Adolescent Flashcards
1
Q
Adolescence
Age Range =
- Early Adolesence =
- Middle Adolescence =
- Late Adolescence =
A
11-21
- 11-14
- 15-17
- 18-21
2
Q
Health Disparities Impact Youth as a Class
- Differences in ____ to health care, including preventative and curative services
- Differences in the _____ of care received
- B___, prejudice, and st_____ on part of HCPs
A
- access
- quality
- Bias, stereotyping
Bias of HCP especially if they live in the same community as the pts they are treating
3
Q
Barriers to Care for Adolescents
-
Internal
- Reliance on p____ or ____ members for health _____
- ____ experience with health and/or social system
- Sense of in_____/v_____
- ___ self-esteem
- C_____ and lin_____ barriers
-
External
- Perceived lack of c______* and fear or p_____ disclosure
- Poor c_____ and/or counseling by providers
- In_____ attitudes in regard to culture and sexuality
- Provider lack of ______ and skills in regards to youth
- Lack of m_____, in_____ (or care) and tran______
- Inaccessible lo_____ and/or hours, especially after school
A
-
Internal
- peers, family, information
- Past experience
- invincibility/vulnerability
- Low
- Cultural, linguistic
-
External
- confidentiality*, parental
- communication
- insensitive
- knowledge
- money, insurance* (alot of times parents hold the insurance cards)I, transporation
- location
4
Q
Communication: Approaches to the Young Adolescent Patient
- Greet the ____ first, not the ____
- Treat each as an ______ (be respectful, warm, understanding, non-judgemental, and “___able”)
- Explain need for _____ to parents and youth together (ground rules for exception: abuse, homicide, suicide risk)
- Interview and exam with patient ___ of room
- C_____ appearance/achievements: pay attention, look interested, and listen
- ____ if some issues are confidential
- Transitions may be more difficult with over_____ parents or guardians, or with absent or in______ guardians
A
- youth, parent
- individual
- privacy
- out
- Complement
- Ask
- overprotective, inappropriate
5
Q
Guidelines in Interviewing Adolescents
- Ensure c______**
- Conduct interview and physical exam ______ parent present
- Show concern for adolescent’s _____ (ie. I’d like to know what you think is happening..)
- Health history mneumonic =
A
- confidentiality*
- without
- perspective
- HEADSS FIRST (home, education, activities/employment, drugs, suicidality, and sex)
6
Q
Erickson’s Theory of Psychosocial Development
What Stage?
A
Stage 5
Ego Identity vs. Role Confusion (12-18yo)
7
Q
Erickson’s Psychosocial Stage Summary Chart
A
8
Q
Psychosocial Development
- Erickson: Identity vs. Role Confusion
- “___ am I”?
- Begins at age __-__ young adulthood
- During this stage, adolescents search for a sense of ____ and personal ______, through an intense exploratio nof personal v____, b____, and g____.
- _____ developments process
- _____ developments process
A
- Identity vs. Role Confusion
- Who
- 9-11
- self, identity, values, beliefs, goals
- Positive
- Negative
9
Q
PMH/PSH
- _____/Medication and Food
- I______ history
- Pediatric _____ Clinic - know where
- Pediatric _ _ visits
- Common Questions
- PMH: (3)
- PSH (3)
A
- Allergies
- Immunization
- Wellness
- ER
- Astham, OM (recurrent), Fractures
- Appendectomy, Tonsillectomy, Myringotomy
- Children/Adolescents are healthy for the most part so ask about common conditions: Asthma, Recurrent OM, Fractures*
- Myringotomy - incision in eardrum to relieve pressure/drain fluid*
- NYS has immunization registry*
10
Q
Interview: Home
- “___ lives in the home with you?”
- “Do you live in a ____ or a_____?”
- Do you ____ a room or have your own?”
- Are there any n___ people living in your home?”
- How are your re_____ with siblings, parents, other important relatives?”
- What are the r____ like at home?”
- Ever been home____ or in sh____ care?”
- Ever been in f____ care or residential g____ home?”
A
- Who
- house, apt
- share
- new
- relationship
- rules
- homeless, shelter
- foster, group
11
Q
Teenagers Health Care and the Law
New York defines a minor as anyone under the age of __.
A
18
12
Q
Professional Consequences for Confidentiality Violations
- Violating confidentially is professional m_____
- HCP’s may face law___ by pts for breach of confidentiality.
- If the person violating confidentiality is a g_____ employee (eg. school principal) disclosure of private information could violate the c_______
A
- misconduct
- lawsuits
- government, constitution
13
Q
Confidentiality and Parent Access
- The law requires _____ authorization before releasing a pts medical information to a third party.
- Parents or guardians may _______ access minors medical information
- when a parent or guardian has ______ for the care on ____ of the minor, or
- when care was provided to minor _____ parental consent bc of _____
- If minors consent to care on their own, providers _____ give parents info about the care without the minor’s _____ consent
A
- written
- independtly
- consented, behalf
- without, emergency
- cannot, written
14
Q
Confidentiality and Minors’ Health Care
- All services provided to minors, when they have the right and _____ to consent on their ____, must remain ______.
- In addition to this general rule, NY law specifically forbids disclosure of information pertaining to a minor’s _____ or ___ treatment to her parents or guardians without her consent.
