National Academies Press: OpenBook

Adolescent Health Services: Missing Opportunities (2009)

Chapter: 3 Current Adolescent Health Services, Settings, and Providers

« Previous: 2 Adolescent Health Status
Suggested Citation:"3 Current Adolescent Health Services, Settings, and Providers." National Research Council and Institute of Medicine. 2009. Adolescent Health Services: Missing Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/12063.
×
Page 135
Suggested Citation:"3 Current Adolescent Health Services, Settings, and Providers." National Research Council and Institute of Medicine. 2009. Adolescent Health Services: Missing Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/12063.
×
Page 136
Suggested Citation:"3 Current Adolescent Health Services, Settings, and Providers." National Research Council and Institute of Medicine. 2009. Adolescent Health Services: Missing Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/12063.
×
Page 137
Suggested Citation:"3 Current Adolescent Health Services, Settings, and Providers." National Research Council and Institute of Medicine. 2009. Adolescent Health Services: Missing Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/12063.
×
Page 138
Suggested Citation:"3 Current Adolescent Health Services, Settings, and Providers." National Research Council and Institute of Medicine. 2009. Adolescent Health Services: Missing Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/12063.
×
Page 139
Suggested Citation:"3 Current Adolescent Health Services, Settings, and Providers." National Research Council and Institute of Medicine. 2009. Adolescent Health Services: Missing Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/12063.
×
Page 140
Suggested Citation:"3 Current Adolescent Health Services, Settings, and Providers." National Research Council and Institute of Medicine. 2009. Adolescent Health Services: Missing Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/12063.
×
Page 141
Suggested Citation:"3 Current Adolescent Health Services, Settings, and Providers." National Research Council and Institute of Medicine. 2009. Adolescent Health Services: Missing Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/12063.
×
Page 142
Suggested Citation:"3 Current Adolescent Health Services, Settings, and Providers." National Research Council and Institute of Medicine. 2009. Adolescent Health Services: Missing Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/12063.
×
Page 143
Suggested Citation:"3 Current Adolescent Health Services, Settings, and Providers." National Research Council and Institute of Medicine. 2009. Adolescent Health Services: Missing Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/12063.
×
Page 144
Suggested Citation:"3 Current Adolescent Health Services, Settings, and Providers." National Research Council and Institute of Medicine. 2009. Adolescent Health Services: Missing Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/12063.
×
Page 145
Suggested Citation:"3 Current Adolescent Health Services, Settings, and Providers." National Research Council and Institute of Medicine. 2009. Adolescent Health Services: Missing Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/12063.
×
Page 146
Suggested Citation:"3 Current Adolescent Health Services, Settings, and Providers." National Research Council and Institute of Medicine. 2009. Adolescent Health Services: Missing Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/12063.
×
Page 147
Suggested Citation:"3 Current Adolescent Health Services, Settings, and Providers." National Research Council and Institute of Medicine. 2009. Adolescent Health Services: Missing Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/12063.
×
Page 148
Suggested Citation:"3 Current Adolescent Health Services, Settings, and Providers." National Research Council and Institute of Medicine. 2009. Adolescent Health Services: Missing Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/12063.
×
Page 149
Suggested Citation:"3 Current Adolescent Health Services, Settings, and Providers." National Research Council and Institute of Medicine. 2009. Adolescent Health Services: Missing Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/12063.
×
Page 150
Suggested Citation:"3 Current Adolescent Health Services, Settings, and Providers." National Research Council and Institute of Medicine. 2009. Adolescent Health Services: Missing Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/12063.
×
Page 151
Suggested Citation:"3 Current Adolescent Health Services, Settings, and Providers." National Research Council and Institute of Medicine. 2009. Adolescent Health Services: Missing Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/12063.
×
Page 152
Suggested Citation:"3 Current Adolescent Health Services, Settings, and Providers." National Research Council and Institute of Medicine. 2009. Adolescent Health Services: Missing Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/12063.
×
Page 153
Suggested Citation:"3 Current Adolescent Health Services, Settings, and Providers." National Research Council and Institute of Medicine. 2009. Adolescent Health Services: Missing Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/12063.
×
Page 154
Suggested Citation:"3 Current Adolescent Health Services, Settings, and Providers." National Research Council and Institute of Medicine. 2009. Adolescent Health Services: Missing Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/12063.
×
Page 155
Suggested Citation:"3 Current Adolescent Health Services, Settings, and Providers." National Research Council and Institute of Medicine. 2009. Adolescent Health Services: Missing Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/12063.
×
Page 156
Suggested Citation:"3 Current Adolescent Health Services, Settings, and Providers." National Research Council and Institute of Medicine. 2009. Adolescent Health Services: Missing Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/12063.
×
Page 157
Suggested Citation:"3 Current Adolescent Health Services, Settings, and Providers." National Research Council and Institute of Medicine. 2009. Adolescent Health Services: Missing Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/12063.
×
Page 158
Suggested Citation:"3 Current Adolescent Health Services, Settings, and Providers." National Research Council and Institute of Medicine. 2009. Adolescent Health Services: Missing Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/12063.
×
Page 159
Suggested Citation:"3 Current Adolescent Health Services, Settings, and Providers." National Research Council and Institute of Medicine. 2009. Adolescent Health Services: Missing Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/12063.
×
Page 160
Suggested Citation:"3 Current Adolescent Health Services, Settings, and Providers." National Research Council and Institute of Medicine. 2009. Adolescent Health Services: Missing Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/12063.
×
Page 161
Suggested Citation:"3 Current Adolescent Health Services, Settings, and Providers." National Research Council and Institute of Medicine. 2009. Adolescent Health Services: Missing Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/12063.
×
Page 162
Suggested Citation:"3 Current Adolescent Health Services, Settings, and Providers." National Research Council and Institute of Medicine. 2009. Adolescent Health Services: Missing Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/12063.
×
Page 163
Suggested Citation:"3 Current Adolescent Health Services, Settings, and Providers." National Research Council and Institute of Medicine. 2009. Adolescent Health Services: Missing Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/12063.
×
Page 164
Suggested Citation:"3 Current Adolescent Health Services, Settings, and Providers." National Research Council and Institute of Medicine. 2009. Adolescent Health Services: Missing Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/12063.
×
Page 165
Suggested Citation:"3 Current Adolescent Health Services, Settings, and Providers." National Research Council and Institute of Medicine. 2009. Adolescent Health Services: Missing Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/12063.
×
Page 166
Suggested Citation:"3 Current Adolescent Health Services, Settings, and Providers." National Research Council and Institute of Medicine. 2009. Adolescent Health Services: Missing Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/12063.
×
Page 167
Suggested Citation:"3 Current Adolescent Health Services, Settings, and Providers." National Research Council and Institute of Medicine. 2009. Adolescent Health Services: Missing Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/12063.
×
Page 168
Suggested Citation:"3 Current Adolescent Health Services, Settings, and Providers." National Research Council and Institute of Medicine. 2009. Adolescent Health Services: Missing Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/12063.
×
Page 169
Suggested Citation:"3 Current Adolescent Health Services, Settings, and Providers." National Research Council and Institute of Medicine. 2009. Adolescent Health Services: Missing Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/12063.
×
Page 170
Suggested Citation:"3 Current Adolescent Health Services, Settings, and Providers." National Research Council and Institute of Medicine. 2009. Adolescent Health Services: Missing Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/12063.
×
Page 171
Suggested Citation:"3 Current Adolescent Health Services, Settings, and Providers." National Research Council and Institute of Medicine. 2009. Adolescent Health Services: Missing Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/12063.
×
Page 172
Suggested Citation:"3 Current Adolescent Health Services, Settings, and Providers." National Research Council and Institute of Medicine. 2009. Adolescent Health Services: Missing Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/12063.
×
Page 173
Suggested Citation:"3 Current Adolescent Health Services, Settings, and Providers." National Research Council and Institute of Medicine. 2009. Adolescent Health Services: Missing Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/12063.
×
Page 174
Suggested Citation:"3 Current Adolescent Health Services, Settings, and Providers." National Research Council and Institute of Medicine. 2009. Adolescent Health Services: Missing Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/12063.
×
Page 175
Suggested Citation:"3 Current Adolescent Health Services, Settings, and Providers." National Research Council and Institute of Medicine. 2009. Adolescent Health Services: Missing Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/12063.
×
Page 176
Suggested Citation:"3 Current Adolescent Health Services, Settings, and Providers." National Research Council and Institute of Medicine. 2009. Adolescent Health Services: Missing Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/12063.
×
Page 177
Suggested Citation:"3 Current Adolescent Health Services, Settings, and Providers." National Research Council and Institute of Medicine. 2009. Adolescent Health Services: Missing Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/12063.
×
Page 178
Suggested Citation:"3 Current Adolescent Health Services, Settings, and Providers." National Research Council and Institute of Medicine. 2009. Adolescent Health Services: Missing Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/12063.
×
Page 179
Suggested Citation:"3 Current Adolescent Health Services, Settings, and Providers." National Research Council and Institute of Medicine. 2009. Adolescent Health Services: Missing Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/12063.
×
Page 180
Suggested Citation:"3 Current Adolescent Health Services, Settings, and Providers." National Research Council and Institute of Medicine. 2009. Adolescent Health Services: Missing Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/12063.
×
Page 181
Suggested Citation:"3 Current Adolescent Health Services, Settings, and Providers." National Research Council and Institute of Medicine. 2009. Adolescent Health Services: Missing Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/12063.
×
Page 182
Suggested Citation:"3 Current Adolescent Health Services, Settings, and Providers." National Research Council and Institute of Medicine. 2009. Adolescent Health Services: Missing Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/12063.
×
Page 183
Suggested Citation:"3 Current Adolescent Health Services, Settings, and Providers." National Research Council and Institute of Medicine. 2009. Adolescent Health Services: Missing Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/12063.
×
Page 184
Suggested Citation:"3 Current Adolescent Health Services, Settings, and Providers." National Research Council and Institute of Medicine. 2009. Adolescent Health Services: Missing Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/12063.
×
Page 185
Suggested Citation:"3 Current Adolescent Health Services, Settings, and Providers." National Research Council and Institute of Medicine. 2009. Adolescent Health Services: Missing Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/12063.
×
Page 186
Suggested Citation:"3 Current Adolescent Health Services, Settings, and Providers." National Research Council and Institute of Medicine. 2009. Adolescent Health Services: Missing Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/12063.
×
Page 187
Suggested Citation:"3 Current Adolescent Health Services, Settings, and Providers." National Research Council and Institute of Medicine. 2009. Adolescent Health Services: Missing Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/12063.
×
Page 188
Suggested Citation:"3 Current Adolescent Health Services, Settings, and Providers." National Research Council and Institute of Medicine. 2009. Adolescent Health Services: Missing Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/12063.
×
Page 189
Suggested Citation:"3 Current Adolescent Health Services, Settings, and Providers." National Research Council and Institute of Medicine. 2009. Adolescent Health Services: Missing Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/12063.
×
Page 190
Suggested Citation:"3 Current Adolescent Health Services, Settings, and Providers." National Research Council and Institute of Medicine. 2009. Adolescent Health Services: Missing Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/12063.
×
Page 191
Suggested Citation:"3 Current Adolescent Health Services, Settings, and Providers." National Research Council and Institute of Medicine. 2009. Adolescent Health Services: Missing Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/12063.
×
Page 192
Suggested Citation:"3 Current Adolescent Health Services, Settings, and Providers." National Research Council and Institute of Medicine. 2009. Adolescent Health Services: Missing Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/12063.
×
Page 193

Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

3 Current Adolescent Health Services, Settings, and Providers Summary A Systems Perspective • Five objectives identified by the World Health Organization provide a basis for assessing the quality of current and future systems of health services for adolescents: accessibility, acceptability, ap- propriateness, effectiveness, and equity. Primary Care Services • Evidence shows that while private office-based primary care ser- vices are available to most adolescents, those services depend significantly on fee-based reimbursement and are not: –  ccessible to adolescents who are uninsured or underinsured. a –  ffered in acceptable settings that foster open communication o of sensitive behaviors or health conditions. –  rovided by personnel who are skilled in addressing health p conditions and behaviors that are appropriate for this stage of development. –  ffective at fostering health promotion or addressing risky be- e haviors that are prevalent among adolescents, such as sub- stance use and unsafe sexual activity. 135

