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Guidelines for adolescent well care: is there consensus?

Tracy K. Richmonda, Gary L. Freedb,c, Sarah J. Clarkb and Michael D. Cabanad

Purpose of review Introduction


This paper reviews recent clinical guidelines for adolescent The major sources of adolescent morbidity and mortality
well care put forth by seven national organizations. are tied to preventable behaviors and conditions such as
It compares the guidelines recommendation by alcohol and drug use, failure to wear seatbelts, carrying a
recommendation in order to assess consistency between firearm, unsafe sexual practices, and interpersonal vio-
them. lence [1]. In addition, habits commonly established in
Recent findings adolescence such as smoking, poor diet, and limited
We found 102 specific preventive care recommendations participation in physical activity can have health con-
that encompassed eight different domains. The only sequences into adulthood [2]. Regular screening for high-
recommendations consistent in the seven guidelines are risk behaviors and health conditions by primary care
measuring height and weight with a physical exam, updating providers could allow earlier identification of adolescents
immunizations, and addressing general anticipatory at risk for poor health outcomes and provide opportu-
guidance. The greatest inconsistencies were noted in nities for more timely and targeted interventions.
specific recommendations in the behavioral/developmental
and counseling/anticipatory guidance domains. Clinical practice guidelines have the potential to improve
Summary healthcare delivery. Despite the development of preven-
When compared recommendation by recommendation, we tive care guidelines and measures focused specifically on
found that the guidelines for adolescent preventive care adolescents, adherence remains low [3–5]. The reasons
vary considerably. A unified set of guidelines may help for nonadherence include lack of time, poor reimburse-
reduce the number of conflicting recommendations and ment, restrictions on referral if subspecialty care is
may increase provider confidence and adherence to needed, inadequate training, reluctance to discuss sensi-
adolescent-specific clinical guidelines. tive issues, ineffective communication skills [6] and lack
of consistent recommendations for preventive care [4–9].
Keywords
adolescent well care, clinical guidelines, preventive care Several national organizations have developed recom-
mendations for adolescent preventive services including
Curr Opin Pediatr 18:365–370. ß 2006 Lippincott Williams & Wilkins. the American Academy of Pediatrics (AAP) [10], the
American Academy of Family Practice (AAFP) [11,12],
a
Division of Adolescent Medicine, Children’s Hospital Boston and Harvard Medical
School, Boston, Massachusetts, USA, bChild Health Evaluation and Research Unit
the Maternal Child Health Bureau (MCHB) through
(CHEAR), Ann Arbor, Michigan, USA, cDepartment of Pediatrics and Bright Futures [13], the American Medical Association
Communicable Diseases, University of Michigan Health System, Ann Arbor,
Michigan, USA and dDepartment of Pediatrics, University of California San
(AMA) through the Guidelines for Adolescent Preventive
Francisco, California, USA Services (GAPS) [14], and the United States Preventive
Correspondence to Tracy Richmond MD, MPH, Division of Adolescent Medicine, Services Task Force (USPSTF) [15]. The federal gov-
Children’s Hospital Boston, 333 Longwood Ave., Boston, MA 02115, USA ernment has also offered guidance regarding the pro-
Tel: +1 617 355 7170; fax: +1 617 730 0185;
e-mail: tracy.richmond@childrens.harvard.edu vision of adolescent preventive services through its basic
requirements of states’ Early and Periodic Screening,
Supported in part by Leadership Education in Adolescent Health Training Program
T71MC00009-14 and NICHD grant 5T32 HD 043034-02. Diagnosis, and Treatment (EPSDT) programs for Med-
icaid-enrolled adolescents [16]. Finally, the National
Current Opinion in Pediatrics 2006, 18:365–370
Committee for Quality Assurance (NCQ) has recently
Abbreviation added adolescent specific metrics to its Health Plan
USPSTF United States Preventive Services Task Force Employer Data Information Set (HEDIS) measures for
assessing quality of the delivery of healthcare using
ß 2006 Lippincott Williams & Wilkins administrative data [17,18]. In his 1998 review, Elster
1040-8703
[19] found that there were many similarities on general
topics among five guidelines reviewed though he focused
less on individual recommendations.