A
- capacity, consent on their own, confidential
- abortion or STI tx
15
Q
Types of Minors Who Can Consent on their own
- P_____ minors
- Minors who are p_____
- M_____ minors
- E_____ minors
- Ma____ minors
- Review the THC pdf
A
- Pregnant
- parents
- Married
- Emancipated
- Mature
First 4 minors are most important- emancipated minor must be a designated legal status
16
Q
Pregnant Minors
- Can consent to any and all ______ care
- Can consent to care that might ____ their _____
A
- prenatal
- any care that impacts pregnancy
17
Q
Minors Who Are Parents and Married Minors
- Minors who are parents ___ consent to care
- Includes both ____ and _____
- Can consent to care for ____ and their ____
- Minors who have been married can consent to their ___ care - even if they are s____ or d_____.
A
- can
- mothers and fathers
- themselves and children
- own, separated, divorced
18
Q
Emancipated Minors
- “Emancipation” =
- Who is considered “emancipated”?
- Minors who are or have been in the?
- Minors who are ____ apart from parents and are _______ independent through gainful _____
A
- renunciation of parental rights to a child
- Who?
- Armed services
- living apart, economically, employment
19
Q
Types of Care to Which any Minor Can Consent on their own
- R______ health care
- Testing and treatment of __ __ ___
- Sexual _____ care
- E_____ care
- SOME _____ abuse treatment
- SOME _____ health care
A
- Reproductive
- STI’s
- assault
- Emergency
- substance abuse
- mental health
20
Q
Reproductive Health Care
(that minors can consent for)
- _______ tests
- Birth _____ and emergency ______
- A_____
- Pregnancy cou_____, ______ care, _/_ services
- Post sexual _____ care
A
- Pregnancy
- control, contraception
- counseling, prenatal, L/D
- assault
21
Q
STI Testing and Treatment
(that minors can consent to)
- T____ and T_____ for STI’s
- Testing for H _ _
- _ _ _ vaccine
- Approved for women and girls aged __ - __
- HCPs are also permitted to provide HPV vaccination to sexually ___ minors without parental/guardian consent
A
- Testing and Treatment
- HIV
- HPV
- 9-26
- sexually active minors (law changed in NY 2018- HCP allowed to give HPV vaccination wihtout parental/guardian consent)
22
Q
Substance Abuse Treatment
- Non-Medical
- For non-medical tx such as counseling, is parental consent required?
- Medical
- Parental consent is not required for inpatient or outpatient medical treatment for alcohol or substance abuse if:
- Provider cannot reasonably _____ the parents
- Parents refuse or ___ to communicate with provider and program _____ okays treatment
- A physician determines the involvement of parent/guardian would have a de_____ effect on tx
- Parent/guardian _____ to consent and physician believes that tx is ____ and in child’s best _____.
- Parental consent is not required for inpatient or outpatient medical treatment for alcohol or substance abuse if:
A
- Non-Medical
- No
- Medical
- find
- fail, director
- detrimental
- refuse, but necessary, best interest of child
With these situations, you should collaborate with a physician bc the law is written around the word physician
23
Q
Mental Health Care
(when minors can consent)
- Outpatient
- Parental Consent not required if? (3)
- Inpatient
- A minor > ___ can seek inpatient care, including m_____, on their own, but younger teens must obtain parental consent
- Special protections for a self-admitted minor exist
- Information about l____ services
- Notice to M____ Hy___ Legal Services
A
- Outpatient
- Parent not reasonably available
- Parental involvement detrimental to tx
- Parent refuses, physician determines tx is necessary/best interest of minor
- Inpatient
- > 16, medication
- younger teens
- legal
- Mental Hygiene Legal
24
Q
Example: Types of Care
- After testing HIV positive, a 15 yr old tells his physician that he won’t receive treatment if he has tot ell his parents, because they are deeply religious. He believes they will kick him out of the house when they find out he’s gay or HIV+. Can he receive treatment without parental involvement?
- _____. If physician determines that the minor has the _____ and _____ capacity to give informed consent. That he can co___ with tx regimen and involving parents might prove harmful. She can treat him under the _____ minors doctrine. Physicians should document determination of maturity in the MR.
A
- PROBABLY. emotional, intellectual, comply, “mature minors doctrine”
25
For More Information on Confidentiality in NY
## Footnote
(2)
Teen Health Initiative
NY Civial Liberties Union
26
State Policies/Minors Consent
## Footnote
Where can we find policies by state?
Guttmacher.org/state-policy/explore/overview-minors-consent-law
27
Vital Signs
## Footnote
Routine VS also include (2)
Menstrual Cycle (recommendation of AAP and ACOG)
BMI
28
Puberty (not on test)
## Footnote
* Female
* Breast development ave age: \_\_-\_\_
* Maximal Growth Rate: \_\_-\_\_ months before \_\_\_\_
* Males
* Testicular Development ave age:
* Growth "spurt" - _____ peak height velocity
* Female
* 0-10
* 6-12m before menarche
* Males
* 11
* greater
29
Physical Growth --Review
## Footnote
* Slower rate of growth in (2)
* Facial features and adult stature established at ___ yrs for female and __ yrs for males
* Muscle strength and size influenced by sex h\_\_\_\_, nut\_\_\_\_, and ex\_\_\_\_
* Endurance depends ___ capacity, ___ size, ___ strength
* Voice changes in r\_\_\_\_ and st\_\_\_\_, more pronounced in males than females
* HT and WT
* 18, 20
* hormones, nutrition, exercise
* resonance, strength
30
Physical Exam/Include
## Footnote
* Growth: __ and \_\_
* App\_\_\_\_ and Be\_\_\_
* Gr\_\_\_\_ and Hy\_\_\_\_
* Po\_\_\_\_
* Coo\_\_\_\_
* Comm\_\_\_\_
* In\_\_\_\_ in health care
* HT, WT
* Appearance, Behavior
* Grooming, Hygiene
* Posture
* Coordination
* Communication
* Interest
31
Physical Exam/Review
## Footnote
* Hair: O\_\_\_\_, Body hair appears on ___ and ___ in males, ____ in both sexes
* Skin: A\_\_\_ on face, back, chest, large pores, presence of bruises, burns, bites must be \_\_\_\_\_
* Lymph: ____ lymph tissue
* Teeth: Ca\_\_\_, dental hy\_\_\_\_, need for ortho\_\_\_
* Heart: __ HR, __ BP
* Lungs: ___ RR
* Breasts: Breasts dev\_\_\_\_\_, gyn\_\_\_\_\_ in males
* Oily, chest, face, axilla
* Acne, evaluated
* decreased
* Carries, hygiene, orthodontia
* Low, High
* Low
* developing, gynecomastia
32
\*\*Physical Exam\*\*
## Footnote
* Genitalia:
* Males
* Pubic hair =
* Penile =
* Testes =
* Females
* Pubic hair =
* Labia =
* Vaginal =
* Males
* increases in amount to adult distribution, becomes **coarse and curly**
* enlargement continues
* enlargement
* Females
* increases in amount to adult distribtuion, becomes course and curly
* matures
* discharge
33
Physical Exam
## Footnote
* Musculoskeletal
* Increased (3)
* Assess for (1)
* Sleep Patterns & Elimination: should be able to?