136 ADOLESCENT HEALTH SERVICES • Evidence shows that safety-net health services for adolescents are –  ccessible to many adolescents who are uninsured or do not a find private office-based services acceptable for their needs. – requently more acceptable to adolescents who are uncomfort- f able with private office-based primary care providers, especially when they can establish relationships with providers who are sensitive to their needs and promote open communication. –  ometimes able to offer a more appropriate mix of skills and s counseling services that address risky behaviors. –  ble to provide effective disease prevention and health pro- a motion services while also addressing issues related to risky behavior. However, such centers often can become unstable during times of fiscal uncertainty and may experience frequent personnel transitions. They also face unique challenges associ- ated with financing of prevention and health promotion services that cannot be reimbursed. – mportant mechanisms for resolving the disparities and inequi- i ties that exist within private office-based primary care. Specialty Care Services • Evidence shows that specialty care services for the adolescent population are not accessible to most adolescents. Existing spe- cialty services in the areas of mental health, sexual and repro- ductive health, oral health, and substance use treatment and prevention are generally insufficient to meet the needs of many adolescents. While evidence-based therapies are available in a number of these areas, they are not integrated into many practice settings. • Even when specialty services are accessible, many adolescents do not find them acceptable because of concerns about disclo- sure of treatment in sensitive areas (such as substance use or sexual health). • Many specialty providers lack appropriate training to address the needs of adolescent patients, and certification programs for treating adolescents are frequently unavailable in many specialty areas. • The lack of appropriate specialty services that are suitable for adolescents means that effective treatment is often delayed, care is of limited duration, and services are poorly reimbursed. • Limitations in the quality of or access to specialty services are especially prevalent among at-risk adolescents in whom problems

CURRENT ADOLESCENT HEALTH SERVICES 137 in the above areas frequently co-occur, contributing to health care inequities and disparities. Prevention and Health Promotion • Routine screening for risk factors and unhealthful behaviors that emerge during adolescence is not available or accessible for most adolescents. • Many health care providers who treat adolescents fail to adhere to recommended prevention guidelines, to screen for appropriate risk factors and unhealthful behaviors that emerge during adoles- cence, and to provide effective counseling that would reduce risks and foster health promotion. Racial and Ethnic Disparities • Disparities and biases affect the quality of health services for adolescents and deserve serious consideration in any efforts to improve access to appropriate services and reduce inequities in the health system. Confidential Services • Evidence shows that health services that are confidential increase the acceptability of services and the willingness of adolescents to seek them, especially for issues related to sexual behavior, reproductive health, mental health, and substance use. • Existing state and federal policies generally protect the confiden- tiality of adolescents’ health information when they are legally allowed to consent to their own care. T his chapter introduces a framework for examining the strengths and limitations of current health system approaches for adolescents. This framework comprises five major objectives—accessibility, accept- ability, appropriateness, effectiveness, and equity—that serve as criteria for assessing the use, adequacy, and quality of adolescent health services. The chapter then reviews the current array of mainstream and safety-net primary care services, as well as specialty services, that respond to the ado- lescent health needs identified in Chapter 2; a brief discussion of inpatient hospital services for adolescents is also presented. This review is followed by a discussion of what is known about adolescents’ use of health services.

138 ADOLESCENT HEALTH SERVICES The chapter then considers how context matters—that is, how such factors such as income, race and ethnicity, and community affect access to and utilization of adolescent health services. Next is a discussion of consent and confidentiality and their influence on the acceptability of health ser- vices to adolescents. The chapter ends with a summary of the gaps between adolescents’ health service needs and the services and settings that exist to address those needs. This chapter deals with several important issues: the overall inadequacy of preventive screening, counseling, and health education for adolescents, which are crucial to high-quality care for this population; the value of hav- ing health services available in diverse locations; the lack of an integrated health system that recognizes and reflects the particular needs and interests of adolescents; and the importance of confidentiality and privacy of visits between adolescents and providers. Chapter 4 responds to the findings presented in this chapter by exploring elements of improved health services within an adolescent health system that would be more accessible, accept- able, appropriate, effective, and equitable relative to adolescents’ current health status, health service needs, and population variations. OBJECTIVES OF HEALTH SERVICES FOR ADOLESCENTS An array of studies has emerged describing the types of health services frequently used by adolescents in the United States and other countries, as well as gaps between the nature of these services and the health needs of adolescents, as identified in Chapter 2 (Chung et al., 2006; Tylee et al., 2007; U.S. Congress and Office of Technology Assessment, 1991). While evidence is insufficient to indicate that any one particular setting or prac- tice structure meets the complex needs of all U.S. adolescents better than others, a variety of national and international organizations studying both adolescents and health care providers (Donovan et al., 1997; Ford et al., 1997; Ginsburg et al., 1995; Kang et al., 2003; Veit et al., 1996) have (1) defined critical elements of health services that would improve adolescents’ access to appropriate services, (2) highlighted design elements that would improve the quality of those services, and (3) identified ways to foster patient–provider relationships that can lead to better health for adolescents. This research from various sources and the experiences of adolescents and health care providers, health organizations, and research centers have di- rected attention to the importance of designing primary care services that can attract and engage adolescents, create opportunities to discuss sensitive health and behavioral issues, and offer high-quality health services as well as guidance on both disease prevention and health promotion. Through a series of reports and consultations, the World Health Orga- nization focused attention on the importance of adolescent-friendly health

CURRENT ADOLESCENT HEALTH SERVICES 139 services (Brabin, 2002; Tylee et al., 2007; World Health Organization, 1999, 2001). These activities led to a general consensus on five objectives that promote responsive adolescent health services: • Accessible. Policies and procedures ensure that services are broadly accessible. • Acceptable. Policies and procedures consider culture and relation- ships and the climate of engagement. • Appropriate. Health services fulfill the needs of all young people. • Effective. Health services reflect evidence-based standards of care and professional guidelines. • Equitable. Policies and procedures do not restrict the provision of and eligibility for services. These objectives provided the committee with a valuable framework for assessing the use, adequacy, and quality of adolescent health services; com- paring and contrasting the extent to which different services, settings, and providers address the health needs of young people in the United States; identifying the gaps that keep services from meeting these objectives; and recommending ways to fill those gaps. Using such a framework is superior to relying solely on process measures, such as rates of utilization, profes- sional licensure standards, or anecdotal reports of institutional reputations. This framework could be used to inform future local, state, and national as- sessments of adolescent health and health services, and to monitor progress toward achievement of the 21 Critical Health Objectives for adolescents and young adults (a subset of the Healthy People 2010 goals, as described in Chapter 2 [U.S. Department of Health and Human Services, 2007]), as well as the oral health objectives for adolescents (U.S. Department of Health and Human Services, 2000). It and the framework of behavioral and contextual characteristics presented in Chapter 1 complement each other and together help to provide a more comprehensive picture of the features of the health system that should be improved to provide adolescents with high-quality care and thus improve their health status, addressing the health needs of all adolescents while also attending to the needs of specific, often underserved, subpopulations and high-risk groups. The committee compared the five WHO objectives with the fundamen- tal aims for the health system set forth by the Institute of Medicine (IOM, 2001) as described in Box 3-1. Table 3-1 summarizes this comparison and illustrates that while there is considerable overlap between the two frame- works, there are important differences that merit consideration. The IOM framework reflects concerns about how to improve quality and reduce inefficiencies in services received by patients who have access to health care providers, especially those who need specialty care for chronic conditions

140 ADOLESCENT HEALTH SERVICES BOX 3-1 Characteristics of Two Frameworks for Delivering Health Services World Health Organization Framework for Delivering Adolescent-Friendly Health Services (as summarized by Tylee et al., 2007) • Accessible—Policies and procedures ensure that services are broadly accessible. •  cceptable—Policies and procedures consider culture and relationships and the A climate of engagement. • Appropriate—Health services fulfill the needs of all young people. •  ffective—Health services reflect evidence-based standards of care and professional E guidelines. • Equitable—Policies and procedures do not restrict the provision of and eligibility for services. Institute of Medicine Framework for Delivering Quality Health Services (as set forth in Institute of Medicine, 2001) • Efficient—Services are designed to reduce unnecessary time and costs. • Timely—Waiting times between assessment and treatment are reduced. • Patient-centered—Services are sensitive to the needs and preferences of the patient. • Equitable—Services do not reflect disparities within the general population. • Effective—Services reflect accepted standards of clinical care. • Safe—Protocols are in place to reduce medical errors and foster quality assurance. (such as diabetes or eating disorders, which generally involve coordina- tion of multiple specialty services). By contrast, the WHO framework is focused on how to improve access to and engagement with appropriate primary care services. Since all adolescents need to interact with primary care providers and fewer need specialty services, the WHO framework of- fers a more appropriate conceptual design for an analysis of the adolescent health system. With the WHO framework in mind, the committee reviewed compo- nents of the current adolescent health system—adolescent health services, the settings where these services are delivered, how services are delivered in these settings, and by whom. The committee considered the extent to which these services are accessible, acceptable, appropriate, effective, and equitable. Health services for adolescents in the United States are delivered through two sectors: primary care and specialty care. Each sector involves

TABLE 3-1  Comparison of Criteria of the Institute of Medicine and World Health Organization Frameworks for Delivering Health Services IOM Framework Efficient Timely Patient-Centered Equitable Effective Safe WHO Framework   Accessible X   Acceptable X   Appropriate X   Effective X X   Equitable X NOTES: IOM = Institute of Medicine; WHO = World Health Organization. SOURCES: Institute of Medicine (2001); Tylee et al. (2007). 141

142 ADOLESCENT HEALTH SERVICES multiple providers and institutions, and some providers work with specific subpopulations of youths. Primary care programs strive to meet the basic health needs of all adolescents, including routine checkups, immunizations, anticipatory guidance, and screening and assessment for disorders and risk factors. Specialty care programs serve adolescents with specific health needs (for example, those with chronic illnesses such as diabetes or asthma, those with eating disorders, those needing reproductive health services or treat- ment for sexually transmitted infections [STIs], those with clinical mental health needs, or those with substance use disorders). In some situations, specialty health services may be offered through primary care settings, and primary care services may sometimes be available within specialty clinics. Examples include the primary care services offered by Planned Parenthood clinics (which specialize in reproductive health care), as well as mental health services that are offered within certain types of community health or hospital-affiliated primary care clinics. Assessing the relative merits of various care settings requires close at- tention to the nature of their interactions and their experience with differ- ent health conditions and subpopulations of adolescents. It also requires consensus on the criteria that should be applied in weighing the strengths and limitations of particular service settings. The adolescent health system shares the same basic problems as those embedded in the organization of adult health services: the lack of communi- cation, collaboration, and system-level planning among various private and public health services, settings, and providers (Institute of Medicine, 2003). As noted in the IOM (2003) report, the vast array of clinicians, hospitals, other health care facilities, insurance plans, and purchasers operate in vari- ous configurations of groups, networks, and independent practices that are collectively termed “the health care delivery system.” However, this phrase suggests an order, integration, and accountability that do not exist, and whose absence results in barriers to and gaps in care. In some areas, such as the organization of mental health services for adolescents, the system of ser- vices is in substantial disarray because of financial barriers, eligibility gaps, the limited availability of providers, and concerns about confidentiality and privacy that impede smooth transitions across health service settings. Finding: •  ive objectives identified by the World Health Organization pro- F vide a basis for assessing the quality of current and future systems of health services for adolescents: accessibility, acceptability, ap- propriateness, effectiveness, and equity.

CURRENT ADOLESCENT HEALTH SERVICES 143 PRIMARY CARE SERVICES Traditional primary care encompasses provider-based services offered in private practices, such as pediatric, family medicine, and dental offices, as well as safety-net programs that include community health centers or hospital-affiliated primary care services. School-based health centers are also generally considered part of the primary care sector. Some primary care settings are structured to serve the health needs of specific populations with unique profiles (such as those who are homeless or runaways; those who are involved in the foster care or juvenile justice system; or those who are lesbian, gay, bisexual, or transgender [LGBT]). Private Office-Based Care The majority of adolescents have private insurance through family plans offered by one or both parents’ employers. These adolescents com- monly receive their primary medical care from private provider offices, usually a pediatrician, family physician, general internist, or nurse prac- titioner, or for older female adolescents, a gynecologist. Adolescents with public insurance (such as Medicaid or the State Children’s Health Insurance Program [SCHIP]) also routinely interact with provider offices in the private or public sectors that accept their insurance plans. Private office-based primary care services frequently cover the follow- ing: health maintenance or well-care visits (the scope of which is often guided by local school board policies), basic diagnostic tests (such as height, weight, and blood pressure), vision and hearing screening, and brief con- sultation on health concerns or health promotion. The administration of recommended vaccines may or may not be included in an annual office visit, depending on local school requirements, state programs for free vaccines, insurance coverage, and reimbursement practices. Significant variations frequently occur in private and public health plans that limit or influence the nature and duration of services eligible for reimbursement in private office-based primary care settings. For example, traditional plans allow reimbursement for health maintenance visits, labo- ratory tests, care for certain categories of acute and chronic medical condi- tions, and prescription medications. They generally do not cover extended or periodic counseling services beyond the brief contact associated with a health maintenance visit, nor do they reimburse many of the counseling or case management expenses associated with treatment of a number of   The group referred to as “lesbian, gay, bisexual, and transgender” sometimes also encom- passes the term “questioning” and is commonly referred to by the acronym LGBT (or GLBT) or LGBTQ (or GLBTQ). For the purposes of this report, the identifier “lesbian, gay, bisexual, and transgender” or LGBT is used.