Review of guidelines
In this paper, we have systematically reviewed and
assessed seven guidelines and measures. We found 102
365

Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
366 Adolescent medicine

recommendations that represented the following guideline. ‘No’ was used for those recommendations
categories: general medical (n ¼ 17), reproductive health which were mentioned in a guideline but were clearly
(n ¼ 13), sensory screening (n ¼ 4), screening labs (n ¼ 7), advised against for the adolescent population.
immunizations (n ¼ 9), developmental/behavioral screen-
ing (n ¼ 20), counseling/anticipatory guidance (n ¼ 27), Comparing the guidelines
and dental health (n ¼ 5). Five coding categories (yes, When examining the individual categories such as gen-
implied, unclear, not mentioned, and no) were used to eral medical (Table 1), the reader notes that four of the
describe how each of the seven guidelines did or did not guidelines recommend annual visits for all adolescents
address each of the possible recommendations. ‘Yes’ while the three others refer to a nonspecific ‘periodic’
indicated that the guideline was clear in both including health exam (Tables 2–4). As expected, there is con-
the recommendation as well as endorsing it. ‘Implied’ siderable uniformity to the recommendations regarding
indicated that the recommendation was not specifically immunizations (Table 5). The seven guidelines expli-
mentioned but appeared to be intended by the context citly follow the recommendations of the Centers for
surrounding other recommendations. For example, sev- Disease Control’s (CDC) Advisory Committee on Immu-
eral guidelines recommend screening sexually active nization Practices (ACIP) [20]. Among the 20 develop-
females for chlamydia but do not specifically mention mental/behavioral recommendations, GAPS and Bright
asking the patient about onset of sexual activity. We Futures emphasize this domain most heavily while
indicated that screening for sexual activity was implied USPSTF and HEDIS, as expected, place less emphasis
in this guideline. ‘Uncertain’ was reserved for those on this category (Table 6). All of the guidelines either
recommendations which were in some way mentioned implicitly or explicitly recommend general anticipatory
but the endorsement or lack thereof remained ambigu- guidance (Table 7).
ous. Uncertain was also used for recommendations which
were specified by the USPSTF or AAFP to have insuffi- Possible explanations for discrepancies
cient evidence to recommend for or against. ‘Not men- The tables indicate that there is clearly variability across
tioned’ was applied to those recommendations that were the guidelines, with the greatest consistency in measur-
not mentioned at all in the guideline and that had no ing height and weight with a physical exam, updating
inferences based on other recommendations within the immunizations, and addressing general anticipatory

Table 1 General medical recommendations


EPSDT AAP BF GAPS USPSTF AAFP HEDIS
a c
Annual visit recommended X & & & X X &
‘Periodic’ health examination & X X X & & X
Comprehensive physical exam to be included with
annual adolescent preventive visit X & & X X X &
three of the annual visits (one each in early, mid, and late adolescence) X X X & X X X
unspecified periodicity & X X X X & X
comprehensive physical exam not specifically mentioned X X X X & & X
Physical exam to include
height and weight & & & & & & b