* MSK
* Muscle mass, strength, tone
* scoliosis
* Sleep
* maintain an established schedule
* Scoliosis often diagnosed with growth spurts*
* Red flag: sleeping 16 hr/day (get to the bottom f it, sometimes not pathologic, maybe stress, etc)*
34
Sexual Maturity
## Footnote
* Menstruation
* Regular \_\_\_\_\_
* Premenstrual \_\_\_\_\_
* Menstrual dis\_\_\_\_\_
* _____ Emission part of normal physical development
* Experimentation is normal, if frequent and obsessive practice intrvention and referral is needed = \_\_\_\_\_\_\_
* Menstruation
* Periods
* symptoms
* discomfort
* Nocturnal Emission
* Masturbation
*Sometimes we don't see regular periods until late adolescence , and ask about last menstrual cycle*
35
Male Tanner Stages (not on test)
## Footnote
* **Male Genital Development**
* ****Which stage do these describe?
* The testes, scrotal sac, and penis have size/proportion similar as seen in early childhood (preadolescent)
* Adult genitalia with regard to size and shape
* Further growth in penile length and circumference, growth in testes and scrotum
* Penis significantly enlarged in length and circumference & development of glans penis, darkening of scrotal skin
* Enlargement of scrotum and testes, and change in texture of scrotal skin. Reddening of scrotal skin is normal.
* **Stage 1**
* **Stage 5**
* **Stage 3**
* **Stage 4**
* **Stag 2**
36
Male
## Footnote
* **Male Pubic Hair Development Stages**
* ****(Preadolescent) No androgen-sensitive pubic hair
* Hair Distribution is adult in quantity and type, can spread to medial surface of thighs
* Darker, coarser, curlier, hair. Distribution now at junctin of pubes
* Distribution is adult like, but still less in quantity. No spread to medial surface of thighs
* Sparse long, pigmented downy hair, can be curled or straight, seen at base of penis
* **Stage 1**
* **Stage 5**
* **Stage 3**
* **Stage 4**
* **Stage 2**
37
Female Tanner Stages
## Footnote
* **Female Breast Development**
* ****Mature female breasts have developed. Recession of areola
* (Preadolescent) Only the papilla is elevated above chest wall level
* (Breast Budding) Elevation of breasts and papillae as a small mound with some increased diameter of areola
* Areola and papillae elevate above level of breasts and forms secondary mounds with further development of overall breast tissue
* Breasts and areola continue to enlarge, but with no separation of contour
* **Stage 5**
* **Stage 1**
* **Stage 2**
* **Stage 4**
* **Stage 3**
38
Female
## Footnote
* **Female Pubic Hair Development Stages**
* ****(Preadolescent) No sexual hair
* Darker, coarser, curlier hair. Distribution now at junction of pubes
* Distribution is adult like, but still less in quantitiy. No spread to medial surface of thighs.
* Appears as inverse triangle in shape. Hair distribtuion is adult in quantity and type, can spread to medial surface of thighs but not above base of inverse triangle.
* Sparse, long, pigmented downy hair, can be curled or straight, seen along labia.
* **Stage 1**
* **Stage 3**
* **Stage 4**
* **Stage 5**
* **Stage 2**
39
Smoking
## Footnote
* For adolescents, the provider should ask about nicotine use including? at each health maintenance visit
* In addition to e-cigarettes, the provider should ask about other types of electronic nicotine delivery systems including?
* Clinicians should allow time during each visit to speak with the patient _____ parents present to facilitate disclosure. The clinician should establish _______ rules with the pt at start of these visits, to faciiltate disclosure and frank discussion.
* smoking, e-cigs, other alternative
* e cigars, e-pipes, e-hookahs, vape pens or pipes, or atomizers
* without parents, confidentiality
40
United States National Institute on Alcohol Abuse and Alcoholism (NIAAA)
## Footnote
* 9-14
* Do you have any ____ who drank beer, wine, or drink containing alcohol in the past year?
* Followed by: How about ____ - in the past \_\_\_\_, on how many ___ have you had more than a few ___ of beer, wine, or other alcohol?
* Younger than ___ yo, any drinking is?
* 14-18
* In the past \_\_\_, on how many ___ have you had more than a few ___ of beer, wine, or drink containing alcohol?
* If your \_\_\_\_\_s drink, how many ____ do they usually drink on \_\_\_\_\_?