144 ADOLESCENT HEALTH SERVICES behavioral problems, such as anorexia or bulimia, substance use, sexual or reproductive health practices, trauma, or behavioral or emotional problems that fail to meet the threshold criteria for a clinical disorder (Fox, Limb, and McManus, 2007; Fox, McManus, and Reichman, 2003; see Chapter 6 for more detail). A review of several studies found that 70 percent of adolescent mor- bidity and mortality involves consequences from such behavior as unsafe sexual activity, violence, substance use, tobacco use, poor nutritional habits, risky driving, and inadequate physical activity (National Research Council, 1999). Yet even though this age group is at significant risk for the onset of many health conditions that may persist into adulthood, only a minority of adolescents receive developmental or psychosocial services through routine assessment (Chung et al., 2006). While clinician surveys indicate that most private providers perform routine surveillance for risky behaviors, diet, and exercise, fewer than half of adolescents responded affirmatively to survey items asking whether they had spoken with their provider about sexual activity, other risk behaviors, STIs, diet, exercise, and emotional health (Bethell, Klein, and Peck, 2001; Chung et al., 2006; Ellen et al., 1998; Halpern-Felsher et al., 2000; Millstein and Marcell, 2003; Millstein, Igra, and Gans, 1996). Several factors account for the lack of appropriate private office-based health services for adolescents that are tailored to their behavioral and developmental needs. For example, insurance reimbursements are often inadequate to compensate for the time it takes to offer adequate health pro- motion or disease prevention services for adolescents (McManus, Shejavali, and Fox, 2003; O’Connor, Johnson, and Brown, 2000). This and other finance issues are discussed in more detail in Chapter 6. Another challenge involves the nature and skills of the workforce that is available to address the health needs of adolescents. According to the National Medical Ambulatory Survey and the National Hospital Ambula- tory Medical Care Survey, 40 percent of health visits for adolescents aged 11–14 were to pediatricians during 1994–2003. As adolescents matured and reached adulthood, they encountered a more diverse array of providers, moving from pediatricians to family physicians, internal medicine physi- cians, and gynecologists. For example, among females and males aged 18– 21, only 4 percent and 7 percent, respectively, had met with pediatricians. For the two age groups, 22 percent and 29 percent of visits, respectively, were to family physicians. Half of female and 70 percent of male health maintenance visits in the older age group were to family physicians. After age 18, females were more likely to visit obstetricians/gynecologists than any other type of physician (Rand et al., 2007). In some cases, adolescents are able to interact with a specialist in adolescent medicine in a private office-based primary care setting. An ado-

CURRENT ADOLESCENT HEALTH SERVICES 145 lescent medicine specialist has received extensive training in the particular health conditions and concerns of adolescents, as discussed later in this chapter and further in Chapter 5. These specialists may be more prepared than other practitioners to address multiple health problems faced by ado- lescents, identify specific behavioral disorders, and offer guidance on health promotion and disease prevention. But access to adolescent specialists is se- verely limited, since these practitioners are commonly available only in aca- demic health centers. According to one recent estimate, just 466 certificates in adolescent medicine were issued from 1996 to 2005 (for a population of about 40 million people aged 10–19), compared with 2,839 certificates issued in geriatric medicine during the same period (Hoffman, 2007). In addition to difficulties associated with insurance conditions and the shortage of specialists, opportunities to engage adolescents in discussions pertinent to their particular needs and circumstances and to monitor their general health status are severely constrained by a lack of continuity with a clinician or place of care, a lack of privacy, a lack of clinical awareness or skill, racial and ethnic barriers, language-related barriers, clinician and patient gender-related barriers, and a lack of time to provide comprehen- sive preventive care even if adolescents attend their recommended visits (Chung et al., 2006). In their review of the literature, Chung and colleagues (2006) found that fulfilling only the most conservative (i.e., evidence- and cost/benefit-based) counseling recommendations of the U.S. Preventive Care Task Force would take an average clinician nearly 40 minutes per adoles- cent per year. Both national surveys of pediatricians and case studies have found that insurance reimbursements are inadequate to cover the necessary time (McManus, Shejavali, and Fox, 2003; O’Connor, Johnson, and Brown, 2000). Several group plans and managed care organizations have recognized the importance of offering primary care services tailored to the needs of adolescents. These plans and organizations tend to provide greater oppor- tunity for adolescents and their parents to engage with providers who are specially equipped to address their concerns and are skilled in discussing sensitive health issues, such as pubertal changes, sexual activity, behavioral and mental health conditions, and substance use. More commonly, however, providers in private office-based primary care settings believe they are inadequately trained in adolescent health, and they are uncomfortable with discussing sensitive health issues of particular concern to adolescents and their families (as discussed further in Chapter 5). Moreover, few of these providers are aware of the Guidelines for Ado- lescent Preventive Services (discussed in Chapter 4) or the Healthy People 2010 objectives for adolescents and young adults (described in Chapter 2) (American Medical Association, 1997; U.S. Department of Health and Hu- man Services, 2007). They fail to recognize the importance of incorporating

146 ADOLESCENT HEALTH SERVICES health promotion and disease prevention as a fundamental part of routine health services for adolescents. Most providers practice in environments that fail to encourage adolescents to ask health questions, express their health concerns, or explore disease prevention strategies that might prepare them to address significant risks and vulnerabilities that often emerge in adolescence (such as the use of tobacco, alcohol, and drugs; sexual activity; risky driving; and violent behavior) (Klein and Wilson, 2002). One study of ambulatory care for children in different settings found that few medical practitioners are able to provide comprehensive, coordi- nated, or sensitive health services tailored to adolescent needs (Mangione- Smith et al., 2007). Likewise, adolescent disease prevention services received the lowest score for quality among clinical services for children and youths (as measured by eight indicators): 4.5 percent as compared with 92 percent for treatment of upper respiratory tract infections and 85.3 percent for treatment of allergic rhinitis (Mangione-Smith et al., 2007). In summary, while many adolescents have access to private office-based primary care services, such services are not suited to the particular behav- ioral and developmental needs of this stage of life. The lack of reimburse- ment for counseling and case management services, as well as the diversity of health care providers who are involved in the care of adolescents, cre- ates unique challenges that affect both the availability and acceptability of prevention and health promotion services. Even when effective services are available, they are frequently not integrated into routine primary care settings. Furthermore, few centers are specifically focused on the primary care needs of special subpopulations of adolescents, such as those who are in the foster care system, in families that have recently immigrated, or LGBT. The lack of quality private office-based primary care services for these groups creates service gaps that constitute basic disparities and inequities in the health care system. These special subpopulations rely on safety-net centers for their health care, as discussed in the following section. Findings: •  vidence shows that while private office-based primary care ser- E vices are available to many adolescents, those services depend significantly on fee-based reimbursement and are not: – accessible to adolescents who are uninsured or underinsured. – offered in acceptable settings that foster open communication of sensitive behaviors or health conditions.

CURRENT ADOLESCENT HEALTH SERVICES 147 –  provided by personnel who are skilled in addressing health conditions and behaviors that are appropriate for this stage of development. –  effective at fostering health promotion or addressing risky be- haviors that are prevalent among adolescents, such as substance use and unsafe sexual activity. Safety-Net Primary Care Services Many adolescents are uninsured or underinsured and are therefore in- eligible to receive primary care services from private office-based providers. Other adolescents may not have an established relationship with a primary care provider or may be concerned about the confidentiality of visits with their primary care provider. These young people often rely on safety-net providers, defined as “those providers that organize and deliver a significant level of health care and other health-related services to uninsured, Medic- aid, and other vulnerable patients” (Institute of Medicine, 2000, p. 21). Core safety-net providers have two distinguishing characteristics: (1) they have a legal mandate or explicit mission to “maintain an ‘open door,’ offer- ing access to services to patients regardless of their ability to pay; and (2) a substantial share of their patient mix is uninsured, Medicaid, and other vulnerable patients” (Institute of Medicine, 2000, pp. 3–4). As noted in earlier IOM studies, the safety net consists of public hos- pital systems; academic health centers; community health centers or clinics funded by federal, state, and local public health agencies; and local health departments. An additional feature of the safety net for adolescents is the presence of school-based health centers. The organization and delivery of safety-net services vary widely from state to state and community to community. A literature review presented at a workshop convened in January 2007 as part of this study revealed that many reports focused on improving services and outcomes for adolescents frequently omit safety-net health services (see, for example, National Research Council and Institute of Medicine, 2002). Studies of the quality of adolescent safety-net health ser- vices vary in methodological rigor; randomized studies are rare; extensive variations exist in populations, settings, topics, and time; single-site studies predominate; and a meta-analysis or synthesis of essential components is not possible given the quality of the available research (Dougherty, 2007). Overall, the review presented in the study workshop was striking in reveal- ing the absence or low quality of the existing evidence on safety-net sites of care for adolescents (see Table 3-2).

148 ADOLESCENT HEALTH SERVICES TABLE 3-2 Studies Evaluating the Delivery of Adolescent Health Services in School-Based and Community Health Centers Site/System Study Design School-Based Health Centers Effectiveness Britto et al. ������ (2001) 2-year comparison with control schools (within state) Crespo and Shaler (2000) 3-year national comparison with other school-based health centers Culligan (2002) Survey of adolescent users of school-based health centers statewide Guo et al. (2005) ������ 2-year comparison with control schools (within a metropolitan area) Key, Washington, and Hulsey (2002) Retrospective 3-year comparison with adolescents not enrolled in center, but in the same school Kisker and Brown (1996) Comparison with national sample in other urban areas Mental health programs Armbruster and Lichtman (1999) Comparison with community clinic services Chatterji et al. (2004) Estimate of costs of a mental health screening and treatment program; implemented all students Slade (2002) Comparison with services in other settings; population-based survey Comprehensive pregnancy programs Barnet, Duggan, and Devoe (2003) Comparison with a hospital-based pregnancy program Disease management programs Anderson et al. (2004) Nonrandomized controlled comparison with other schools without disease management program Quality Center for Reproductive Health Research Comparison of countywide program with Policy (n.d.) schools without centers Gance-Cleveland, Costin, and Degenstein Comparison of quality standards in centers (2003) (statewide) Kalafat and Illback (1998) Evaluation of programs (statewide)

CURRENT ADOLESCENT HEALTH SERVICES 149 Populations Findings Middle and high school students Increased receipt of needed health care among users of school center Middle and high school students Increased enrollment and continued high utilization among users of school center Middle and high school students Improved health knowledge and reported health behavior among users of school center Elementary and middle school students with Lower risk of asthma-related hospitalization asthma and emergency department utilization among users of school center General population aged 10–15 Decrease in emergency department utilization among users of school center High school students Increased access to health services and improved health knowledge among users of school center Children and adolescents aged 5–18 Comparable improvement on Children’s Global Assessment Scale and Global Assessment of Function Middle school students, mostly Hispanic, Baseline cost of implementation for 2 years, low-income societal perspective Students in grades 7–12 Increased utilization of mental health counseling services in school-based program Primarily pregnant African American Lower risk of low-birthweight infants in adolescents school-based program Children and adolescents, low-income Lower emergency department utilization and hospitalization, less follow-up for asthma among users of school center Elementary, middle, high school students Increased receipt of needed health care in schools with centers; provided a baseline for further evaluation Elementary, middle, high school students Mixed results; set baseline goals for improvement Elementary, middle, high school students Qualitative associations to provide a baseline for further evaluation Continued

150 ADOLESCENT HEALTH SERVICES TABLE 3-2 Continued Site/System Study Design Community Health Centers Lieberman (1974) Evaluation of quality Orso (1979) Utilization data of center calculated using city population census data Shields et al. (2002) Retrospective with comparison (hospital outpatient department and solo/group physicians) Tatelbaum et al. (1978) Local comparison (hospital clinic) NOTE: Excluded studies with populations only in elementary schools. Community-Based Health Centers Community-based health centers are a fundamental component of the safety-net primary care system. They offer a broad array of primary care services for populations that frequently lack access to traditional services or do not find such services acceptable for meeting their needs. Several examples of community-based programs that serve more vul- nerable adolescents are described in Chapter 4. The adolescents served by these programs often are difficult to engage in mainstream primary care centers for many reasons, such as a lack of insurance or a history of trauma and victimization. Community-based centers frequently emphasize outreach to difficult-to-reach or -serve populations (sometimes through the use of paraprofessionals or peer educators), case management and social support programs, and comprehensive medical and behavioral health services. They attract personnel who are trained in adolescent health and development, are skilled in establishing trust with more vulnerable adolescents, and are comfortable in discussing sensitive health issues with young people. While many community-based health centers have the capacity to offer reproduc- tive health or behavioral health services, few have the resources to provide routine or specialized oral health services for adolescents. These free-standing centers are frequently housed in locations that provide easy access to and opportunities for unscheduled encounters with adolescents in need. In some places, drop-in centers and mobile units have been used to deliver health services to particularly vulnerable populations, including those who are homeless, are from families that have recently im- migrated, or live in rural settings (Diaz-Parez Mde, Farley, and Cabanis, 2004; C. A. Jones et al., 2005; Lee and O’Neal, 1994; Slesnick et al., 2008).

