Risky Behavior Poses Biggest Health Threat to Adolescents

A quiet crisis among a noisy group — teenagers — was revealed in a report released last December by the prestigious Institute of Medicine (IOM) here in Washington.

“Most adolescents are considered healthy,” the IOM said, but that’s because we’re looking in all the wrong places for teen medical troubles by focusing on adult-type illnesses. In our brave new world, it’s not cancer or allergies or rare diseases that strike most teens. Rather, it’s car crashes, homicides and suicides that cause three-fourths of all adolescent deaths in the United States.

In 2004, suicide was the third leading cause of mortality in the 10 to 19 age group, and many deadly accidents are linked to teenage drinking and driving or other forms of risky behavior.

Risk-taking is routine among adolescents: One survey showed nearly half of high school students in this country are having sexual intercourse but only 37 percent of them report using condoms. This fuels the most commonly reported infectious diseases among this age group: sexually transmitted diseases (STDs) such as chlamydia, gonorrhea and syphilis, the IOM report said.

Moreover, 60 percent of students have tried cigarettes by the 12th grade, while adolescent obesity rates have tripled since 1980 — which doesn’t bode well for their health now or later in life.

These statistics are surprising not only because of how widespread the problem is, but because it’s the result of voluntary, preventable action. “Behavior that is unhealthful and/or risky, rather than infectious or chronic diseases, is the leading cause of [death] among adolescents,” the IOM warned, citing risk factors such as the “use of alcohol, tobacco, and illicit drugs and carrying a weapon.”

Recent research at the National Institute of Mental Health suggests the reason behind much of this — a reason many parents know all too well. The teen brain is going through a growth spurt and simply isn’t all there yet. Parts that dictate impulse control, planning and good judgment just aren’t fully formed at that stage in life.

System Abandons Adolescents Unfortunately, the health care system hasn’t caught up with this longstanding trend. “Adolescents don’t get the health care they need or deserve” in this country, said Dr. Lawrence D’Angelo of D.C.’s Children’s National Medical Center, one of the country’s leading hospitals for young medical care, with model services for teens. D’Angelo is chief of adolescent and young adult medicine at Children’s and the incoming president of the Society for Adolescent Medicine.

“We have come so far in terms of health care technology, but it’s in the simple things, such as how you talk to an adolescent,” that we’re seeing medical failure. “We have a lot to learn,” he said.

Fueling this quiet crisis is “exceptionally poor reimbursement” for teen care, argued Dr. David Reitman, chairman of pediatrics at Suburban Hospital in Bethesda, Md. “Pediatrics is the worst-paying medical specialty and adolescent medicine has the worst reimbursements in pediatrics,” he lamented.

This has had two results, according to D’Angelo, who said there are not enough specialists to provide care for young people, and not enough training in adolescent medicine given to pediatricians, family physicians and nurses.

Many experts in fact agree that quality care for our growing teens is rare. It’s most often found in government-supported community or school clinics or in major academic centers — all few and far between in many parts of the United States. Large group practices can also partly fill the void if parents have private insurance.

Another complicating factor: Teens are tough to treat. Society generally believes that they’re the picture of perfect health, and they typically don’t — or won’t —get prevention information or willingly have regular checkups. This is especially true if they have to endure a visit in a busy, crowded emergency room, noted Dr. David Ascher, chairman of the Department of Pediatrics at Virginia’s Inova Fairfax Hospital for Children — which is ramping up its multidisciplinary adolescent medicine focus this year.

“Teenagers put things off. It’s hard to get them to show up,” added Dr. Lisa Tuchman of Children’s Hospital of Philadelphia, which, like the Children’s National Medical Center in D.C., is also at the forefront of adolescent medicine.

“It’s a time-intensive group,” Suburban’s Reitman concurred, recommending that every medical encounter with teenagers start with the HEADSS concept — questions about home, education, activities and hobbies, drugs, suicide and sex.

Many doctors and nurses lack the skills to manage what seems like a simple feat — talking to a teenager — or can tolerate the poor payment for what can in truth be a 40-minute soul session with a difficult adolescent. “Sixty percent of what I do has to do with behavioral health,” Reitman said, stressing that the current payment system doesn’t recognize that.

Hospitals Tackle Teen Health Not everyone is dismissing this phenomenon as pure teen angst. Many hospitals are addressing adolescent health by creating centers for primary care on their home grounds or at community medical satellites.

Interestingly, one driver of this growth is the recession as hospitals attempt to stem the tide of emergency room visits whose costs are higher than preventative checkups. “Primary-Care Patients Overwhelming Hospitals” was a recent headline in the Washington Post, which reported that many Virginia hospitals are “at the breaking point” — while conversely Howard University Hospital in Washington is opening a free primary care clinic to reduce the load on its ER.

This trend is not just local. The National Association of Children’s Hospitals cited members such as Missouri’s Children’s Mercy Hospitals and Clinics, Children’s Hospital of Wisconsin, and the Texas Children’s Hospital in Houston. All offer seamless access to one-stop-shopping for teenage patients, with primary care doctors and specialists in one place. These centers send nurse educators into shelters, they drive children to neighborhood clinics, and they save money for their hospitals in the process.