* 9-14
* friends
* you, year, days, sips
* \<14, CAUSE FOR CONCERN\* *Intervention is important! And needs to happen immediately (probably pediatric psychiatry needs to be involved)*
* 14-18
* year, days, sips
* friends, drinks on occasion
41
Drugs/Questions
## Footnote
* Do you sm\_\_\_\_ or chew t\_\_\_\_?
* Do you drink \_\_\_\_\_?
* How m\_\_\_\_ and how of\_\_\_?
* What _____ of alcohol (beer, wine, wine coolers, hard liquor)?
* Any \_\_\_\_outs? Ever p\_\_\_ out?
* Ever do anything you r\_\_\_\_\_ while high?
* Do you use ill\_\_\_\_\_ drugs?
* Mar\_\_\_\_\_\_, inh\_\_\_\_\_, Coc\_\_\_\_ or Cr\_\_\_, Her\_\_\_\_, p\_\_\_\_,
* L _ \_, Ecs\_\_\_\_\_, Crystal ____ or other drugs?
* Do you use anabolic s\_\_\_\_\_?
* smoke, tobacco
* alcohol
* much, often
* kind
* blackouts, pass out
* regret
* illicit
* Marijuana, inhalants, cocaine or crack, heroin, pills
* LSD, Ecstasy, Crystal Meth
* steroids
42
Drug Use
## Footnote
* When you go out with your friends or to a \_\_\_\_\_, do most of the people you hang out with \_\_\_\_or \_\_\_\_\_? Do \_\_\_?
* How fr\_\_\_\_\_ do you use drugs or alcohol? How much?
* A\_\_\_\_\_ towards cutting back? Towards q\_\_\_\_\_?
* Have you ever received drug _____ or counseling?
* _____ do you most _____ use drugs or alcohol? Socially, alone, time of day, day of week?
* How is your drug use su\_\_\_\_\_? Have you ever had any arr\_\_\_\_?
* party, drink, smoke, you
* frequently
* attitudes, quitting
* treatment
* When, often
* supported, arrests
43
Drugs/Questions/Tools
## Footnote
* _____ history important, friends ex\_\_\_\_\_\_
* S\_\_\_\_\_ approaches
* **\_\_\_\_\_\_ SCREEN** for alcohol and drug use
* C
* R
* A
* F
* F
* T
* _\>_ ___ positives suggest a problem
* Family, experience
* screening
* **CRAFFT**
* ****Car (have you ridden in a car driven by someone high?)
* Relax (do you use it to relax or fit in?)
* Alone (do you ever use alone?)
* Friends (Do family or friends ever tell you to cut down?)
* Forget (Do you ever forget what you did while using?)
* Trouble (Have you ever gotten in trouble while using?)
* 2\*
44
Substance Abuse and Mental Health Services (SAMHSA)
## Footnote
1. To find alcohol, drug, or mental health treatment facilities and programs around the country at findtreatment.samhsa.gov.
2. Find information on locating physicians and treatment programs authorized to treat opioids, such as heroin or prescription pain relievers www.samhsa.gov/medication-assisted-treatment/physician-program-data/treatment-physician-locator
3. Find treatment programs in your state that treat addiction and dependence on opioids, such as heroin or prescription pain relievers, at dpt2.samhsa.gov/treatment/
1. **Behavioral Health Treatment Services Locator**
2. **Buprenorphine Physician & Treatment Program Locator**
3. **Opioid Treatment Program Directory**
*Synthetic fentanyl (we have no idea how strong it is bc its being made by something else) - so educate on this! No drugs from strangers*
45
Firearms
## Footnote
* Homicide is the ___ leading cause of death in adolescents
* Always consider all guns _____ and potentially l\_\_\_\_\_
* Learn ___ gun ____ before attempting to ____ a gun or h\_\_
* D\_\_\_\_ (ie Russian roulette) using firearms have tragic outcomes, do not try to ______ with firearms
* 2nd
* loaded, lethal
* safe, handling, clean or hunt
* Dares, impress
46
Gun Violence
## Footnote
* **Office Based**
* Know the ____ of gun violence in your area to help understand the impact on your pt population
* Ask pts and their families if there are guns in the \_\_\_\_. If "yes" discuss safe st\_\_\_\_\_ of firearms and ammunition. Encourage participation in gun safety cl\_\_\_\_\_.