CURRENT ADOLESCENT HEALTH SERVICES 151 Populations Findings Children and adolescents under age 17 Only 17 percent of children and adolescents received high-quality care Local community High rates of center utilization for adolescent boys (63%) and girls (81%) in center Children and adolescents with asthma Higher visit rates for asthma compared with both; lower emergency department utilization compared with hospital; higher hospitalization rates compared with solo/ group physicians Adolescents, high proportion receiving Lower rates of anemia and pre-eclampsia in Medicaid pregnant adolescents Such centers often encourage interdisciplinary teams and integrated case management among their staff; in some situations, they assist adolescents in resolving housing, school, employment, legal, and family problems that contribute to their health conditions. Community-based adolescent health centers frequently are vulnerable to the same limitations that characterize many other community-based programs: they serve a limited population of adolescents; they have a low-volume patient base; they are often poorly reimbursed for services associated with counseling, team interaction, and case management; they frequently rely on part-time health care providers and have difficulty at- tracting and retaining skilled personnel (because of limited funding, time demands, and difficulty securing malpractice insurance); and they often require supplemental funds from local or state health departments, the fed- eral government, private donors, or other sources since fee-based services alone are not sufficient to support their programs (Institute of Medicine, 2000). Little is known about the effectiveness of different service models used by community-based health centers in reaching these particularly vul- nerable adolescents for disease prevention, case management, and health promotion. Hospital-Affiliated Primary Care Services A number of hospital centers have established adolescent clinics that function as community health clinics and serve the primary care needs of adolescents; examples include Mount Sinai Hospital in New York City, Denver Health in Colorado, and the Arkansas Children’s Hospital and

152 ADOLESCENT HEALTH SERVICES Adolescent Center in Little Rock (see Chapter 4). These adolescent clinics may be located within the hospital itself or organized as a satellite facility elsewhere within the community. Most offer basic primary care services and also emphasize reproductive health care; some have specialized exper- tise in the management of specific disorders, such as STIs, substance use, or mental health disorders (Fisher and Kaufman, 1996; Macfarlane and Blum, 2001). One important feature of safety-net care associated with hospital-based settings is adolescents’ high utilization of emergency care services at public hospitals for acute injuries and illnesses, as well as for routine primary care needs (a topic discussed later in this chapter). Surprisingly, few studies document trends in this area or identify strengths and gaps associated with the accessibility, acceptability, appropriateness, or effectiveness of health services for adolescents in emergency departments. A few specialized pro- tocols for treatment and brief motivational interventions for adolescents (e.g., related to substance use) have been developed for use by emergency care providers (Burke, O’Sullivan, and Vaughan, 2005). School-Based Health Centers One important source of primary care for adolescents is schools, espe- cially those with school-based health centers. Almost 30 years ago, New York State launched the first state-funded grant program to support school- based health centers (Brindis et al., 2003). By last count, the number of such centers nationwide had reached 1,709 in 45 states (Juszczak, Schlitt, and Moore, 2007). While school-based health centers serve students from kindergarten through high school, more than 50 percent serve mainly adolescents. Since schools are where most school-aged adolescents spend a signifi- cant portion of their time, school-based health centers appear to be a logical means of improving access, efficiency, and economies of scale in adolescent health services. Significant debate has persisted, however, about the relative merits and disadvantages of a population-based versus a selective high-risk approach to offering primary care services in school-based health centers. As noted in the 1997 IOM report Schools and Health: Our Nation’s In- vestment (Institute of Medicine, 1997), the population-based approach can have a large impact on the population as a whole, but the benefits for selected individuals may be small. Most adolescents in school already have access to and utilize mainstream primary care services. Yet many high-risk adolescents—a significant and growing segment of the population accord- ing to the 1997 IOM study—may be better served by providers in school- based health centers if they lack access to other community health personnel or do not find their local providers to be sensitive to their needs.

CURRENT ADOLESCENT HEALTH SERVICES 153 While no single model exists for school-based health centers, many share certain common characteristics. Centers are located inside the school building or on the school campus. Philip J. Porter, MD, an early architect of school-based health centers, once said, “Health services need to be where students can trip over them. Adolescents do not carry appointment books, and school is the only place where they are required to spend time” (The Center for Health and Health Care in Schools, 1993). In most instances, the centers are sponsored by mainstream health organizations. One study found that hospitals were the leading organizers of school-based health centers, sponsoring 32 percent of the total number. Health departments and federally funded community health centers each sponsored 17 percent, school districts 15 percent, and community-based nonprofit organizations 12 percent (Juszczak et al., 2003). Students receive care in school-based health centers from a multidis- ciplinary team of professionals. Typically, a medical assistant supports a nurse practitioner or physician assistant. More than half of the centers provide mental health services, most frequently through a master’s-level social worker, psychologist, or substance abuse counselor. A part-time pediatrician or family physician may also be part of the staff. A center may have access to part-time professionals as well, including nutritionists, health educators, social services case managers, dentists, dental hygienists, substance abuse counselors, and others, depending on the needs of the students and the resources available in the community (Juszczak, Schlitt, and Moore, 2007). The fundamental reason school-based health centers have drawn sup- port is their capacity to increase access to basic health care for low-income children and adolescents. Data on large numbers of such centers document their acceptability to students and families, as well as their capacity to ad- dress the critical needs of the adolescents they serve (Dryfoos, 1994; Insti- tute of Medicine, 1997). And because the centers can be targeted to schools that enroll large numbers of underserved racial and ethnic minorities, they have the potential to foster equity in access to care and to improve in health outcomes among the most vulnerable populations. Despite this evidence that school-based health centers have moved from the margin to the mainstream, however, two issues—funding and debate about the role and mission of the centers and their place in community health systems—represent a potential constraint on their growth. Funding remains an issue because state governments subject to pay-as- they-go constraints are reluctant to create new programs that require an- nual infusions of large amounts of state funds. The tendency is to hope that programs can be funded through existing public revenues, most commonly Medicaid. The experience thus far has been that patient care revenues are

154 TABLE 3-3  Potential Strengths and Weaknesses of School-Based Health Centers Type of Primary Care Strengths Weaknesses First-contact care Eliminates many barriers to access; reaches Tight budgets restrict hours and days of operation, underserved, low-income, and high-risk resulting in access problems. populations; often is the sole source of care. Continuous care Can serve as “health care homes.” High turnover of personnel prevents long-term relationships between students and staff. Coverage must be arranged during summer, other vacations, evenings, and weekends. Comprehensive care A wide range of essential health services is usually Little research has evaluated the adequacy and quality provided to meet the physical, mental, and social of the apparently wide range of services provided needs of adolescents. against the actual needs of the populations served. The scope of provided services is largely a function of funding. Provider availability may dictate the scope of services offered. Many centers are unable to provide a full range of reproductive health care services on site. Many are not able to employ full-time providers.

Coordinated care Data management and outcome analysis systems Difficulties are faced in coordinating care with other are increasingly being used. Some programs have community providers. Overall, little coordination successfully coordinated services with managed care with managed care organizations occurs. organizations. Community-oriented care Incorporating a community or population Few are able to expand their services beyond the perspective can meet the needs of all children and student population. adolescents, involve the community in planning and governance, and provide an impetus for community needs assessment and resource mapping. Family-centered care Meets health care needs without disrupting Care is usually not provided to the entire family. This everyday family functions. Limited data suggest limits the gathering of family information and the popularity with parents and families. Efforts are development of client management strategies. made to respect both confidentiality and the right of the family to be informed. Creative ways of involving families are being developed. Culturally competent care Provides care for culturally diverse populations. Few data exist to allow assessment of cultural competence. A shortage of adequately trained bilingual or bicultural providers exists. SOURCE: Institute of Medicine (1997), adapted, with permission, from Santelli et al. (1995). The Women’s and Children’s Health Policy Center, The Johns Hopkins Bloomberg School of Public Health, Copyright (1995). 155

156 ADOLESCENT HEALTH SERVICES insufficient to support school-based health centers, and additional core grants are required to sustain quality programs. The other major challenge in developing primary care services for ado- lescents in school-based health centers lies in the relationship between the U.S. health system, which is predominantly private, and the U.S. education system, which is publicly financed through local and state funds. The low levels of financing for school-based health centers restrict their ability to at- tract the necessary providers, and conversely, local providers are frequently not aware of or well integrated into the centers’ system of care. The funda- mental mismatch and lack of engagement between the health and education systems remains a source of persistent concern. Table 3-3, drawn from the above-mentioned IOM report (Institute of Medicine, 1997) and a study by Santelli and colleagues (1995), highlights the strengths and shortcomings of school-based health centers. Summary Safety-net health centers play an important role in addressing the in- equities and shortcomings of mainstream primary care services, especially for more vulnerable populations of uninsured or underinsured adolescents. Hospital-, community-, and school-based health centers provide valuable services for adolescents who have difficulty gaining access to mainstream primary care services or who require additional support in engaging with health care providers. While an extensive literature on the quality of school- based health services for adolescents is available, few studies have exam- ined the quality of hospital- or community-based primary care services for adolescents. Safety-net centers constitute an important community resource within the broader public health and primary care system of each region. Safety-net centers depend largely on public funding rather than fee-for- service reimbursement. Findings: • Evidence shows that safety-net health services for adolescents are: –  accessible to many adolescents who are uninsured or do not find private office-based services acceptable for their needs. –  frequently more acceptable to adolescents who are uncomfort- able with private office-based primary care providers, especially when they can establish relationships with providers who are sensitive to their needs and promote open communication. –  sometimes able to offer a more appropriate mix of skills and counseling services that address risky behaviors.

CURRENT ADOLESCENT HEALTH SERVICES 157 –  able to provide effective disease prevention and health promo- tion services while also addressing issues related to risky behav- ior. However, such centers often can become unstable during times of fiscal uncertainty and may experience frequent person- nel transitions. They also face unique challenges associated with financing of prevention and health promotion services that can- not be reimbursed. –  important mechanisms for resolving the disparities and inequi- ties that exist within private office-based primary care. SPECIALITY CARE SERVICES The preceding section reviewed knowledge of and experience with an array of programs and centers that offer primary care services for ado- lescents. This section focuses on specialty services in the areas of mental health, sexual and reproductive health, oral health, and substance use treatment and prevention. While some of these specialty services may be integrated into comprehensive primary care programs, they are more fre- quently located in separate sites and systems, which makes it difficult to blend them with primary care. Mental Health As noted in Chapter 2, mental disorders are common among adolescents and may impose a tremendous health burden for this population. Emo- tional and behavioral symptoms often co-occur with other health problems seen in the health system and in the juvenile justice and foster care systems (see Chapter 2). Traditionally, the mental health sector has been responsible for treatment of adolescents with mental disorders. This sector comprises a diverse workforce of psychiatrists, psychologists, social workers, and other, lesser-trained individuals organized into loose networks of providers. The reimbursement system for mental health services has traditionally focused on the severely and persistently mentally ill, and has limited capacity to address emerging mental illness and adolescents who are functioning but not healthy. In case studies in four major cities, mental health providers reported that insurers rarely covered telephone calls to parents, teachers,   Although an appreciation for the importance of mental disorders in adolescence has emerged over the past two decades, changes made to enhance mental health services for adolescents have been modest at best. For the purposes of this report and brevity, discussion of this subject—which can involve the use of various terms, including “mental health prob- lems,” “mental disorders,” “emotional and behavioral disorders,” “psychosocial problems,” “emotionally disturbed,” “mentally ill,” and the like—is limited to mental disorders and related services.

