How to get into heads of teens in initial visit

How can clinicians make the first reproductive health visit for a young teen a successful one? Use the HEEADSSS method of interviewing to perform a psychosocial review of systems, says Melissa Kottke, MD, MPH, MBA, assistant professor in the Department of Gynecology and Obstetrics at Emory University School of Medicine in Atlanta.¹ HEEADSSS is a mnemonic for Home environment, Education and employment, Eating, peer-related Activities, Drugs, Sexuality, Suicide/depression, and Safety from injury and violence. Kottke presented on the subject at the recent Contraceptive Technology Quest for Excellence conference.²

The major causes of morbidity and mortality in the adolescent population are unintentional injuries, many of which are related to alcohol and drug use.³ Other causes of morbidity, such as unintended pregnancy, sexually transmitted infections, eating disorders, and depression, often are not teased out during the traditional patient/physician model of health interviewing; this is where the HEEADSSS method is most effective.³

The HEEADSSS method allows clinicians to explore a wide range of topics in an efficient manner during the initial reproductive visit, says Kottke. Questions in the HEEADSSS method give clinicians a "key opportunity" to spot risky behavior in adolescents and talk with them about it, particularly when it comes to risky sexual behavior, says Kottke.

Adolescence is a time of increased risk-taking, and HEEADSSS questions about sexual health, such as "Have any of your relations ever been sexual relationships?" and "What are you using for birth control?" can help identify potential problems.

Many teens are sexually active. According to the most recent Youth Risk Behavior Surveillance System, a survey conducted by the Centers for Disease Control and Prevention (CDC) to monitor priority health-risk behavior in youth and young adults, 47.4% said they had ever had sexual intercourse, with 33.7% having sexual intercourse during the previous three months. Of sexually active youth, 39.8% said they did not use a condom the last time they had sex.⁴

Set the stage

The HEEADDSSS method of history taking helps clinicians understand how an adolescent is functioning in life, says Melanie Gold, DO, FAAP, clinical professor of pediatrics at the University of Pittsburgh School of Medicine and a staff physician at the University’s Student Health Service. By telling teens, "I am asking you these questions to help me find out if there is anything that may be putting your health at risk and to tell me what kind of exam and tests I should do," clinicians are helping to set the stage for sensitive questions that lie ahead, says Gold.⁵

If a clinician just looks at a teen’s body mass index (BMI), a possible eating disorder might be missed, notes Gold. Asking such questions as "How do you feel about your weight? Do you want to weigh more or less or stay the same?" can help tease out such information, she notes.

When to schedule visit?

When should such a teen’s initial reproductive health visit be scheduled? The American College of Obstetricians and Gynecologists (ACOG) recommends that the first dedicated reproductive health visit take place between age 13 and 15. During the visit, the clinician should provide health guidance, screening, and preventive health care services.⁶ Stay tuned: updated guidance from ACOG is slated to be released in the next few months, says Kottke. (Review the current guidance, as well as other ACOG teen resources, in its free Tool Kit for Teen Care, available at http://bit.ly/1d5WZn9.)

Realize that the first time an adolescent accesses an adult healthcare facility, it can be quite a different environment from the "happy" office surroundings previously encountered in a pediatric care setting, notes Kottke. Take steps to make your clinic welcoming, says Kottke. The CDC has developed an infographic on a teen-friendly reproductive health visit. Download it at http://1.usa.gov/10965gP.

Be sure to use the initial reproductive health visit as a time to review needed vaccinations, including immunization against human papillomavirus (HPV). An analysis of 2012 survey data shows that not receiving a healthcare provider’s recommendation for HPV vaccine was one of the five main reasons parents reported for not vaccinating their daughters.⁷

Do not downplay the importance of counseling, for it is as important as tests and physical exams, says Eva Lathrop, MD, MPH, assistant professor in the Department of Gynecology and Obstetrics at Emory University School of Medicine. Speaking at the Quest for Excellence conference, Lathrop said her previous day in the teen clinic was filled with adolescent patients. However, her contact was never physical; all of her work involved listening and talking to each teenager, she noted.⁸

REFERENCES

1. Goldenring JM, Rosen D. Getting into adolescents heads: an essential update. Contemp Pediatrics 2004; 21:64-90
2. Kottke M. Right from the start: a sensible approach to the teen’s first reproductive health visit. Presented at the 2013 Contraceptive Technology Quest for Excellence conference. Atlanta; November 2013.
3. Physicians for Reproductive Health. Adolescent friendly health services. Accessed at http://bit.ly/1gxfDc6.
4. Gold MA, Seningen AE. Interviewing adolescents. In: McInerny, TK, Adam HM, Campbell DE, et al, eds. American Academy of Pediatrics Textbook of Pediatric Care. Washington, DC: American Academy of Pediatrics; 2009.
5. Eaton DK, Kann L, Kinchen S, et al. Centers for Disease Control and Prevention (CDC). Youth risk behavior surveillance — United States, 2011. MMWR Surveill Summ 2012; 61(4):1-162.
6. Committee opinion no. 460: the initial reproductive health visit. Obstet Gynecol 2010; 116(1):240-243.
7. Centers for Disease Control and Prevention (CDC). Human papillomavirus vaccination coverage among adolescent girls, 2007-2012, and postlicensure vaccine safety monitoring, 2006-2013 — United States. MMWR 2013; 62(29):591-595.
8. Lathrop E. Effective counseling strategies that improve contraceptive use. Presented at the 2013 Contraceptive Technology Quest for Excellence conference. Atlanta; November 2013. n