* **Community Based**
* Know the ____ of gun violence in your area to better understand the impact on your community
* Participation in ______ that address violence in your community
* rates
* homes, storage, safety classes
* rates
* programs
47
Motor Vehicle Accidents - ED
## Footnote
* Motor Vehicle - _____ cause of death in adolescents (single greatest source of unintentional injury (78%) in young people)
* Insistence of ______ maturity rather than age qualification to obtain license (sense of responsibility toward others)
* Drive responsibly:
* **Always wear your \_\_\_\_\_!**
* Respect speed \_\_\_\_\_
* Do not ____ and Drive
* Handsfree \_\_\_\_\_
* Have a _______ driver (do not drive under the influence or ride as a passenger with someone under the inf of drugs or alcohol)
* Minimize dis\_\_\_\_\_\_ (cell phones, eating)
* Helmets and appropriate clothing for use of _____ and scooters (appealing bc low cost and convenience)
* leading
* emotional
* **belt**
* limits
* Text
* Phone
* Designated
* distractinos
* Motorcycles
48
Athletic Injuries
## Footnote
* Use ____ equipment (face ____ for hockey, ___ for football, \_\_guards for soccer)
* Do not attempt to participate/compete beyond physical \_\_\_\_\_
* Careful preparation for sports through t\_\_\_\_\_ and con\_\_\_\_\_ is essential
* protective, masks, pads, shinguards
* limits
* training, conditioning
* Ask if there are team trainers, etc to monitor ability to participate in sports*
* Hydration in sports, after sports, how to relax*
49
Nutrition
## Footnote
* Healthy a\_\_\_\_\_ and healthy s\_\_\_\_
* Eating _____ portion \_\_\_\_\_
* Essential _____ for adolescent diets
* appetites, snacks
* disorders, control
* nutrients
50
Snack Habits
## Footnote
* Typically want to eat whatever takes the least amount of ____ to prepare and consume (fast food, soda, sweets, empty-calorie snacks)
* Like to _____ against parents by refusing to eat what parents think is ___ for the child
* time
* rebel, X what parents think is good
51
Snack Habits - Education
## Footnote
* Important to ___ cabinets and fridge with healthy choices like ___ and _____ and m\_\_/j\_\_\_ rather than soda
* Allow room for com\_\_\_\_\_ - ie. order pizza for dinner once a week
* Encourage child to participate in _____ dinner, _____ for groceries, this can be a valuable lesson without conflit
* stock, fruits and vegetables, milk/juice
* compromised
* cooking, shopping
*Cooking classes, farmers markets, other resources*
52
Essential Nutrients
## Footnote
* (3) are the most common deficiencies
* (1) is needed for increased blood volume in males and females and blood loss dt menstruation in females
* (1) is needed for skeletal growth
* Iron, Calcium, Zinc
* Iron
* Calcium
* Non meat eaters: iron through beans, green veggies, oats*
* Prenatal vitamins: essential for persons no matter what age (so even for adolescents who are preggers/plan to get pregnant)*
53
Healthy Habits - Sleep, Exercise and Hygiene
## Footnote
* Parents can encourage this by being good r\_\_\_ m\_\_\_\_
* __ hrs of sleep or more is often needed
* Daily exercise maintains muscle ___ and provides an outlet for t\_\_\_\_\_
* ADA recommends _____ twice a day and ____ once a day and getting routine _____ and oral exams
* role models
* 8
* tone, tension
* brushing, flossing, cleaning
54
Approach to lipid screening in children and adolescents 2019
## Footnote
* With no risk factors
* \<9 yrs
* 9-11 yo =
* 12-16 yo =
* 17-21 yo =
* NOT indicated
* ONCE
* Lipid screening is **not** recommended during this age range bc changes in lipid levels that normally occur during puberty decrease the sensitivity and specificity of screening
* Should undergo lipid screening once during this age range\*
*Start with dietary and lifestyle medications\*\**
55
AAP Cholesterol Screening
## Footnote
* Selective cholesterol screening in children ages \_\_-\_\_ with risk factors
* **\_\_\_\_\_\_ screening** at ______ between ages \_\_-\_\_ and \_\_-\_\_ yrs
* 2-21
* **Universal**, ONCE, 9-11, 17-21
56
HTN Screening
## Footnote
USPSTF Recommendations
Current evidence is insufficient to balance ben and harms of screening for primary HTN in asymptomatic children and adolescents to prevent CV disease in childhood or adulthood
*HOWEVER, BP is checked at every visit*
57
Risk factors for HTN in children _\>_ 3
## Footnote
* Check BP at all health encounters for children with
* O\_\_\_\_
* Type 1 or 2 \_\_\_\_\_
* R\_\_\_\_ disease
* History of aortic arch ob\_\_\_\_ or co\_\_\_\_
* Treatment with or taking drugs known to ____ BP such as?
* Obesity
* DM
* Renal
* obstruction, coarctation
* increase: decongestants, caffeine, NSAIDs, Glucocorticoids, Stimulants, Hormonal contraception, TCA's Amphetamines, Cocaine
58
Eating Disorders
## Footnote
* "Eating disorders have the ____ mortality rate of any mental illness, but too often a patient's care is determined by their _____ company instead of their health needs"
* AMA Urges ___ Health Care Access for Eating Disorders Jun 15, 2016
* highest mortality rate, insurance
* Equal
*In primary care, we do not have the resources to independently manage an adolescent with an eating disorder- must collaborate with community programs! (psych, SW, etc)*
59
Eating Disorders
## Footnote
(2)
Anorexia
Bulemia
NEDA National Eating Disorder Association 1800-931-2237
60
DSM-5 Diagnostic criteria for Anorexia Nervosa
## Footnote
Mild: BMI =
Moderate: BMI =
Severe: BMI =
Extreme: BMI =
_\>_ 17
16-16.99
15-15.99
\<15
*Important to gather history and know the BMI when you refer to programs*
61
DSM-5 diagnostic criteria for Bulimia Nervosa
## Footnote
* Mild =
* Moderate =
* Severe =
* Extreme =
* 1-3 episodes/wk
* 4-7 ep/wk
* 8-13 ep/wk
* 14 or more ep/wk
* Diagnosis is done by specialist, Just know that these 2 eating disroders are most common in adolescents*
* Vomiting -\> electrolyte disturbances -\> Arrhthmias\**
62
Sex and Internet Safety
## Footnote
* Advice (ie treatment of STI's, relationships, question and answer forum etc..) www.go\_\_\_\_\_.com sponsored by Columbia University
goaskalice.com
## Footnote
*For adolescents to gather info/giving accessible links*
63
HPV Vaccine
## Footnote
For whom?
\_\_\_\_\_ __ protects agains HPV types 6, 11, 16, 18, 31, 33, 45, 52, and 58
Male and Female
## Footnote
**Gardasil 9**
64
Hepatitis B Screening AAFP 2019
## Footnote
* Who especially needs to be screened? (2)
* Hep B vaccine is recommended for all medically ____ infants weight 2,000g or more within 24 hrs of birth
* Acute hep B should not be treated with \_\_\_\_\_\_
* All infants born to mothers positive with Hep B should receive?