158 ADOLESCENT HEALTH SERVICES and primary care providers; team conferences; or care coordination. In ad- dition, these mental health providers reported that few insurers accepted diagnostic codes for psychosocial problems not yet considered diagnosable mental disorders (McManus, Shejavali, and Fox, 2003). Treatment for adolescents with mental disorders generally involves the use of psychotropic medication and/or psychotherapy. Effective therapeutic interventions with fewer adverse effects have emerged in both areas over the last two decades. Unfortunately, despite the lack of effectiveness of usual clinical care, most routine community practices fail to incorporate evidence- based therapies for mental health problems into their delivery systems (Weisz, Hawley, and Doss, 2004; Weisz et al., 1995, 2005). In other words, community practices rarely incorporate effective care for mental disorders as assessed through randomized trials; therefore, the benefits of effective therapeutic interventions are not available to the majority of adolescents and families seeking care for mental health problems within their commu- nities. In most communities, effective treatment is also hampered by severe shortages of trained professionals, limited coverage of useful care, and poor coordination among providers from different disciplines (Ben-Dror, 1994; McManus, Shejavali, and Fox, 2003). These factors have contributed to long waiting lists, low levels of satisfaction, and little evidence of effective- ness for routine community mental health services. An analysis of 2003 data from the National Survey of Children’s Health reveals that a significant percentage of adolescents need but fail to receive mental health or counseling services. On a national basis, 36 percent of adolescents aged 12–17 with current behavioral problems that require treatment or counseling do not receive mental health services; this percent- age ranges from 63 percent in Texas to 10 percent in Wyoming (Child and Adolescent Health Measurement Initiative, 2008). Sexual and Reproductive Health The American Medical Association and the American College of Ob- stetricians and Gynecologists, among others, recommend that adolescents receive guidance and counseling on responsible sexual behavior, including abstinence, methods of birth control, and prevention of STIs and HIV in- fection (American Medical Association, 1997; Committee on Adolescent Health and American College of Obstetricians and Gynecologists, 2006). Current guidelines recommend that adolescents who have had sexual inter- course be screened for STIs. According to data from the 2002 National Survey of Family Growth, approximately half (49 percent) of all adolescent girls aged 15–19 had

CURRENT ADOLESCENT HEALTH SERVICES 159 visited a medical provider for reproductive health services in the previous year (Suellentrop, 2006b). This proportion varies according to age and race or ethnicity. As young adolescents mature, their use of reproductive health services increases. Slightly more than one-third (38 percent) of adolescent females aged 15–17 reported receiving reproductive health services in the past year, increasing to 65 percent for those aged 18–19 (Chandra et al., 2005; Suellentrop, 2006b). Non-Hispanic black and non-Hispanic white adolescent females were more likely than Hispanic adolescent females to report the use of reproductive health services in the past year (57 percent, 49 percent, and 41 percent, respectively). Eight of ten sexually experienced adolescent females had visited a provider in the past year for reproductive health services (Suellentrop, 2006b). Female adolescents who had received reproductive health services in the past year reported that they had visited private doctors or managed care providers (55 percent) at around the same rate as clinics (53 percent). Older adolescents (aged 18–19), however, were significantly more likely than younger adolescents (aged 15–17) to report going to a private doctor or managed care organization as opposed to a clinic (Suellentrop, 2006b). A Pap test and birth control were the most commonly reported re- productive health services. Almost three-quarters of adolescent females (71 percent) reported receiving a Pap test in the past year. Hispanic ado- lescent females were much less likely than non-Hispanic black adolescent females and non-Hispanic white adolescent females to have received a Pap test in the past year (55 percent, 80 percent, and 72 percent, respectively) (Suellentrop, 2006b). Approximately two-thirds of adolescent females who had used reproductive health services (64 percent) had received birth con- trol or a prescription for birth control in the past year. Almost half re- ported receiving counseling or information about birth control (Suellentrop, 2006b). Counseling on different methods of birth control is particularly impor- tant for adolescent girls and may be helpful in reducing the proportion of girls who discontinue using their method of contraception. In 2002, almost one-third of sexually experienced adolescent girls indicated that they had ever stopped using a method of contraception, and more than half reported that they had stopped using a method because of side effects (53 percent). A majority of the adolescent girls who reported that they had stopped using a method of contraception were using the pill (Suellentrop, 2006c).   Reproductive health services include family planning services and/or related medical ser- vices. Family planning services include such services as receipt of a birth control method or prescription, a test or checkup for a birth control method, or counseling or information about birth control from a medical provider. Medical services include, for example, a Pap smear, a pelvic exam, counseling, testing or treatment for STIs, or a pregnancy test.

160 ADOLESCENT HEALTH SERVICES Adolescent boys have particularly low rates of use of primary care—1.7 visits annually reported in 2000, compared with 2.2 visits annually for adolescent females (Ma, Wang, and Stafford, 2005). According to the National Survey of Family Growth, almost one-third of adolescent boys reported that they had received no health services in the past year. Among those who had visited a health care provider in the past year, approxi- mately one-quarter had received counseling or advice from their provider about methods of birth control, STIs, or HIV/AIDS. Close to one in five adolescent boys reported that they had visited a family planning clinic for health services. Sexually experienced adolescent boys were more likely than inexperienced adolescent boys to report having visited a family planning clinic (Suellentrop, 2006a). Studies evaluating the effectiveness of clinic services tailored specifically to adolescents have found that clinic interventions can increase adolescents’ use of contraception, reduce rates of adolescent pregnancy, and increase adolescents’ knowledge about sexual and other reproductive health issues (Burlew and Philliber, 2007). In 1995, approximately two-thirds of all fam- ily planning agencies (such as Planned Parenthood) are estimated to have provided one service specifically tailored to adolescents (Frost and Bolzan, 1997). Such tailoring usually involves offering longer appointment times, having specific counseling appointments, offering a variety of support ser- vices, or spreading a visit over two appointments (the first for counseling and the second for a pelvic exam). The convenience of a clinic in terms of location, hours of operation, types of services offered, and costs also affects its use by adolescents. Research suggests that adolescents are more inclined to rely on clinics when they offer a wide range of services in addition to family planning, when the services are provided at little or no cost, and when confidentiality is ensured. In a recent study, 59 percent of adolescent girls (under age 18) who were attending a Planned Parenthood clinic indi- cated that they would refuse family planning services and delay STI testing and treatment if their parents were notified that they were being prescribed oral contraceptives (Reddy, Fleming, and Swain, 2002). (See the section on confidentiality and privacy later in this chapter.) Active outreach strategies are also important to draw adolescent clients to a clinic and ensure that the right services are being offered. Such strate- gies include forming partnerships with other organizations in the commu- nity, maintaining a presence at community events, and inviting adolescents to refer their peers to the clinic. Clinic personnel, especially those interested in and dedicated to working with adolescents, can also influence the clinic’s success (Burlew and Philliber, 2007).

CURRENT ADOLESCENT HEALTH SERVICES 161 Oral Health Dentistry has significantly different characteristics from medicine that directly influence the quantity, quality, accessibility, and affordability of dental services for adolescents. Service characteristics associated with oral health also result in environmental constraints that impede coordination of care with other basic medical and developmental health services; foster varying systems of professional education and training, financing, staffing, service delivery, accreditation, licensure, and professional governance; and contribute to differing involvement in government health programs and sometimes profound differences in professional culture, mores, and norms. As a result, observations and recommendations based on the medical pro- fessions typically cannot easily be extrapolated to dental services. Dental services are used with approximately the same frequency as medical services among adolescents (see Table 3-4). Orthodontic and aes- thetic concerns generate dental visits, and dental pathologies are both com- mon and often symptomatic among adolescents. This frequent contact gives dentists both opportunities and responsibilities to engage their adolescent patients in promoting salutary health behaviors, to detect eating disorders and risky behaviors, and to identify health conditions that require refer- ral. Despite the frequency with which adolescents visit dentists, however, the dental profession and its pediatric specialty have until recently focused relatively little on adolescence beyond orthodontic issues. While 80 percent of adolescents’ parents report that they obtained a dental visit in a year on the National Health and Nutrition Examination Survey (NHANES) in Table 3-4, overreporting of dental services is a well- recognized problem that is evidenced by discrepancies between federal surveys (Macek et al., 2002). This may result from the social expectation that all children should receive two preventive dental visits each year, an expectation that is not shared with medical care. Because of its more inten- sive surveillance approach, the Medical Expenditure Panel Survey (MEPS) is regarded as the most reliable national data source on adolescents’ use of dental services. MEPS reports that 53 percent of adolescents ages 6 through 20 received at least one dental visit in the year 2004, virtually unchanged from 51 percent reported in 1996 (Manski and Brown, 2007). A variety of recognized barriers to dental care, including coverage inadequacies, work- force shortages, and adolescents’ failure to use dental services (as occurs with medical services), combine to reduce utilization of dental care among adolescents. The percentages of adolescents who report dental care needs reflect compromised oral health status among the adolescent population: half of those aged 10–19 (53.5 percent) are reportedly in need of dental care (National Institute of Dental and Craniofacial Research, 1994, NHANES III data 1988–1994).

162 ADOLESCENT HEALTH SERVICES TABLE 3-4 Doctor and Dentist Visits by Children and Adolescents (aged 6–17) in Last 12 Months Doctor Visit (%) Dentist Visit (%) Age (years)     6–10 87 82 11–14 85 83 15–17 83 80 Sex     Male 85 81 Female 86 83 Race/Ethnicity     White 89 86 Black 84 79 Hispanic 77 70 Other 82 81 Total 85 82 NOTE: Data from 2005 National Health Interview Survey child sample questionnaire. SOURCE: Reprinted, with permission, from Schuchter and Fairbrother (2008). Copyright (2008) by Cincinnati Children’s Hospital. National surveys reveal higher levels of unmet need among racial and ethnic minorities relative to whites. For children aged 6–18, parents report rates of unmet need that are 1.6 times higher for blacks and 2.1 times higher for Mexican Americans than for whites (Vargas and Ronzio, 2002). Minority status may be confounded by other characteristics of social dis- advantage, such as parental educational attainment. Two to three times more parents with only or less than a high school education (3.0 times and 2.3 times, respectively) than parents with more than a high school educa- tion report that their children aged 6–18 have unmet needs for dental care. Parents of children and adolescents with special health needs also report higher unmet dental needs (Schultz, Shenkin, and Horowitz, 2001). Data compiled by Schuchter and Fairbrother (2008) reveal increases in unmet need for dental care with advancing age, as well as variations by race or ethnicity and gender (see Table 3-5). Unmet need for preventive dental care among children and adolescents who have not seen a dentist in the past year increases steadily by age to one in five adolescents aged 12–17 (Maternal and Child Health Bureau, 2005). Substance Use Treatment and Prevention Studies of referral patterns for alcohol and drug treatment centers indicate that schools infrequently detect substance use disorders among

CURRENT ADOLESCENT HEALTH SERVICES 163 TABLE 3-5 Unmet Dental Needs, Last 12 Months Characteristic Percentage Age (years) 11–14 9 15–17 9 18–21 12 22–24 17 Sex Male 9 Female 12 Race/Ethnicity White 9 Black 11 Hispanic 14 Other 7 NOTE: Data from 2005 National Health Interview Survey. SOURCE: Reprinted, with permission, from Schuchter and Fairbrother (2008). Copyright (2008) by Cincinnati Children’s Hospital. adolescents and make referrals for treatment. In 2004, only 11 percent of admissions to alcohol and drug treatment for adolescents aged 12–17 were due to school referrals (Substance Abuse and Mental Health Services Administration, 2006a). Schools may be more likely to handle drug use by punishing students than to refer them to or provide treatment (McAndrews, 2001). Rates of substance use are particularly high among adolescents who are engaged with certain institutional sectors. For example, in one county in California, Aarons and colleagues (2001) found high proportions of ado- lescents (under age 18) with substance use disorders in the juvenile justice system (62 percent), the mental health system (41 percent), and the foster care system (19 percent). Prevalence rates for older youths aged 18–25 in institutional care are thought to be even higher. The criminal justice system is the major source of referrals for adolescent substance use treatment. In 2004, for example, the criminal justice system accounted for 52 percent of referrals for admission to treatment among adolescents aged 12–17, and the same percentage was reported for older adolescents aged 18–21 (Substance Abuse and Mental Health Services Administration, 2006a). According to data from the National Survey on Drug Use and Health (2003–2004), 6.1 percent of adolescents aged 12–17 needed treatment for alcohol use, and 5.4 percent needed treatment for illicit drug use (Substance Abuse and Mental Health Services Administration, 2006b). Of those ado-