BMI & & & & & & &


sexual maturity rating b b & b & & b

blood pressure b & & & & ?d b

scoliosis or kyphosis b b & b & X b

male gynecomastia b b & b & & b

acne b b & b & & b

evidence of abuse or neglect b b & b & & b

evidence of sports injuries or orthopedic problems & b & b & & b

dental pathology & b & b & & b

tattoos and piercings b b & b & & b

&, yes; , implied; &, not mentioned; ?, not clear; X, no. EPSDT, Early and Periodic Screening, Diagnosis, and Treatment; AAP, American Academy
of Pediatrics; BF, Bright Futures; GAPS, Guidelines for Adolescent Preventive Services; USPSTF, United States Preventive Services Task Force;
AAFP, American Academy of Family Practice; HEDIS, Health Plan Employer Data Information Set.
a
The EPSDT manual indicates that ‘under the EPSDT benefit, you must provide for screening at intervals which meet reasonable standards of medical
and dental practice established after consultation with recognized medical and dental organizations involved in child healthcare’ [15].
b
EPSDT, AAP, GAPS and HEDIS require a ‘comprehensive unclothed’ exam. We felt that a comprehensive exam would include the listed components
with the exception of body mass index (BMI) which would require a calculation [10,13,15,16,18].
c
In the periodicity table for Periodic Health Examinations, the AAFP recommends screening one time between the ages of 11 and 12, one time between
the ages of 14 and 16 and one time at age 18 [19].
d
The AAFP reports there is insufficient evidence to recommend screening adolescents for hypertension [11,19].

Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Guidelines for adolescent well care Richmond et al. 367

Table 2 Reproductive health recommendations


EPSDT AAP BF GAPS USPSTF AAFP HEDIS

Screen all sexually active females for cervical cancer (i.e. perform Pap tests) & & & & &c &c &c
Screen all sexually active females for chlamydia ?a b & & & & &c
Screen all high-risk adolescents for
gonorrhea ?a b & & & & &
syphilis ?a b & & & & &
HIV ?a ?b & & & & &
trichomoniasis ?a b & & & & &
herpes simplex virus ?a b & & & X &
bacterial vaginosis ?a b & & & & &
HPV/genital warts ?a b & & & & &
Screen for history of STDs & & & & & & &
Teach breast self exams (for girls) & & & & & & &
Teach testicular self exams (for boys) & & & & & & &
MVI w/folic acid for females planning/capable of pregnancy & ? & & & & &
&, yes; , implied; &, not mentioned; ?, not clear; X, no. EPSDT, Early and Periodic Screening, Diagnosis, and Treatment; AAP, American Academy
of Pediatrics; BF, Bright Futures; GAPS, Guidelines for Adolescent Preventive Services; USPSTF, United States Preventive Services Task Force;
AAFP, American Academy of Family Practice; HEDIS, Health Plan Employer Data Information Set; HPV, human papilloma virus; MVI, multivitamin
infusion.
a
EPSDT recommends that ‘states identify as statewide screening requirements the minimum laboratory tests or analyses to be performed by medical
providers for particular age or population groups. Examples of some of the tests you should consider including as part of your statewide screening
requirement are hematocrit or hemoglobin screening, urinalysis, TB skin testing, STD screening and cholesterol screening’ [15].
b
The AAP recommends that all sexually active females be screened for sexually transmitted diseases (STDs). No specific STDs are indicated, however.
Since HIV testing requires a different mode of sample collection, we felt that the recommendation for testing for HIV was unclear [10].
c
The USPSTF, AAFP and HEDIS recommend Pap smears every 3 years [11,14,16,18,19]. HEDIS recommends chlamydia screening for sexually active
adolescents over the age of 16 [16,18].

Table 3 Sensory screening recommendations


EPSDT AAP BF GAPS USPSTF AAFP HEDIS
a b b
Vision screening – objective ? & & & & & &
Vision screening – subjective ?a &b &b & & & &
Hearing screening – objective ?a &c &c & X & &
Hearing screening – subjective ?a &c &c & X & &
&, yes; , implied; &, not mentioned; ?, not clear; X, no. EPSDT, Early and Periodic Screening, Diagnosis, and Treatment; AAP, American Academy
of Pediatrics; BF, Bright Futures; GAPS, Guidelines for Adolescent Preventive Services; USPSTF, United States Preventive Services Task Force;
AAFP, American Academy of Family Practice; HEDIS, Health Plan Employer Data Information Set.
a
EPSDT requires that states administer an ‘age appropriate vision assessment’ and an ‘age appropriate hearing assessment’. It is unclear if it would be
indicated for the adolescent population to have an objective or subjective hearing or vision assessment [15].
b
The AAP and Bright Futures recommend that adolescents have an objective vision screen at ages 12, 15, and 18. They recommend subjective
screening for all other years [10,12].
c
The AAP and Bright Futures both recommend objective hearing screening at ages 12, 15, and 18. They recommend subjective hearing assessments
on all other years [10,12].