* First line tx for chronic Hep B (3)
* Pregnant women, Adolescents/Adults with high risk of chronic infection
* Stable infants
* Antivirals
* Immunoglobulin and Hep vaccine by 24 hrs of life
* Pegylated interferon alfa-2a (Pegasys), Entecavir (Baraclude), Tenofovir
*All pregnant women should be screened, RF such as IVDU*
65
Young Men (YMSM)
## Footnote
* Young men who have sex with men (YMSM) are most at risk for?
* What vaccine is routinely recommended?
* Anal cancer
* Hepatitis A - *make sure insurance covers it*
66
Sexual Health Clinic
## Footnote
* Provide low to no cost for (2) Patients are seen on ____ come, first serve basis
* ___ apt necessary
* Anyone __ y and older can be seen, regardless of imm\_\_\_\_\_ status. __ parental consent is necessary.
* Anyone __ y and older who wants testing for (4) can receive these services, even if no symptoms
* What happens when you dont' have health insurance or can't pay the fee?
* Know the community you practice in...
* www.1.nyc.gov/site/doh/services/sexual-health-clinics.page
* **STIs** and **HIV** tx, first come first serve
* No apt
* 12, immigration, no parental consent
* 12, HIV, chlamydia, gonorrhea, syphilis
* can still get the service
## Footnote
*Syphilis and Gonorrhea are reportable diseases*
67
AAP REDBOOK
## Footnote
What is it?
Book on managing Pediatric Infectious Diseases including immunizations
68
Gender-Expansive Children Statement Support
## Footnote
* AAP Statement in Support of _____ Children, Adolesents, and Young Adults
* https://healthychildren.org/English/news/Pages/Support-for _____ and Gender _____ Children and Adolescents.aspx
* Human _____ Campaign
* ______ of Terms
* Transgender
* Transgender, Gender diverse
* Human Rights Campaign
* Glossary
*Needs further education and specialty training in LGBTQ/trans/hormone therapy etc.*
69
Bare it All
## Footnote
What is it?
* **Tell your doctor which name and _____ they should use**
* **Be honest about the kinds of ___ you have**
* **Tell your doctor about your sexual \_\_\_\_\_**
* **Be honest about your d\_\_\_, to\_\_\_, al\_\_\_ use**
Citywide campaign encouraging LGBTQ pts to have open and honest discussions with their HCP. A few tips include
* **pronoun:** even if the ymust use name and gender marker of your insurance card for billding, doctor and other staff must address you with your preferred name and pronoun
* **sex:** gender of your partners, and your typical safer sex practices
* **history:** even if they don't bring up the topic
* **drug, tobacco, alcohol:** you and doc can use this info to keep you safe and reduce your risks
70
Teen Depression
## Footnote
* *3rd leading cause of death for 15-24 yo and 6th leading cause of death for 5-14 yo. The number of attempted ____ is even higher.*
* It's essential for parents to recognize when adolescent child is \_\_\_\_\_, bc treatment is more effective with _____ intervention
* Common causes: st\_\_\_\_, influence of sex h\_\_\_\_\_, ind\_\_\_\_\_ conflicts with parents, reaction to a dis\_\_\_\_ event such as death of friend/relative, a _____ with bf or gf, _____ at school
* Typical signs of depression
* Adolescent feels "\_\_\_" most of the time, and is irr\_\_\_\_\_
* ___ loss or gain (more than 10% of normal weight)
* In\_\_\_\_ or sleeplessness, or the opposite, _____ need for sleep, low energy
* S\_\_\_\_\_- thoughts, ideation, threats (with or without a plan)
* Drop in gr\_\_\_\_\_, social activities, interactions with peers, sudden change in friend
* *Suicide*
* depressed, early
* stress, hormones, independence, disturbing, breakup, failure
* Signs
* "low", irritable
* Insomnia, excessive sleep
* Suicidal
* grades
71
PHQ-2
## Footnote
What is it?
(2)
Patient Health Questionnaire (2 item screen) that screens adolescents for depression
Over the past two weeks:
1. Little interest or pleasure in doing things?
2. Feeling down, depressed, hopeless?
72
PHQ-A
## Footnote
* The S\_\_\_\_\_ Measure for Depression, Child age \_\_-\_\_ (adapted from PHQ-9 modified for Adolescents (PHQ-A)) is a __ item measure that assesses the severity of depressiv disorders and episodes (or clinically significant symptoms of depressive disorders and episodes)
* The measure is completed by the child ____ to a visit with the clinician. Each item asks the child to ___ the severity of his or her depression symptoms **during the past __ days.**
* Severity, 11-17, 9
* before, **past 7 days**
73
PHQ-A Questions
## Footnote
0-3 =
1. Feeling d\_\_\_, dep\_\_\_\_\_, irr\_\_\_\_\_, or h\_\_\_\_\_?
2. Little in\_\_\_\_ or pl\_\_\_\_ in doing things?
3. Troubling falling \_\_\_\_, staying asleep, or sleeping too \_\_\_\_?
4. Poor app\_\_\_\_, weight \_\_\_\_, or \_\_\_eating?
5. Feeling t\_\_\_\_, having little \_\_\_\_\_?
6. Feeling bad about _____ - or feeling that you are a f\_\_\_\_, or that you have let yourself or your family down?
7. Trouble con\_\_\_\_\_ on things like school work, reading, watching TV?
8. Moving or speaking ____ that other ppl have noticed?/Or opposite so fid\_\_\_\_ or r\_\_\_\_\_ that you were moving around alot more than usual?
