Adolescent Medicine - Scope of Care

Scope of Care

Providers of care for adolescents generally take a holistic approach to the patient, and attempt to obtain information pertinent to the patient's well-being in a variety of different domains. This approach, similar to the biopsychosocial model, is encapsulated in the HEADSS assessment, which is a screening acronym for adolescent patients. This has been expanded to HEEADSSS to include additional question sets (indicated with a *). It includes:

• Home -- how is the adolescent's home life? How are his/her relationships with family members? Where and with whom does the patient live? Is his/her living situation stable?
• Education (or Employment) -- how is the adolescent's school performance? Is he/she well-behaved, or are there discipline problems at school? If he/she is working, is he/she making a living wage? Are they financially secure?
• Eating* (incorporates body image) -- does the patient have a balanced diet? Is there adequate calcium intake? Is the adolescent trying to lose weight, and (if so), is it in a healthy manner? How does he/she feel about his/her body? Has there been significant weight gain/loss recently?
• Activities -- how does the patient spend his/her time? Are they engaging in dangerous or risky behavior? Are they supervised during their free time? With whom do they spend most of their time? Do they have a supportive peer group?
• Drugs (including alcohol and tobacco) -- does the patient drink caffeinated beverages (including energy drinks)? Does the patient smoke? Does the patient drink alcohol? Has the patient used illegal drugs? If there is any substance use, to what degree, and for how long?
• Sex -- is the patient sexually active? If so, what form of contraception (if any) is used? How many partners has the patient had? Has the patient ever been pregnant/fathered a child? Do the patient and their partners get routine reproductive health and STD checks and physical examinations? Are there any symptoms of a sexually transmitted infection? Does the patient identify as heterosexual, homosexual, or unsure? Does the patient feel safe discussing sexuality issues with parents or other caregivers?
• Suicidality (including general mood assessment) -- what is the patient's mood from day to day? Has he/she thought about/attempted suicide? In broader terms, is their mental and emotional state so dysfunctional that the activities of daily living are largely impaired or they present a risk to themselves or others?
• Safety* -- does the patient regularly wear a bicycle helmet? seatbelt? Does the patient drive while intoxicated or with a driver who is intoxicated? Does the patient wear safety equipment while participating in sports?
• Some providers favor the addition of Strengths to the list, in an effort to avoid focusing on issues of risk or concern, and reframe the patient interaction in a manner that highlights resilience.

In addition to a detailed history, adolescents should have a comprehensive physical exam (including a developmental and neurological assessment, STI testing, and a reproductive system exam) and mental health status exam on at least a yearly basis, in addition to yearly dental and ocular exams. Developmental progression, including an assessment of Tanner stage, should be noted at every yearly visit, and appropriate endocrinological work-ups undertaken for patients that fail to develop in an anticipated manner. Young women and young men should be taught how to examine their breast tissue for signs of breast cancer, and young men should be taught how to examine their testicles and penis for cancer and STDs. Screening lab tests, including a complete blood count to screen for anemia, and either a spot cholesterol check or (ideally) a fasting lipid profile to screen for hyperlipidemia, should be obtained at least once during adolescence. For patients who are sexually active, particularly in areas of high prevalence or with patients participating in higher-risk behaviors, screening tests for sexually transmitted diseases should be performed, including an RPR or VDRL for syphilis, screening for gonorrhea and chlamydia, and HIV. Sexually active females should have a pelvic examination and a physical examination if indicated by the presence of symptoms concerning for an STI; males should have a urological examination and a physical examination. Needed immunizations include: a tetanus vaccination or booster shot, a meningitis vaccination, the Gardasil vaccine against HPV (Human Papillomavirus, a leading cause of cervical cancer and genital warts) and a yearly influenza vaccination.