Coming of age
Physicians rise to challenges of adolescent medicine
Just as teenagers experience significant developmental changes as they mature, they also undertake a shift in how they receive health care. In many ways, the two are interwoven, the latter driven by the former and also through the expertise of physicians trained to navigate the complexities of adolescent medicine.
“You’re dealing with kids who are transitioning from pediatric to adult care, going from a pediatric focus where the parents are really in charge of health to, hopefully, the other end where the teen is prepared to take control of their own health,” said Wayne Sells, MD ’88, MPH, Director of Adolescent Health at Oregon Health & Science University. “So you really have two patients, the child and parent. That’s a challenge – sometimes they have the same agenda, sometimes it’s very different.”
Many of the health issues in the teen population are sensitive, pertaining to reproductive health, sexual activity, substance use or abuse, risk-taking and mental health. The topics’ nature makes some adolescents wary of being forthcoming with their doctor, let alone their parents. Physicians find themselves needing to encourage and facilitate improved communication between child and parent while navigating and respecting confidentiality requirements.
Parents, Dr. Sells said, must be encouraged to provide structure, to be allies in monitoring their teen’s behavior and adherence to a treatment plan, and to talk to their kids about their own views and values. Patients, similarly, need to be given the tools and motivation to make good decisions and to discuss their activities and health questions with their parents, in addition to being open and honest with their doctor.
“The more you work with teenagers, the more you understand, a teen’s living environment plays a big role,” Dr. Sells said. “Youth who may be abusing substances may not be completely honest with their provider for fear of the consequences. Patients with eating disorders may not tell you because they are not sure they want to get better. I’m committed to taking care of teens, but it’s important we help families improve their parenting skills.”
Reconciling differences and trying to get the teen patient and parent on the same page is just one of the unique aspects of adolescent medicine. Although generally healthy, teens do face certain medical problems that are more prevalent in their age group than any other. Among them are growth and hormonal changes including menstrual problems, acne, anorexia, anemia and overuse injuries among athletes. The chief threat to adolescent health, however, is that which is largely within individual control – risky behavior.
“We can’t ignore that 75 percent of adolescent deaths are not really medical issues,” said James A. Meyer, MD ’82, an adolescent medicine specialist at Marshfield Clinic. “They are behavioral issues – unintentional injuries, homicide, suicide – and we have to be working on behavioral issues that impact on risk-taking, which leads to those terrible statistics. I don’t think you go into adolescent medicine without believing you can help your patients make better choices.”
For some adolescents, risk-taking may involve tobacco, alcohol or drug use. It may mean lack of seat belt use or helmet use or unsafe driving. It could mean sexual activity or firearm access. Combinations of these compound the risk, as drinking or drug use impairs judgment, thus increasing the likelihood of intoxicated driving, unprotected sex or even suicide.
Providing health care for adolescents, specialists say, is challenging because their views on life are in constant flux. At the younger end of the spectrum, they have limited comprehension of how present activity affects their life in the future. As they age, they develop an awareness of the future and of the consequences of their actions, but they still need the guidance that physicians can provide.
Wendi Ehrman, MD ’88, talks with Zinamalasha Reinecker following her check-up at the Downtown Health Center in Milwaukee. Zinamalasha is a patient of the Milwaukee Adolescent Health Program, run by The Medical College of Wisconsin and Children’s Hospital and Health System. Dr. Ehrman is Medical Director of the program.
“In general, this group of patients tends to be a healthy group of kids and a good group of patients,” said Wendi Ehrman, MD ’88, Assistant Professor of Pediatrics (Adolescent Medicine) at The Medical College of Wisconsin. “But this is adolescence, and puberty is going on and hormones are flaring, and they take risks. So we need to talk to them about risk prevention so they can continue to stay healthy.”
While most teens are guilty of engaging in risky behavior, at least occasionally, some are inherently at risk due to socioeconomic status, family history or living environment. Dr. Ehrman is Medical Director of a Medical College program specifically designed to care
and advocate for patients in Milwaukee’s central city.
The Milwaukee Adolescent Health Program (part of the Division of Adolescent Medicine with a consultative clinic and inpatient services at Children’s Hospital of Wisconsin), consists of a primary care clinic, a specialized teen-tot clinic for adolescent parents and their children, and a school-based health center. Case managers provide substance abuse treatment, family planning services and assistance to adolescent job seekers and those with educational needs. They also provide health screens and acute care to detained juveniles at the Milwaukee County Juvenile Detention Center.
Early health screenings, particularly for substance abuse, sexual activity and depression, are a key component of the program so the most appropriate care can be provided on a medical and social level. Confidentiality is an ongoing challenge, Dr. Ehrman said, especially as clinic staff attempt to engage patients’ parents or guardians, since Wisconsin law requires confidentiality for patients’ reproductive health information, regardless of age. Confidence can only be broken if the patient is a danger to themselves or others.
Statutory rape cases and abuse from a family member are among the most difficult cases Dr. Ehrman faces, but more prevalent are teen pregnancies. Often, the teens are not cognitively age appropriate but romanticize pregnancy as a way to keep a boyfriend or a way out of their current environment.