164 ADOLESCENT HEALTH SERVICES lescents who needed treatment for alcohol use, however, only 7.2 percent had received specialty treatment (including inpatient hospitalization, treat- ment in a rehabilitation facility, or treatment in a mental health center) in the past year. The corresponding figure for treatment for illicit drug use was 9.1 percent. Many adolescents, however, do not perceive a need for or seek treat- ment and may not volunteer information about their use of substances un- less they have established a rapport with a health professional or counselor. In the National Survey on Drug Use and Health (2003–2004), among those who were classified as needing treatment but had received no specialty treatment in the past year, only 2.2 percent perceived a need for treatment for alcohol use problems and only 3.5 percent for drug use problems (Sub- stance Abuse and Mental Health Services Administration, 2006b). Similar findings were reported in the Cannabis Youth Treatment Study: 80 percent of adolescents saw no need for treatment (Mensinger et al., 2006). Adoles- cents who experience more negative consequences from their substance use show more motivation to change (Battjes et al., 2003; Breda and Heflinger, 2004). Several studies have identified certain characteristics associated with successful treatment outcomes for adolescents who use substances. These characteristics include severity and comorbidity (Dobkin et al., 1998; Grella and Joshi, 2003; Hser et al., 2001; Rounds-Bryant, Kristiansen, and Hubbard, 1999; Tomlinson, Brown, and Abrantes, 2004) and longer periods of time in treatment (Hser et al., 2001), especially for those with comorbid psychiatric disorders. Recent research suggests that substance use may affect neural systems that are important for reward and for self-regula- tion and inhibition. If adolescents suffer from these substance use–related changes in neural systems, sufficient duration of treatment may be impor- tant for addressing these problems (Kalivas and Volkow, 2005; Leshner, 1997; Volkow and Li, 2005). While duration is important, however, provid- ers frequently have difficulty retaining adolescents in treatment programs. Retention in treatment is predicted by the presence of fewer deviant peers, the absence of emotional problems due to substance use, and a positive assessment of the counselor’s skills on the part of the patient (Battjes et al., 2004). Treatment success is also associated with characteristics of the post-treatment environment, such as not being involved with others who engage in risky behavior (family substance use, peer networks), taking part in support groups (e.g., Alcoholics Anonymous or Narcotics Anonymous), and participating in substance-free leisure activities (Godley et al., 2005). One problem with the delivery of substance use treatment may be a lack of professional training and certification in working with adolescents. As of 2002, for example, no U.S. state had adolescent-specific provider certification for such treatment. And as of 2004, the certification program

CURRENT ADOLESCENT HEALTH SERVICES 165 of the National Association of Alcoholism and Drug Abuse Counselors had no adolescent-specific requirements (McLellen and Meyers, 2004). Another problem is that, despite their availability, appropriate screening instruments and treatment guidelines are not routinely incorporated into substance use treatment programs for adolescents (see the discussion of screening later in this chapter). One study of 144 “highly regarded programs” found that the average program score for these elements was 23.8 out of a possible 45 (Brannigan et al., 2004). The low levels of availability, accessibility, and acceptability of effec- tive treatment services for adolescents with substance use disorders are particularly disturbing in light of evidence demonstrating the effectiveness of such interventions (Brannigan et al., 2004). Positive treatment effects for significant reductions in marijuana use, heavy drinking, and other il- licit drug use have been found for many different types of interventions, including multisystemic therapy, family therapy, contingency management, cognitive-behavioral therapy, 12-step programs, and motivational enhance- ment therapy (Williams, Chang, and the Addiction Centre Research Group, 2000). More time in treatment is associated with better outcomes (Hser et al., 2001). Although a number of treatment approaches are promising (Deas and Thomas, 2001; Liddle and Dakof, 1995; Szapocznik et al., 2006; Waldron and Kaminer, 2004; Winters et al., 2000), studies of the relative effective- ness of a limited number of adolescent substance use treatment programs have been unable to demonstrate that one particular program or approach consistently works better than others (Godley et al., 2004; Morral et al., 2006; White, White, and Dennis, 2004). In the absence of evidence-based studies supporting the choice of any one treatment method, government and professional organizations have identified key principles of effective treatment that can serve as the basis for adolescent treatment strategies (Bukstein et al., 2005; Drug Strategies, 2003; National Institute on Drug Abuse, 1999). Examples of these principles include adapting treatment interventions to individual needs; continuing treatment for an adequate period of time; continuously monitoring for possible drug use; using devel- opmentally appropriate programs; and attending to individuals’ multiple needs, not just their drug use. Positive outcomes for certain treatment strategies generally involve short-term effects, and relapse rates remain high (Winters, 1999). Some forms of relapse may be related to the above-noted structural changes in the brain that involve inhibition and reward centers (Kalivas and Volkow, 2005). Treatment regimens may therefore best be derived from a chronic disease management rather than an acute care model (National Institute on Drug Abuse, 2006; Volkow and Li, 2005). Important lessons for treatment and prevention services for adolescents can be drawn from treatments for

166 ADOLESCENT HEALTH SERVICES diabetes and hypertension in older populations (which involve chronically relapsing and remitting disorders with major challenges of adherence to treatment regimens). At present, aftercare for adolescents with substance use disorders re- mains inadequate, and comorbid mental health problems receive insufficient attention. One review of 53 studies found that fewer than half of adoles- cents discharged from treatment programs (38 percent) remained abstinent from substance use after 6 months, even when aftercare plans were in place (Williams, Chang, and the Addiction Centre Research Group, 2000). Data reported by Godley and colleagues (2007) for some aftercare models, such as “assertive” continuing care (in which the clinician rather than the patient has responsibility for linkage and retention), suggest that these models can improve linkage to aftercare for adolescents who have received residential drug treatment. However, while the authors found that substance use de- creased as expected when these models were employed, the results were not significant (low statistical power, which limited conclusions). A recent (as yet untested) approach is for aftercare programs to implement “adaptive” interventions, which vary in focus and intensity in response to changes in individual needs (McKay, 2006). Summary Evidence-based therapies are available for adolescents in the specialty areas of mental health, sexual and reproductive health, oral health, and substance use treatment and prevention. Yet these interventions are com- monly not integrated into routine health care practices, particularly for those who depend on public financing for their routine care. Many adoles- cents have difficulty gaining access to specialized services because of finan- cial restrictions, shortages of skilled personnel, and the lack of appropriate or convenient settings that are suitable for their stage of development. Adolescents with comorbid conditions (such as mental health, sexual, and substance use conditions) are especially difficult to serve within the current fragmented array of health care services and settings. Findings: •  vidence shows that specialty care services for the adolescent popu- E lation are not accessible to most adolescents. Existing specialty services in the areas of mental health, sexual and reproductive health, oral health, and substance use treatment and prevention are generally insufficient to meet the needs of many adolescents. While evidence-based therapies are available in a number of these areas, they are not integrated into many practice settings.

CURRENT ADOLESCENT HEALTH SERVICES 167 •  ven when specialty services are accessible, many adolescents do E not find them acceptable because of concerns about disclosure of treatment in sensitive areas (such as substance use or sexual health). •  any specialty providers lack appropriate training to address the M needs of adolescent patients, and certification programs for treating adolescents are frequently unavailable in many specialty areas. •  he lack of appropriate specialty services that are suitable for ado- T lescents means that effective treatment is often delayed, care is of limited duration, and services are poorly reimbursed. •  imitations in the quality of or access to specialty services are L especially prevalent among at-risk adolescents in whom problems in the above areas frequently co-occur, contributing to health care inequities and disparities. InPatient Hospital Services for Adolescents Most hospitals in the United States do not have a sufficient volume of adolescent patients to justify the creation of specific inpatient services for this population. During the 1970s and 1980s, many youth advocates called for the creation of adolescent inpatient units. The Society for Adolescent Medicine estimated that there were 40–60 such units in the United States by the mid-1990s (Fisher and Kaufman, 1996; Macfarlane and Blum, 2001). In some cases, however, these units were simply sections within other wards. Although adolescent specialists have consistently advocated for separate adolescent inpatient units in both pediatric and general hospitals as an optimal approach to the delivery of developmentally appropriate health care for this population (Watson, 1998), it is unlikely that this ideal will be realized in response to current trends. More commonly, hospitals rely on a multidisciplinary team approach involving health professionals with interest and expertise in adolescent health to meet the inpatient needs of adolescents. The Society for Ado- lescent Medicine has formulated guidelines for the care of adolescents in hospitals so that those with the greatest expertise in and awareness of developmental issues pertinent to adolescence can be involved with young people’s care (Fisher and Kaufman, 1996). Adolescents aged 13–17 account for 11 percent of all hospital stays by those aged 0–17. Adolescents are a distant second to neonates (less than 1 year of age), who account for 71 percent of hospital stays by children and adolescents (Owens et al., 2003). Adolescent pregnancy is one of the most important reasons for hospi- talizations before age 18, accounting for 3 percent of all pediatric hospital- izations. Adolescent girls (aged 10–17) have the highest rates of obstetrical

168 ADOLESCENT HEALTH SERVICES trauma (e.g., perineal lacerations) during delivery among all females and are 35 percent more likely than older females to experience such trauma without instrument assistance (Owens et al., 2003). Medicaid bears a larger burden of care for pregnant adolescents than private insurance—more than two-thirds of all adolescent admissions for pregnancy or childbirth are billed to state Medicaid programs, while one- fourth are billed to primary insurance—the converse of the distribution of pregnancy expenses for adult women (Owens et al., 2003). While adoles- cent deliveries are more likely to involve diagnoses of early or threatened labor, hypertension complicating pregnancy, and excess amniotic fluid, pregnant adolescents with no health insurance coverage are the least likely to deliver by Caesarian section, a fact that raises questions about the influ- ence of insurance status on the choice of procedures (Owens et al., 2003). Mental health disorders (primarily depression) are one of the ten main reasons for hospitalization among children. By age 13–17, affective dis- orders are the most common cause of hospitalization for conditions not related to pregnancy (Owens et al., 2003). Injuries, including leg injuries, medication poisonings, and head injuries, are also a primary reason for hos- pital stays among those aged 13–17 (Owens et al., 2003). Adolescents from low-income families are more likely to be admitted to the hospital through the emergency department than are adolescents from higher-income areas (Owens et al., 2003). ADOLESCENTS’ USE OF HEALTH SERVICES Understanding the extent to which adolescents report access to and use of health services in various settings is useful in identifying differences between service capacity and utilization rates. Such information can also be helpful in understanding variations in unmet need and the quality of care available to young people. Usual Sources of Medical Care Most adolescents (aged 11–17) have a usual source of medical care—92 percent according to parental reports—while 75 percent of young people aged 18–21 report that they have a usual source of care (Schuchter and Fairbrother, 2008) (see Figure 3-1). This is an important sign of access to health services and is a key indicator to monitor.   Schuchter and Fairbrother (2008) use 2005 National Health Interview Survey (NHIS) data that are based on adolescents aged 18 and over reporting for themselves and parents report- ing for those under age 18. This is the standard methodology for most national household surveys.

CURRENT ADOLESCENT HEALTH SERVICES 169 100 6 8 12 24 80 Proportion 60 More than one 93 91 No usual source 86 40 75 Usual source 20 0 11 –14 15–17 18–21 Average (11–21) Age FIGURE 3-1 Percentage of adolescents with a usual source of care, 2005 National Health Interview Survey. Figure 3-1 NOTE: Percents may not add to 100 because of rounding and small categories of less than 1 percent. Adolescents aged 18 and over answer for themselves; parents answer for those under 18. SOURCE: Reprinted, with permission, from Schuchter and Fairbrother (2008). Copyright (2008) by Cincinnati Children’s Hospital. Adolescents who have a usual source of medical care rely predomi- nantly on a doctor’s office or managed care organization (approximately 77 percent) or a clinic or health center (a little over 20 percent). Privately in- sured adolescents aged 11–17 are more likely than publicly insured adoles- cents to report a doctor’s office or managed care organization as their usual source of care (85 percent versus 66 percent) (see Table 3-6) (Schuchter and Fairbrother, 2008). These rates remain generally consistent as adolescents grow older, as indicated in Figure 3-2. Publicly insured adolescents are more likely than their privately insured counterparts to name a clinic or health center as their usual source of medical care (30 percent versus 14 percent) (Schuchter and Fairbrother, 2008). Low reimbursement rates in public insurance programs (Medicaid and SCHIP) may cause many providers to limit the number of publicly insured patients they see, contributing to these disparities (Cunningham and Nichols, 2005; Tang, Yudkowsky, and Davis, 2003). A very small proportion of adolescents report nontraditional sites, such as school-based health centers, hospital emergency departments, or family planning centers, as their usual source of

170 ADOLESCENT HEALTH SERVICES TABLE 3-6  Usual Source of Care (%), by Age and Insurance Type, 2005 National Health Interview Survey Age (years) Insurance Source of Average Type Care 11–14 15–17 18–21 (11–21) Private Doctor’s office or 85 85 80 83 HMO Clinic or health 14 14 17 15 center Public Doctor’s office or 64 68 62 65 HMO Clinic or health 32 28 32 31 center NOTE: HMO = health maintenance organization. SOURCE: Reprinted, with permission, from Schuchter and Fairbrother (2008). Copyright (2008) by Cincinnati Children’s Hospital. 100 90 21 20 21 23 80 70 More than one Some other place Proportion 60 Hospital ED 50 Hospital OPD 40 76 78 75 71 Clinic or health center 30 Doctor’s office or HMO 20 10 0 11–14 15–17 18–21 Average (11–21) Age FIGURE 3-2 Usual source of care for adolescents (%), by age and setting, 2005 National Health Interview Survey. NOTES: ED = Emergency Department, HMO = health maintenance organization, OPD = Outpatient Departments. Those aged 18 and over answer for themselves; Figure 3-2 parents answer for those under 18. Respondents are not asked about well-child checkups after age 17. SOURCE: Reprinted, with permission, from Schuchter and Fairbrother (2008). Copyright (2008) by Cincinnati Children’s Hospital.