Table 4 Screening laboratory tests to be considered at each visit


EPSDT AAP BF GAPS USPSTF AAFP HEDIS

Rubella serology for females & & & & & & &
Hemoglobin/hematocrit in menstruating adolescent ?a & & & X Xe &
Hemoglobin/hematocrit in at-risk populations ?a & & & &c Xe &
Urinalysis ?a & & &b X Xe &
Cholesterol screening for at-risk populations ?a & & & & Xe &
Sickle cell screen for African-American adolescents ?a & & & X Xe &
Screen for type 2 diabetes in at-risk populations & & & & ?d Xe &
&, yes; , implied; &, not mentioned; ?, not clear; X, no. EPSDT, Early and Periodic Screening, Diagnosis, and Treatment; AAP, American Academy
of Pediatrics; BF, Bright Futures; GAPS, Guidelines for Adolescent Preventive Services; USPSTF, United States Preventive Services Task Force;
AAFP, American Academy of Family Practice; HEDIS, Health Plan Employer Data Information Set.
a
EPSDT recommends that ‘states identify as statewide screening requirements the minimum laboratory tests or analyses to be performed by medical
providers for particular age or population groups. Examples of some of the tests you should consider including as part of your statewide screening
requirement are hematocrit or hemoglobin screening, urinalysis, TB skin testing, STD screening and cholesterol screening’ [15].
b
The GAPS recommends urinalysis for sexually active males to screen for sexually transmitted diseases [13].
c
The USPSTF recommends checking hemoglobin or hematocrit for those who are pregnant. We felt that pregnant teens would be considered a high-
risk group [14].
d
The USPSTF considers the evidence to be unclear for screening asymptomatic adolescents for type 2 diabetes [14].
e
These screening labs are recommended for other age groups but not for adolescents [11,19].

Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
368 Adolescent medicine

Table 5 Immunization recommendations


EPSDT AAP BF GAPS USPSTF AAFP HEDIS

Update immunizations & & & & & &


Tetanus–diphtheria boosters & & & & & & ?a
Hepatitis B & & & & & & &
MMR & & & & & & &
Varicella & & & & & & &
Hepatitis A vaccine for high-risk populations & & & & & & ?a
Place PPD in at-risk populations ? & & & & & &
Pneumococcal vaccine for high-risk populations & & & & & & ?b
Influenza vaccine for at-risk populations & & & & & & ?b
&, yes; , implied; &, not mentioned; ?, not clear; X, no. EPSDT, Early and Periodic Screening, Diagnosis, and Treatment; AAP, American Academy
of Pediatrics; BF, Bright Futures; GAPS, Guidelines for Adolescent Preventive Services; USPSTF, United States Preventive Services Task Force;
AAFP, American Academy of Family Practice; HEDIS, Health Plan Employer Data Information Set; MMR, measles, mumps and rubella; PPD, purified
protein derivative.
a
The HEDIS table of measures includes ‘adolescent immunization’. We felt that this implied updating the adolescent’s immunizations. In the section of
the handbook focusing on adolescent well care visits, however, the only immunizations mentioned are hepatitis B series, varicella and MMR. Due to this
we felt that the recommendations regarding tetanus/diphtheria and hepatitis A were unclear [16,18].
b
In the HEDIS table of measures, there are recommendations for giving the influenza and pneumococcal vaccines to older populations but not to
adolescents. Due to this we felt that the recommendations for adolescents were unclear [16,18].