“The developmental level of an adolescent doesn’t always measure up to their age,” she said. “We’re trying to change the behavior of someone who can be a very concrete thinker, especially for pregnancy prevention or STD prevention. They may not comprehend the challenges ahead if they don’t change behavior.”
In his rural, central Wisconsin setting, Dr. Meyer more frequently sees challenges of a different nature. In addition to his primary practice, he has a large referral practice. He finds that what is often overlooked in previous assessments is a successful effort to foster better health and behavior for the adolescent. Many times, there is a mental health component. Dr. Meyer recently saw an 18-year-old who said he had been feeling depressed for several years, but his parents did not want him pursuing mental health care. Now of age, he decided to seek it on his own to get on a path to health.
“What I do crosses the line between classical medical care and psychological support and care,” Dr. Meyer said. “I have to take on that role with there being very little access to psychological care in this rural setting.”
Mental health is an emphasis of adolescent medicine. Depression starts to peak near the end of adolescence and at least 20 percent of teens have had a depression episode by age 18, said Jeffrey Hunt, MD ’84, Associate Professor of Psychiatry & Human Behavior at Brown University. Dr. Hunt is also Director of Training in both the Child and Adolescent Psychiatry Fellowship and the Combined Program in Pediatrics, Psychiatry and Child and Adolescent Psychiatry (Triple Board) at Brown.
“The bigger issue for a child and adolescent psychiatrist is determining whether this is psychopathology or just a deviation from the norm,” said Dr. Hunt, who points to persistence of symptoms, intensity and duration as indicators of pathology. “Those not mentally ill can snap back quickly from a mood swing. Those with disorders do not snap back as readily and continue to have substantial problems with family, friends and school work.”
In younger teens, anxiety is common, and Dr. Hunt said his goal when meeting with these patients is to decipher that particular patient’s mindset, uncover the underlying fear, and get those issues out in the open. Successful communication is essential.
“With adolescents, you frequently have to deal with your relationship with the teen and establishing rapport is critical,” Dr. Hunt said. “You do that with adults as well, but with adults, usually they choose to come to you, but with adolescents, it’s more common that the parents are bringing the kids. More often you have an unwilling person in front of you, often distrustful of why you’re asking questions.”
Clinicians can best interact with teens by showing genuine interest in their activities and demonstrating that it is safe to talk to you and that you are there to help, Dr. Hunt said. Dr. Meyer added that being a good listener and a good reflector are also key to successful communication. The patient must sense that their physician has time for them and values their opinions, he said.
For Robert J. Stevens, MD ’84, GME ’87, communicating with teens is the next stage in caring for patients he may have known since birth. As a family practitioner in Green Bay, Dr. Stevens said he often has an established relationship with an adolescent’s parents or guardians, so he can educate them to encourage personal responsibility in their children’s health care. He also typically has well-defined at-risk behavior knowledge on long-time patients, allowing the implementation of some interventions prior to teenage years.
As valuable as that relationship history may be, the relative well-being of adolescents coupled with stressed family budgets creates a unique obstacle for keeping teens healthy.
“In the time of recession that we live in, families frequently have high deductible insurance policies,” he said. “Preventive care for all family members is viewed as costly. Many families ration health care for acute illness visits, and adolescents typically present only for acute problems.”
Of course, preventive medicine remains perhaps the best way to ensure the risks to which so many teens are predisposed are neutralized or eluded.
“I feel the best cases are those you never hear of,” Dr. Stevens said. “That means preventive measures from myself and parents have been successful in avoiding and reducing adolescent morbidity and mortality.”
Teens’ futures in the balance
The range of cases seen by adolescent medicine physicians can be quite dramatic, as Wayne Sells, MD ’88, MPH, can attest. The Director of Adolescent Health at Oregon Health & Science University, Dr. Sells said that he has cared for teens who go on to attend Yale and Harvard universities, while others struggle to get off the street.
His patients’ conditions can be complicated and at times overwhelming for youth and their families. Dr. Sells regularly saw one teenager who had cancer, and while treatment was going well for the disease, he developed addiction issues and an eating disorder. He has cared for numerous teen athletes with eating disorders who had to take time out from their sport to receive help and get healthy.
In his practice, he has cared for homeless adolescents who have involved themselves in a sex trade to survive on the streets. Others abuse substances in an attempt to escape.
In addition to his university appointment, Dr. Sells is the Medical Director of Outside In, an agency in Portland, Ore., dedicated to helping youth transition from the streets to independent living. Here, he experienced one of his most heart-wrenching cases. He had been caring for a young woman with a heroin addiction, but with his team’s help, she had been clean for three months. The patient and the agency’s staff were celebrating her success, as they had gotten to know her well after treating numerous skin infections she had developed.
A month later, however, she died at the hands of a serial killer who was targeting young women. These, he said, are the situations most difficult to see, but he is also buoyed by the adolescents with whom he has worked over time as they navigate the “rocky middle” to adulthood.
“We have a lot of successes, but they’re not always instant successes,” he said. “It may take years to realize.”
View the entire fall 2009 issue of Alumni News. (opens as a pdf)
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