CURRENT ADOLESCENT HEALTH SERVICES 171 medical care (about 1 percent in each category) (Schuchter and Fairbrother, 2008). Almost half of uninsured adolescents (aged 10–17) have at least one unmet health service need (MacKay and Duran, 2007). Those with special health conditions, such as chronic illnesses or acute injuries, may have frequent encounters with health professionals. The usual source of care for these adolescents may not embody all aspects of a medi- cal home; for example, a recent analysis from the Child and Adolescent Health Measurement Initiative 2005–2006 found that fewer than half of adolescents with special health needs experienced all facets of a medical home (Maternal and Child Health Bureau, 2008). Visits with Health Care Providers While the majority of adolescents visit a health care provider during the course of a year, the proportion decreases with age, especially in later adolescence as young people move into young adulthood. The sharpest decrease occurs at age 18, as adolescents age out of public insurance. Sig- nificant differences in utilization rates are also seen by gender. In 2005, according to the NHIS, 83 percent of adolescents aged 10–19 reported having seen a doctor or other health care provider in the past year (MacKay and Duran, 2007). Males aged 18–19 were much less likely to have made a recent health visit than their younger counterparts; in contrast, health care utilization was much more consistent across the adolescent and young adult age spectrum for females. More than 34 percent of males aged 18–19 reported not having a health care visit in the past 12 months compared with 16 percent of females in the same age group (MacKay and Duran, 2007). Especially noteworthy are adolescents’ reported high rates of use of hospital emergency departments for routine as well as emergency care, rates that increase with age among both male and female adolescents. Adoles- cents frequently rely on emergency departments for both urgent and nonur- gent health conditions, and their rates of utilization for routine, nonurgent health services in emergency settings are higher than those of any other age group (Nawar, Niska, and Xu, 2007). Summary Most adolescents have a usual source of medical care and see a health care provider annually. The types of settings where adolescents receive health services vary with their insurance plans: those with private insurance are more likely to receive health services in a private provider’s or man- aged care office, while adolescents with public insurance are more likely to see providers in a local clinic or health center. A very small proportion of

172 ADOLESCENT HEALTH SERVICES adolescents report nontraditional sites, such as school-based health centers, hospital emergency departments, or family planning centers, as their usual source of care (about 1 percent in each category). As adolescent males grow older, their annual visits to health care providers decline significantly. The sharpest decrease occurs at age 18, a time when many adolescents age out of insurance, both public and private. Older adolescent females show much less of a decline in annual health care visits. MISSED opportunities FOR PREVENTION AND HEALTH PROMOTION AMONG ADOLESCENTS As reviewed in Chapter 2, more than 70 percent of all deaths among adolescents aged 10–19 can be attributed to three causes: unintentional injuries (including motor vehicle crashes), homicides, and suicide (National Center for Injury Prevention and Control, 2007). Furthermore, unhealthful habits and risky behaviors that are initiated in adolescence extend into adult- hood and contribute directly to poor health conditions and significant mor- bidity and mortality in the short and long terms (Kolbe, Kann, and Collins, 1993). In one national survey, for example, 78 percent of adolescents had not eaten five or more servings of fruits and vegetables a day during the week preceding the survey, 33 percent had not participated in a sufficient amount of physical activity, and 14 percent were overweight. Moreover, 22 percent of high school students had smoked cigarettes in the month preced- ing the survey (Grunbaum et al., 2004). There is a need, then, for adolescent health services focused on prevention and health promotion. Current Status of Prevention and Health Promotion Services for Adolescents Standardized screening instruments, structured tools, and professional guidelines are available to address risky adolescent behaviors, as is discussed in more detail in Chapter 4. Despite the availability of these resources, stud- ies have shown that practitioners fail to provide the recommended screen- ing, counseling, and health education services. Health personnel frequently rely on adolescents or their parents to initiate discussions of health concerns that may involve the use of alcohol, tobacco, or other substances; risky sexual practices; or other problematic behaviors. The frequent practice in some domains, such as mental health, is simply to ask whether there are any general areas of concern during annual health maintenance visits or routine physical examinations or to use specific trigger questions around a particular topic (Olson et al., 2001). This lack of communication about high-risk issues may be especially problematic for adolescents who are

CURRENT ADOLESCENT HEALTH SERVICES 173 marginalized or perceive themselves to be socially distant from health care providers, such as those who are LGBT. For example, there are clear differences in the identification and treatment of mental disorders among racial and ethnic groups, and rates of identification are lower for those who perceive greater social distance from their physicians (Cuffe et al., 1995; Strakowski et al., 1995). In a review of preventive care for children and adolescents, Chung and colleagues (2006) found that in most studies, fewer than half of children had received developmental or psychosocial screening, and fewer than half of adolescents had been asked about various health risks or screened for chlamydia. Bethell and colleagues (2001) report that only 18 percent of adolescents aged 14–18 said they had received counseling on risky behavior (such as smoking, use of alcohol or street drugs, sexual/physical abuse, and violence); 23 percent had received preventive screening and counseling on emotional health and relationship issues; and 36 percent had received pre- ventive screening and counseling on sexual activity and STIs. Furthermore, despite the national concern about obesity, only half of adolescents said they had received preventive screening regarding weight, diet, and exercise (Bethell, Klein, and Peck, 2001). Adolescents generally do not receive routine preventive services for substance use, even though the guidelines of national professional orga- nizations, such as the American Academy of Pediatrics, suggest that they should be screened for drug, alcohol, and cigarette use (Institute for Clinical Systems Improvement, 2007; Kulig and Committee on Substance Abuse, 2005). A 1995 survey of pediatricians showed that fewer than 50 percent screened adolescents for substance use (American Academy of Pediatrics and Division of Child Health Research, n.d.). Another survey from 1991– 1996 showed that only a minority of physicians counseled adolescents about smoking (Thorndike et al., 1999). While several studies have found that routine screening is uncommon for adolescents, providers do target counseling to the highest-risk adoles- cents, a finding that indicates a relationship between engagement of adoles- cents in risky behavior and receipt of counseling for that behavior (Bethell, Klein, and Peck, 2001; Fairbrother et al., 2005; Klein and Wilson, 2002). Many at-risk adolescents, however, do not receive counseling. A survey by Klein and Wilson (2002) found that 71 percent of adolescents engaged in one of eight behaviors with potential health risks. Among this at-risk group, 63 percent had not spoken to their doctor about any of these risks. Fairbrother and colleagues (2005) found that approximately one-third of low-income adolescents in New York City who reported having sexual intercourse had not been counseled about STIs. Even more striking, among adolescents reporting symptoms of depression, almost 70 percent had not been counseled about these feelings.

174 ADOLESCENT HEALTH SERVICES There are a number of reasons for the lack of preventive screening and counseling. First, routine screening requires the use of reliable screening instruments and standardized screening measures. Several such instruments are available for primary care settings (e.g., for substance use—Knight et al., 2002, 2003), yet they are absent or infrequently used in many practices that provide adolescent health care. Second, reimbursement for screening and counseling is inadequate (as discussed in Chapter 6). Third, studies demonstrate that some physicians may avoid screening because they regard it as too time-consuming or fear alienating patients. In the case of substance use, physicians may be unaware of positive treatment outcomes or lack information on treatment resources for adolescents (Kulig and Committee on Substance Abuse, 2005; Van Hook et al., 2007). Another barrier to routine screening for risky and unhealthful behav- iors in adolescents may be the lack of training in screening and counseling among health care providers. Research has demonstrated that educational interventions can improve providers’ screening and counseling of adoles- cents. One project, for example, offered training and tools for providers to improve their screening and counseling regarding tobacco, alcohol, and drug use; sexual behavior; and safety. The study found significantly in- creased screening and counseling rates among providers who had received the intervention compared with those who continued to provide their usual standard of care. The average proportion of adolescents screened and counseled increased from 58 percent to 83 percent and from 52 percent to 78 percent, respectively, while no significant increases occurred in the com- parison group during the same period. The authors report that the training appeared to account for most of this increase, with the tools sustaining the effects of the training (Ozer et al., 2005). Yet while significant increases in screening may occur as a result of such training programs, they are often difficult to sustain for the reasons outlined above. In dealing with adolescents’ risky behaviors, health care providers may need to interact with the education, legal, and/or social service sectors. Addressing another level of coordination, one project sought to improve adolescent screening and counseling through a broad community-level ini- tiative involving partnerships among state Medicaid, managed care plans, and community leaders. Increases in screening and counseling for use of tobacco and other substances for Medicaid populations and improved HIV counseling for all populations were reported, although the gains were more modest than those seen with the training intervention described above (Klein et al., 2003). Differences in the prevalence of unhealthful and risky behaviors among different populations of adolescents raise important questions about the extent to which all adolescents should be screened for use of selected substances or unhealthful practices. Given the specificity and sensitivity of

CURRENT ADOLESCENT HEALTH SERVICES 175 many screening instruments, it is necessary to determine whether they are appropriate for use in a general or selected population. Some screening in- struments may produce a high number of false positives or false negatives that would discount their value in many clinical settings. For example, the Centers for Disease Control and Prevention has provided new guidelines (Branson et al., 2006) for all health care providers in various primary care settings regarding routine screening for HIV in adolescents, especially those participating in risky behaviors leading to exposure to HIV. Moreover, some instruments may be more or less appropriate for diverse populations served in primary care settings. While several screening tools are available in many languages and in both audio and printed formats, others are more limited. Understanding the demographics of the primary care panel is criti- cal to any screening process. Summary Health maintenance visits and health supervision are important com- ponents of primary care services for adolescents. As noted earlier in this chapter, most adolescents visit health care providers annually. Yet few pro- viders screen adolescents for risk factors and unhealthful behaviors, and most providers fail to offer services or resources that could help adolescents improve their future health status as young adults. Findings: •  outine screening for risk factors and unhealthful behaviors that R emerge during adolescence is not available or accessible for most adolescents. •  any health care providers who treat adolescents fail to adhere to M recommended prevention guidelines, to screen for appropriate risk factors and unhealthful behaviors that emerge during adolescence, and to provide effective counseling that would reduce risks and foster health promotion. HEALTH DISPARITIES AND RACIAL AND ETHNIC BIASES Research reported in both the adult and pediatric literature (Cooper and Powe, 2004; Flores and Ngui, 2006; Mayberry, Mili, and Ofili, 2000; West et al., 2006) has shown that disparities and biases in the delivery of health services are unwanted realties that deserve priority attention by both private organizations and federal agencies (Kaiser Family Foundation, 2007). The emphasis in this research has been on general access and service delivery; most of the work has focused on adults or the general pediatric