guidance (Table 8). The variation in adolescent recom- poses and the dearth of evidence upon which to base a
mendations may largely be due to the means by which recommendation. For instance, the USPSTF was com-
the guidelines were constructed and their intended pur- missioned by the US Public Health Service to review the

Table 6 Developmental/behavior screening recommendations


EPSDT AAP BF GAPS USPSTF AAFP HEDIS

General developmental/behavioral assessment & & & & & & &
Assess goals and plans to achieve them & & & & & & &
Assess school performance & & & & & & &
Screen for trouble with work, school or the law & & & & & & &
Assess vocational skills & & & & & & &
Assess high-risk adolescents for conditions that may interfere with school performance & & & & & & &
Assess emotional health a c & & & & &
Screen for depression/suicidal ideation a c & & ?f ?f &
Screen for cruelty to other persons or animals & & & & & & &
Screen for problem drinking & c & & & ?g &
Screen for use of nonprescription drugs including alternative medicines & c & & ?f & &
Assess relationship with peers & & & ?f & &
Screen for presence of peer pressure and assess ability to cope with it & & & & & & &
Screen for involvement in romantic relationship and assess the quality of it & & & & & & &
Screen for initiation of sexual activity ?b d & & & &
Screen for engagement in high-risk sexual activity ?b & & & & &
Assess family relationships & & & e ?f ?f &
Screen for history of abuse & & & & ?f ?f &
Assess body image & & & & & & &
Screen for eating disorders/weight loss measures & & & & & & &
&, yes; , implied; &, not mentioned; ?, not clear; X, no. EPSDT, Early and Periodic Screening, Diagnosis, and Treatment; AAP, American Academy
of Pediatrics; BF, Bright Futures; GAPS, Guidelines for Adolescent Preventive Services; USPSTF, United States Preventive Services Task Force;
AAFP, American Academy of Family Practice; HEDIS, Health Plan Employer Data Information Set.
a
EPSDT recommends screening for ‘psychiatric/psychological problems’ which we assume means to assess emotional health and to screen for
depression or suicidal ideation [15].
b
EPSDT recommends that ‘states identify as statewide screening requirements the minimum laboratory tests or analyses to be performed by medical
providers for particular age or population groups. Examples of some of the tests you should consider including as part of your statewide screening
requirement are hematocrit or hemoglobin screening, urinalysis, TB skin testing, STD screening and cholesterol screening’. As part of the consideration
of sexually transmitted disease (STD) screening is screening for sexual activity as well as high-risk sexual activity [15].
c
Screening for depression, alcohol use and relationship with peers are all included in the AAP’s statement on violence prevention which is referenced in
the recommendations of the AAP [10].
d
Screening for sexual activity is implied by the recommendation to screen sexually active females for STDs [10].
e
The GAPS recommend screening for ‘family dysfunction’ [13].
f
The USPSTF and AAFP report insufficient evidence to recommend for or against screening for suicidal ideation or depression in adolescents or
screening for violence within families and screening for violent relationship with peers. Additionally USPSTF reports insufficient evidence to support
screening adolescents for drug use [14,19].
g
The AAFP recommends screening for problem drinking in adult populations but reports there is insufficient evidence to recommend screening
adolescents [11,19].

Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Guidelines for adolescent well care Richmond et al. 369

