

3. Psychosocial assessment

1. The complex biologic transitions of puberty often impact the psychosocial aspects of an adolescent's life and are an important part of the evaluation.
2. A psychosocial interview tool for providers to use with adolescents is the SSHADESS assessment. Another commonly used rubric is HEADSS, although SSHADESS allows for assessing high-risk behaviors while emphasizing the identification of strengths. Healthy development is more likely to occur when adolescents feel valued and empowered.
3. Strengths: The assessment starts by asking the adolescent what they are good at or about something they are proud of. By identifying strengths within their life experience, you are building a therapeutic alliance and promoting their resilience.
4. School and Home: The assessment asks about school, grades, and relationships with friends and family. Healthy development is promoted when adolescents form healthy social connections within their homes and community. For this reason, any potential for abuse, neglect, or bullying should be addressed.
5. Activities: Clinicians should ask about adolescents' regular activities, focusing on social media. This is an opportunity to educate families about digital literacy, open family communication, and boundary setting on content and display of personal information.
6. Drugs: The American Academy of Pediatrics (AAP) recommends that clinicians screen adolescents for substance use and, if applicable, provide brief intervention, follow-up, and consider referral for weekly or more frequent use.
7. Emotions/Eating: Adolescence can be a time of complex emotional changes that can manifest in various ways that could negatively affect health. Mental health disorders can emerge during this time, and indeed suicide is the third leading cause of death in teenagers. The AAP and U.S. Preventive Services Task Force (USPSTF) recommend routine screening for depression in adolescents using standardized instruments such as the Patient Health Questionnaire or the PHQ-A. The AAP also recommends screening for eating disorders, and the USPSTF is reviewing the data related to the topic with a formal statement forthcoming.
8. Sexuality: Clinicians should counsel adolescents on pregnancy risk, healthy relationships and contraception. Rates of sexually transmitted infections in adolescents have increased over the past ten years. Clinicians should assess sexual behaviors — including the number of sexual partners, condom use, and history of STIs — with annual screens for gonorrhea/chlamydia in sexually active females less than 24 years or more frequently if at high risk. Abstinence, if practiced, should be reinforced.
9. Safety: Clinicians should inquire about an adolescent's safety at home, school, and community. No assumptions should be made about sexual orientation and gender identity, and the clinician must create a safe and inclusive environment with gender-inclusive questioning. Family connectedness and social support are protective against negative mental health outcomes and high-risk sexual behaviors in adolescents, particularly in sexual minority and gender minority populations. If requested by the adolescent, help disclose any pertinent information to family members. If the information was disclosed in confidence, do not violate an adolescent's privacy because unsafe disclosure may lead to unintended health and social consequences such as homelessness, abuse, and suicide.
10. In the United States, motor vehicle collisions are the number one cause of adolescent mortality. Clinicians should encourage seatbelt use and caution against distracted or impaired driving.
11. Appropriate use of protective equipment during sports should be emphasized to minimize common injuries, such as concussions. Access to firearms in the home should be assessed along with the adolescent's risk of violence, including a history of physical abuse, gang involvement, use of weapons, and missed school. Interventions in this area include community mentoring programs and mental health services.
12. When finished with the interview and exam, it is important to ask the adolescent if they have questions or concerns that were not addressed. Remind them that the providers are a safe and confidential resource if any concerns arise about their physical or mental health. Also, ensure they know how to get in contact if they need to. Some adolescents may prefer to access care through secure electronic portals and related mobile apps, and this information should be provided to them.