9. Thoughts that you would be better off \_\_\_, or h\_\_\_\_ yourself in some way?
0 = not at all, 1 = several days, 2 = more than half the days, 3 = nearly every day
1. down, depressed, irritable, hopeless
2. interest, pleasure
3. asleep, much
4. appetite, loss, overeating
5. tired, energy
6. yourself, failure
7. concentrating
8. slowly, fidgety, restless
9. dead, hurting
74
PHQ-A Scoring
## Footnote
* None =
* Mild =
* Moderate =
* Moderately severe =
* Severe =
* 0-4
* 5-9
* 10-14
* 15-19
* 20-27
75
Suicide Screening
## Footnote
USPSTF recommendations
Current evidence insufficient to assess benefits/harms for screening for suicide risk in adolescents, adults, and older adults in primary care
76
USPSTF Recommendations for Screening and Counseling in Adolescents
## Footnote
1. **Cancer**
* **Cervical =**
* **Skin: Behavioral =**
* **Testicular =**
2. **CV Health**
* **HTN =**
* **Lipid Disorders =**
3. **General Health**
* **IPV** **=**
* **Obesity =**
* **Prevention of neural tube defects =**
* **Scoliosis =**
4. **Mental Health**
* **Depression =**
* **Suicide Risk =**
1. **Cancer**
* ****Q3 years w cervical cytology alone 21-29 in women, \<21 not recommended
* Fair skin types minimize exposure to UV radiation
* Screening not recommended
2. **CV Health**
* ****Not recommended if asx but if sx then _\>_ 18 obtain measurements outside of clinic for diagnostic confirmation before starting tx
* Not recommended _\<_20y
3. **General Health**
* ****Screen women of reproductive age and provide or refer women who screen positive to ongoing support services
* Screen and refer to behavioral interventions
* folic acid 0.4-0.8 in all women capable and planning pregnancy, not recommended in 10-18
4. **Mental Health**
* ****Not recommended _\<_11, screen 12-18 including pregnant and post-partum
* Not recommended
77
USPSTF Recommendations
## Footnote
1. **STI's**
* **Behavioral =**
* **Chlamydia and Gonorrhea =**
* **Hep B =**
* **Herpes simplex =**
* **HIV =**
* **Syphilis =**
2. **Substance Abuse**
* **Alcohol =**
* **Tobacco =**
1. **STI**
* ****Behavioral counseling for all sexually active adolescents
* Not recommended in males, Recommended in sexually active females _\<_ 24
* Screen those at high risk (\>2% in country of origin, HIV, IVDU, MSM, immunocompromised) and Pregnant women at first prenatal visit
* Not recommended
* screen _\>_ 15, younger with risk factors = offer prep/ screen pregnant women, and adolescents at increased risk of infection
* Screen Pregnant women
2. **Substance abuse**
* ****not recommended in 12-17, screen in _\>_18 including pregnant women, in those engaged in hazardous drinking refer to behavioral counseling
* Education in preventing use of tobacco, ask _\>_18 about tobacco and advise to stop, provide behavioral interventions for cessation, if nonpregnant offer pharmacotherapy for cessation/ not recommended to screen in pregnant women/not recommended for electronic nicotine delivery system for tobacco cessation
78
Suicide Prevention Hotline - SAMHSA
## Footnote
* **Suicide Prevention L\_\_\_\_\_**
* **1800 273 ______ (8255)**, TTY: 1800 799 4889, website: \_\_\_\_\_\_\_.org
* ___ hr, toll \_\_\_\_, con\_\_\_\_\_ suicide prevention hotline available to anyone in suicidal crisis or emotional distress. Your call is routed to the nearest crisis center in the national network of more than 150 crisis centers
* **Lifeline**
* **TALK,** www.suicidepreventionlifeline
* 24, free, confidential
79
Child and Adolescent Mental Health Services in NYC
## Footnote
NYC Well has a staff of trained mental health professionals that can help callers
* **1800 NYC \_\_\_\_\_**
* **1888 692 9355** (\_\_\_\_\_)
* **1888 692 9355 (**\_\_\_\_\_)
* **711** (TTY for _____ impaired)
Psy\_\_\_\_\_ Emergency Rooms
M\_\_\_\_\_ Crisis Teams
\_\_\_\_\_ Based Crisis Intervention
Intensive Crisis and S\_\_\_\_\_\_ and Treatment
* **WELL**
* Espanol
* Mandarin
* hearing impaired
Psychiatric
Mobiles
Home
Stabilization
80
Community Based Examples
## Footnote
* The P\_\_\_\_\_ NYC Needs Adapted Treatment Model (NATM) is an open dialogue approach to tx for ppl with serious mental illness which engates the person's network. The program is for ppl __ years and older. Access is available within __ hrs.
* _____ also maintains a Children's Mobile Crisis Team (CMCT), providing 24/7 crisis care for children and teens (0-18) and their families who need crisis assessment, crisis stabilization, prevention planning, and caregiver support
* Parachute, 16, 24hrs
* VNSNY
81
Lead
## Footnote
* Children and adolescents between **\_\_\_\_\_ and \_\_\_\_\_** who enter the US as an \_\_\_\_\_, refugee, or international adoptee should be tested for blood lead concentration at time of arrival or at the initial pediatric health care visit
* **6 months and 16 years,** immigrant
Most school entry need venous screening for lead \<5 (overtime can see neurotoxicity, in good practices should test for heavy metals, anemia which is also associated with lead lvls)
82
Scoliosis
## Footnote
Screening Recommendation
Not recommended in asymptomatic adolescents bc results in moderate harms from wearing unnecessary braces and referrals w/o benefits of decreased pain, disability, or clinicall significant scoliosis
*However routine screening done on PE*
83
Scoliosis
## Footnote
* Primary goal of treating adolescent idiopathic scoliosis is preventing progression of the ____ mag\_\_\_\_\_.