That’s exactly what adolescents need, the Institute of Medicine report said. “Health services for adolescents currently consist of separate programs and services that are often highly fragmented, poorly coordinated, and delivered in multiple public and private settings,” it said, noting that mental health is “in substantial disarray” because of financing barriers, eligibility gaps and privacy concerns.

Thus, the IOM’s top recommendation is for federal and state agencies, private foundations, and private insurers to support the development of a coordinated primary health care system for all adolescents.

“I think the IOM is right on,” Tuchman said. At the Children’s Hospital of Philadelphia (CHOP), the Adolescent Care Center offers total health care in one place, including sports medicine, social and emotional support for job and school issues, reproductive health care including family planning for young men and women, and the prevention and treatment of STDs. The hospital also has a large HIV outreach and treatment program for adolescents.

CHOP wisely put all this care in a separate building and gave it its own staff, office suite, waiting area and evening office hours — emphasizing a “partnership” model with its patients. “We love the involved parent,” said Tuchman, whose care center works to promote independent and responsible self-care in teenagers as they transition into adulthood.

A big part of CHOP’s success is careful attention to confidentiality rules. “Under laws in Pennsylvania, anyone 14 and older must have access to confidential care, including reproductive care, substance abuse treatment and HIV testing,” Tuchman explained. “We’ll meet with a parent and a young patient, then with the teen alone, and anything discussed with the teen is confidential unless he or she is in danger. If I’m sufficiently worried to notify a parent I’ll always tell the patient first. We never go behind their backs.”

Though they vary state to state, similar confidentiality laws in Maryland, Virginia and Washington, D.C., cover patients ages 13 to 18 (though Virginia has an exception for abortion issues). D’Angelo of Children’s National Medical Center said that too many health care providers aren’t aware of these laws and don’t know how to talk to teens, offer confidential care, or keep adolescents as allies, all of which discourages teens from trusting their doctors or coming in to see them at all.

D’Angelo’s Adolescent Health Center provides exactly what the IOM recommends: primary care plus access to specialists all in one place, and a setting that’s teen friendly and treats adolescent patients with respect. The center offers, among other things, psychological services, nutritional assistance and help with eating disorders, reproductive health care and an HIV program.

Georgetown University Hospital is also offering this kind of model and a collaborative approach to working with teen patients in its adolescent medicine unit, said Dr. Anisha Abraham, chief of the hospital’s adolescent medicine section and a professor at the medical school.

Abraham warned that “teens in this country are not getting good care. They’re at risk. They’re not able to speak for themselves, so it’s up to us to do it and make sure they get access to the health care they need,” she said.

“There’s a huge lack of mental health resources in particular,” she added. “Adolescence can be a turbulent and challenging time. We try to empower teens, not force them into care.”

In Virginia meanwhile, Inova Fairfax Hospital for Children has several community primary care clinics and outreach programs serving special needs, including the Inova Cares Clinic for Children in Fairfax, which offers integrated and comprehensive care through age 21.

In line with the IOM’s wish list, Inova is exploring new multidisciplinary services dedicated to adolescents, with a focus on obesity and mental health, said the hospital’s head of pediatrics, David Ascher. However, many adolescent programs lose money, Ascher pointed out, so it takes ingenuity and commitment to make them work.

That’s especially true at the typical community hospital, such as Suburban in Bethesda, an acute-care facility that primarily treats inpatient adolescents, Reitman said. “To put together the integrated-services model IOM recommends requires a huge financial investment,” he said, “and very few community hospitals in this country are going to be able to do it.”

Teen Tips for the Parents So how can parents find good health care for their teen? The Washington area is unusually rich in resources for adolescent medical care, but it can still be a struggle.

Larger medical groups or pediatric practices are more likely to have board-certified doctors in adolescent medicine, advised Inova’s Ascher — but make sure that your provider enjoys working with teens. Also look for awareness of your state’s confidentiality laws and a separate entrance or waiting area for adolescent patients in a pediatric practice.

“If the doctor is not asking for time alone with your child or is not comfortable with teen talk, consider looking for another physician,” Suburban’s Reitman added.

Likewise, parents shouldn’t be complacent about a teen who seems to be doing well by most standards, Georgetown’s Abraham cautioned, pointing out that wealth and education do not protect adolescents from the natural pressures most teenagers experience. Teens coming to the United States from another culture will also have extra challenges assimilating to their new identity, Abraham noted.

Be alert to mood swings and persistent sadness as well, although it’s normal for teen moods to go up and down, Reitman said. Bipolar disorders, schizophrenia and clinical depression often emerge in the teen years, and parents shouldn’t hesitate to get an assessment if you have concerns.

In spite of all the challenges, adolescent medicine is “a great field,” Reitman said. “Even the toughest of teens need a lot and respond to good care. It’s very rewarding.”

About the Author

Carolyn Cosmos is a contributing writer for The Washington Diplomat.