Table 7 Anticipatory guidance/counseling recommendations


EPSDT AAP BF GAPS USPSTF AAFP HEDIS

General anticipatory guidance & & & & &


Violence prevention – general & & & & ?a & &
Injury prevention – general & & & & & &
Encourage use of lap/shoulder belt & & & & & & &
Encourage adolescent drivers to minimize risk of automobile accident & & & & & & &
Encourage use of bicycle/motorcycle/ATV helmets & & & & & & &
Encourage use of protective gear for work or sports & & & & & & &
Encourage use of smoke detector and development of fire emergency plan & & & & & & &
Encourage safe storage/removal of firearms & & & & & & &
Avoid high noise levels & & & & & & &
Avoid tobacco use & & & & & ?b &
Avoid underage drinking and illicit drug use [15] & & & & & & &
Avoid alcohol/drug use while driving, swimming, boating, etc. [15] & & & & & & &
STD prevention including abstinence, condom use and avoiding high-risk behavior & & & & & & &
Counsel how to avoid unintended pregnancy/encourage contraception use & & & & & & &
Counsel regarding a healthy diet & & & & & & &
Encourage adequate calcium intake & & & & & & &
Encourage regular physical activity & & & & & ?b &
Limit TV/computer time & & & & & & &
Encourage to learn how to swim & & & & & & &
Avoid excess mid-day sun and use protective clothing for at-risk patients & & & & & & &
Try to get 8 h of sleep per night & & & & & & &
Practice time management skills & & & & & & &
Continue to build sense of identity & & & & & & &
Develop community involvement & & & & & & &
Follow family rules & & & & & & &
Understand the importance of your spiritual needs and try to fill them & & & & & & &
&, yes; , implied; &, not mentioned; ?, not clear; X, no. EPSDT, Early and Periodic Screening, Diagnosis, and Treatment; AAP, American Academy
of Pediatrics; BF, Bright Futures; GAPS, Guidelines for Adolescent Preventive Services; USPSTF, United States Preventive Services Task Force;
AAFP, American Academy of Family Practice; HEDIS, Health Plan Employer Data Information Set.
a
The USPSTF reports insufficient evidence to recommend for or against counseling for violence prevention [14].
b
The AAFP reports insufficient evidence to support the effectiveness of counseling adolescents regarding tobacco use or regular physical activity [19].

Table 8 Dental health recommendations


EPSDT AAP BF GAPS USPSTF AAFP HEDIS
b
Encourage regular visits to dental care provider & X & & & & &
Floss and brush with fluoride toothpaste a & & & & & &
Daily fluoride supplement for those with inadequate water fluoridation & & & & & & &
Ask dentist to check wisdom teeth & & & & & & &
Learn emergency dental care & & & & & & &
&, yes; , implied; &, not mentioned; ?, not clear; X, no. EPSDT, Early and Periodic Screening, Diagnosis, and Treatment; AAP, American Academy
of Pediatrics; BF, Bright Futures; GAPS, Guidelines for Adolescent Preventive Services; USPSTF, United States Preventive Services Task Force;
AAFP, American Academy of Family Practice; HEDIS, Health Plan Employer Data Information Set.
a
EPSDT recommends providing ‘instruction in self-care oral hygiene procedures’ [15].
b
The AAP recommends dental care referrals for younger children only [10].

evidence and construct recommendations for preventive [22]. Yet this minimum can influence state programs to
services. Their recommendations are thus a reflection not deliver fewer services.
only of the strength of the evidence, but of the existence
of published evidence for each of the recommended Timing of the publication of guidelines also needs to be
services. In contrast, the AMA guidelines have relied taken into account when examining the variation in
heavily on expert opinion and consensus [21]. While both recommendations. Clinical recommendations change fre-
the USPSTF and the AMA developed guidelines to aid quently as new evidence is presented. For instance, in
clinicians, HEDIS was developed as a set of performance 2002 the American Cancer Society altered their recom-
measures, trackable by billing codes, created to ensure mendations for Pap smears citing evidence that the first
that healthcare purchasers and consumers can reliably Pap smear can be initiated approximately 3 years after the
compare care provided by healthcare plans, and thus are onset of sexual activity or at age 21, whichever occurs first
not true guidelines. The federal EPSDT program [23]. This was followed by further guidelines by the
encourages each state to confer with experts to determine American College of Obstetricians and Gynecologists
the timing and specifics to be included for each com- generally endorsing the delay of the first Pap smear
ponent of their program with a minimum standard given but suggesting that the decision to delay ‘should be based

Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
370 Adolescent medicine

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Conclusion
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