* Curves less than \_\_\_-\_\_\_ degrees require __ active _____ and can be moniotred, unless the pt's bones are very immature and progression is likely.
* Moderate curves between \_\_-\_\_ degressin pts lacking skeletal maturity used to be treated with \_\_\_\_\_, but this treatment has been \_\_\_\_\_\_
* curve magnitude
* 10-15, no tx
* 25-45, bracing controversial
*If present, referral to ORTHO*
84
Scoliosis
## Footnote
* In pts with a curve _severe_ enough to require surgery = \> ___ degrees in adolescents and \> _____ in adults
* ___ placement and bone ____ may be necessary to achieve partial or complete correction
* \>45, \>50
* Rod, bone grafting
85
Gang Involvement
## Footnote
* Gang members often prey on young teens that come from ____ families or who are desperate to \_\_-\_\_
* "More than 1/3 of NYC students were threatened with physical violence by other students during school year, according to a recent federal city study"
* Anticipatory Guidance
* Talk to teens about \_\_\_- they experience or witness in s\_\_\_/c\_\_\_\_
* Know community resources for teens to turn to for \_\_\_\_\_
* Teach teens about the _____ of gangs
* Teach parents the _____ signs
* unstable, fit in
* Guidance
* violence, school/community
* safety
* danger
* warning signs
86
Gang Prevention and Intervention
## Footnote
What is OSYD?
Family in need of assistance can call (718) 923-5082
NYC Office of Safety and Youth Development
## Footnote
*almost all police precincts have domestic violence officers*
87
Priority Issues -every visit
## Footnote
* Physical G\_\_\_\_ and D\_\_\_\_\_
* Physical and O\_\_\_\_ health, S\_\_\_\_ History, B\_\_\_ Image, Healthy E\_\_\_\_ and Physical A\_\_\_\_\_\_
* S\_\_\_\_\_ and Ac\_\_\_\_\_ Competence
* E\_\_\_\_\_ Well Being
* Cop\_\_\_, m\_\_\_\_ regulation, m\_\_\_\_ health, se\_\_\_\_
* R\_\_\_ Reduction
* To\_\_\_\_, al\_\_\_\_, dr\_\_\_\_, pr\_\_\_\_\_, ST \_, pi\_\_\_\_\_/ta\_\_\_
* V\_\_\_\_\_ and Injury Prevention
* Safety b\_\_\_\_, he\_\_\_\_, dr\_\_\_\_, SA, access to we\_\_\_\_\_, inter\_\_\_\_ violence, ga\_\_, dep\_\_\_\_\_\_
* Growth, Development
* Oral, Social, Sexual, Body, Eating, Activity
* Social, Academic
* Emotional
* Coping, mood, mental, sexuality
* Risk
* Tobacco, alcohol, drugs, pregnancy, STI, piercing/tattoo
* Violence
* belts, helmets, driving, weapons, interpersonal, gang, depression
88
Need to Know
## Footnote
* Health Care Maintenance
* Scr\_\_\_\_\_, Cou\_\_\_\_\_, Imm\_\_\_\_\_
* Review **Recommendations for Preventative P\_\_\_\_ Health Care**
* Follow (4) organizations
* Screening, Counseling, Immunization
* **Pediatric**
* AAFP, AAP, CDC, USPSTF
*BRIGHT FUTURES sheet - what is required in which age - Routinely Hgb/Hct, UA*
89
HEADS-mneumonic
## Footnote
* **H** (2)
* **E** (3)
* **A** (4)
* **D** (3)
* **S** (2)
* Home, habits
* Education, employment, exercise
* Accident, ambition, activities, abuse
* Drugs (tobacco, alcohol, others), Diet, Depression
* Sex, Suicide
90
SAFETEENS-mneumonic
## Footnote
* **S**
* **A**
* **F**
* **E**
* **T**
* **E**
* **E**
* **N**
* **S**
* Sexuality/ Spirituality
* Accidents/abuse
* Firearms/homicide
* Emotions
* Toxins (tobacco, alcohol, others)
* Environment
* Exercise
* Nutrition
* Shots (immunization status), school performance
91
The DOOR
## Footnote
What is the Door?
* The street entrance for The Door is located at 555 _____ Street between Varick and Avenue of Americas (6th Ave)
* The Door is easily accessible by _____ via C/E to Spring Street, A/C/E to Canal Street to Canal Street or 1 to Canal Street, or by taking the M21 bus to Varick and Canal
* **Main Phone 212-941-9090, www.door.org/contact**
*The Door's mission is to empower **young people** to reach their potential by providing comprehensive **youth** developmental services in a diverse and caring environment*
* Broome
* subway
* Medical, dental, substance abuse, psych, legal counsel care*
* Easily accessible resource*
92
Homeless Adolescent
## Footnote
2 Resources (Organizations)
* Covenant House (*big center for homeless adolescents with great psychiatric services on site, often go there after incarceration)*
* The Door
93
Citywide Immunization Registry (CIR)
## Footnote
**Our Mission:**
To improve the immunization status of all NYC residents by consolidating immunization informatin and sharing it with health care providers, families and agencies concerned with public health
94
Know Immunizations Tools
## Footnote
* Recommended Child and Adolescent Immunization Schedule for ages ___ and younger, US, 2020
* www.cdc.gov/vaccines/schedules/hcp/child-adolescent
18
## Footnote
*memorize to 18 at least!*
95
Bright Futures
## Footnote
Periodicity Schedule
96
97
98
99
100
101
102