176 ADOLESCENT HEALTH SERVICES population, with little specific attention to the needs of adolescents who are racial or ethnic minorities. Existing Disparities in Adolescent Health Services The 2001 U.S. Surgeon General’s report emphasized adolescent health needs, with particular attention to violence and health care disparities. Other than this report, little attention has been directed toward strategies for reducing health service disparities among adolescents. A review of racial and ethnic disparities and patient safety by Flores and Ngui (2006) focused on mental health among adolescents. The study found that white psychotherapists who were presented with identical case scenarios rated black less likely than white adolescents to display patho- logical behavior and that providers were less distressed by minority youths’ reporting aggressive, deviant behavior or hating their mothers. This study reaffirmed earlier research indicating that black adolescents are underdiag- nosed for depression and other mental health concerns (Adebimpe, 1981; Martin, 1993; Strakowski et al., 2003). In a review of the literature on disparities in emergency department care, Heron, Stettner, and Haley (2006) found that Hispanic and black adolescents presenting with trauma had an increased rate of testing for drugs and alcohol compared with white adolescents (Marcin et al., 2003). The more frequent testing rates could not be clinically justified as there was no difference in the frequency of positive results. This same review docu- mented disparities in the care for Hispanic adolescents who presented to the emergency department for brain injuries (O’Connor and Haley, 2003). The authors found health care disparities for all pediatric age groups in areas including asthma management (Heron, Stettner, and Haley, 2006). Over the last 5 years, there has been an increase in studies examining disparities in health service delivery. In reviewing data from California and New York, Guagliardo and colleagues (2003) found racial and ethnic disparities in the rate of appendix rupture. Compared with white children and adolescents aged 4–18, Hispanic and Asian children and adolescents had higher odds (1.30 [1.14–1.48] and 1.21 [0.92–1.58], respectively) of a rupture in California; in New York, Asian and black adolescents had higher odds (2.09 [1.36–3.21] and 1.44 [1.07–1.95], respectively). The authors conclude that immigrant groups were more at risk for delayed emergency care in these communities as adjustments for other demographic factors did not fully explain the disparities. Disparities have also been reported for a population of adolescents undergoing hemodialysis. A substantial proportion of minority adolescents (averaging age 12) had received inadequate hemodialysis (Leonard et al.,

CURRENT ADOLESCENT HEALTH SERVICES 177 2004). Similarly, these findings could not be explained by such factors as center size, age, or renal diagnosis. In a review of 31 studies that spanned asthma services, mental health care, reproductive health services, and primary care, racial and ethnic dis- parities that could not be explained by socioeconomic status were found in all service areas (Elster et al., 2003). The authors offer four findings: (1) there is less utilization of health services among racial and ethnic minority adolescents, after controlling for insurance status and socioeconomic status; (2) despite the absence of differences in the prevalence of mental disorders among black, Hispanic, and white adolescents, there is less utilization of mental health services among minority adolescents; (3) minority youths re- ceive more reproductive health services than white adolescents; and (4) so- cioeconomic status has a modest impact on health service delivery but does not completely account for the disparities seen. Summary Health disparities and biases are a persistent feature of the health care delivery system for racial and ethnic minority adolescents, although little research has been focused on this particular age group. Disparities have been reported in studies of mental health services and emergency depart- ment care, as well as in research on adolescents who receive hemodialysis and asthma treatment. While social and economic differences account for some of these disparities, researchers have found that these differences alone cannot explain significant variations in rates of utilization of health services and health outcomes. Finding: •  isparities and biases affect the quality of health services for ado- D lescents and deserve serious consideration in any efforts to improve access to appropriate services and reduce inequities in the health system. CONFIDENTIALITY OF HEALTH Services The extent to which visits with health care providers are kept confi- dential between adolescents and their providers can impact adolescents’ utilization of health services. While some young people may be comfortable sharing their health care needs and information with their parents, others may find it embarrassing or fear disapproval or punishment, particularly for health services related to sexual activity, mental health, or substance use. Additionally, there is a body of overlapping and sometimes conflicting stat-

178 ADOLESCENT HEALTH SERVICES utes, court decisions, and regulations that are relevant to adolescent health services. Various studies have examined the role of confidentiality generally in adolescents’ willingness to seek health care and disclose information to health care professionals. This evidence demonstrates that ensuring access to care that is acceptable to adolescents is important in delivering quality health services. Acceptability Various studies have examined the role of confidentiality generally in adolescents’ willingness to seek health care and disclose information to health care professionals. Ford and colleagues (1997) found through a randomized controlled trial that increased assurance of confidentiality produced an increase in adolescents’ willingness to provide information about sexuality, mental health, and substance use (from 39 percent to 46.5 percent). Such candor with health care professionals who are taking a health history is critical to adolescents’ receiving the most appropriate care. Other positive outcomes, such as willingness to make a return visit, were noted as well. These findings are consistent with those of an earlier statewide survey (Cheng et al., 1993) in which substantial numbers of ado- lescents in Massachusetts cited deep concern regarding confidentiality that affected how and when they sought care. Further, studies have examined the impact of limiting confidentiality on adolescents’ use of specific health services, such as those addressing sexual and reproductive health, mental health, and substance use. Sexual and Reproductive Health Services Evidence suggests that adolescents’ willingness to seek sexual and re- productive health services is negatively affected by a lack of confidentiality, and that a variety of health outcomes with potentially adverse conse- quences―including STIs, pregnancy, and abortion―are likely to increase if ac- cess to confidential care is restricted. In one national study of 1,526 female adolescents under age 18 using publicly funded clinics for reproductive health services, 60 percent of respondents reported that a parent knew of their access to these services. A majority said they would continue to use the clinic services even if parental notification were required, but 18 per- cent said they would go to a private physician under those circumstances. One in five said they would use no contraception at all or would rely on withdrawal, while only one out of a hundred said they would simply stop having sex in response (R. K. Jones et al., 2005; note that some respondents gave multiple responses).

CURRENT ADOLESCENT HEALTH SERVICES 179 These findings are broadly consistent with those of similar statewide surveys. For instance, Reddy and colleagues (2002) surveyed adolescents using family planning clinics in Wisconsin and found that 47 percent would stop using all clinic services if parental notification were mandatory for prescription contraceptives; an additional 12 percent said they would delay testing or treatment for HIV or STIs or discontinue use of specific health services. An urban subset was asked about alternative practices; 29 percent indicated these would include unprotected sex and withdrawal. Of interest, parental notification in one area appears to affect how adolescents view a wider range of reproductive health services: many adolescents said they would alter their use of other health services—STI and HIV testing and treatment or pregnancy testing—even if parental notification were required only for birth control. A commentary on this work underscores the dangers to adolescent health indicated by these findings and cites smaller-scale stud- ies that reinforce this concern (Ford and English, 2002). Mental Health Services Most of the studies cited above and in the literature as a whole pertain to sexual and reproductive health, but recent studies suggest that the situa- tion is similar with respect to mental health. One regional study of 878 ado- lescents who reported receiving needed mental health treatment in the past found that 57 percent had foregone treatment at least once. Of these, 36 percent identified confidentiality concerns as a barrier to seeking treatment. Notably, girls and adolescents living with two parents were more likely than others to forego treatment (Samargia, Saewyc, and Elliott, 2006). Wissow and colleagues (2002) discuss the importance of confidentiality for mental health more broadly and review the earlier literature, finding broad consen- sus that confidentiality is crucial in getting adolescents to seek treatment. Substance Use Services One barrier to adolescent engagement with services to prevent sub- stance use is the lack of opportunity for a private visit with a health pro- fessional. Research by Klein and colleagues (1999), for example, indicates that a third of adolescents failed to seek care that they felt they needed because they wanted to hide the visit from their parents. Similar work by Bethell and colleagues (2001) reveals that only half of adolescents had an opportunity for a private visit.

180 ADOLESCENT HEALTH SERVICES Accessibility In addition to the importance of confidentiality to adolescents’ willing- ness to seek health services and disclose information to health care provid- ers, it is necessary to ensure access to these confidential services. Consent The protection of confidentiality cannot be considered outside of the le- gal framework for consent, as it is in the law governing consent to care that difficulty arises in protecting the secrets of adolescents. As the twentieth century progressed, it became clear that there was some role for children in medical decision making, especially for adolescents approaching adulthood. Scholars increasingly argued that medical care decisions were infused with value considerations and that adolescents had strong feelings about these values. Scholars also pointed out the overlapping interests of child, parent, physician, and the state in how these decisions are made (Bennet, 1976). By common law, at least one parent had to consent to medical care for a child under age 18 except in an emergency, when no parent might be avail- able and when it was assumed that the parent would consent if available. In addition to this emergency exception, a doctrine known as the mature minor doctrine was developed by statute and in the courts and became an accepted part of the law in many states (Johnson, 1998–1999). According to this doctrine, an older adolescent may give consent to care when it is exclusively for his or her benefit; it is in the mainstream of medical practice; and the minor has been informed of the risks and benefits, is capable of giving informed consent, and has not been coerced into agreement. By statute, every state has established a right for minors to consent to their own care in a variety of circumstances. The circumstances vary from state to state, but each state has at least some laws that allow minors to consent on the basis of one or more categories of status (mature, emanci- pated, living apart from parents, over a certain age, married, or parenting) and one or more categories of services being sought (general health care, contraception, pregnancy-related care, STI/HIV care, drug and alcohol care, or outpatient mental health services). Although not every state recognizes each of these categories, every state recognizes some. The most commonly recognized and those supported by the American Medical Association are diagnosis and treatment for STIs, contraceptive services, pregnancy-related care (excluding abortion), and counseling or treatment for drug and alcohol problems (American Medical Association, 1997). By constitutional precedent, the right of privacy protects minors’ choices regarding contraception and abortion. With respect to contraception, the U.S. Supreme Court has decided that access to contraception is protected.

CURRENT ADOLESCENT HEALTH SERVICES 181 With respect to abortion, minors must be allowed, at a minimum, to give their own consent for abortion without first involving their parents. The majority of states have enacted statutes requiring parental consent or no- tification, but creating a judicial bypass procedure that allows minors to make their own decision if they are mature and to receive an abortion with court approval and without parental involvement if it would be in their best interest. Thus, through a combination of common-law decisions, statutory en- actments, and constitutional precedents, the legal framework for health care consent developed over the past half-century has authorized adolescents who are minors to give their own consent for health care in a wide variety of circumstances. This framework not only is consistent with ethical prin- ciples applicable to consent for medical care, but also is the foundation for confidentiality protections in adolescent health services (English, 1999). Confidentiality Legal protections of confidentiality in adolescent health services derive from numerous sources in federal and state law, including evidentiary privi- leges, funding statutes, medical privacy and medical records laws, minor consent laws, and the constitutional right of privacy. It is also important to recognize that a host of nongovernmental institutions, especially univer- sities, have their own regulations that may involve parental notification, especially with respect to substance use and mental health. Universities responding to lawsuits increasingly notify parents or even expel students facing such problems (Bombardieri, 2006; Kinzie, 2006). Federal-level provisions  At the federal level, there are (1) specific programs that fund health services incorporating confidentiality provisions that pro- tect adolescents, and (2) general privacy regulations that affect adolescents. The major federal funding programs at issue are Medicaid and the Title X clinics funded under the Public Health Service Act, both of which provide for minors’ receipt of confidential family planning services (“without regard to age” in the case of Title X, 42 Code of Federal Regulations § 59.5). Other programs, such as SCHIP, either defer largely to states or, like the Maternal and Child Health Block Grant, simply are less explicit in their requirements for confidentiality protection for adolescents (Dailard and Turner Richardson, 2005; English and Morreale, 2001; Jones and Boonstra, 2004). Also at the federal level, the Privacy Rule of the Health Insurance Portability and Accountability Act includes general regulatory require- ments governing the disclosure of private health information, including information pertaining to minors. The rule generally provides a “floor” of

182 ADOLESCENT HEALTH SERVICES privacy protection, which states may choose to exceed. On the question of parents’ access to the private information of minors, however, the rule de- fers to “state or other applicable law.” Although the rule does create some new rights for adolescents to control the release of personal information, it is deferential to other authorities on the question of parental access to information. Thus, if state or other law prohibits disclosure of information to parents without the permission of the adolescent minor, the information may not be disclosed; if state or other law requires disclosure, the informa- tion must be disclosed; and if state or other law permits disclosure or is silent on the issue, the health care provider has the discretion to disclose or not (English and Ford, 2004). The situation is similar with respect to substance use treatment: the federal government has not established its own consent and confidentiality guidelines in that domain, but has added its regulatory weight to existing state frameworks (English and Kenney, 2003). State-level provisions  At the state level, there is broad variation with re- spect to the degree of confidentiality protection accorded adolescents, as recently reviewed by Fox and Limb (2008). Often, confidentiality protec- tions track the circumstances in which minors are authorized to consent to their own care, granting them a correlative right to control disclosure of the information. Sometimes, however, states are silent on the question of confidentiality or explicitly permit, without requiring, health professionals to disclose information to parents; often when they do so, states articulate criteria related to the minor’s health for how that discretion should be exer- cised. Except with respect to abortion, it is rare for states to mandate disclo- sure to parents, especially when the minor has the right to consent. When physicians or other health professionals are granted discretion to disclose, the exercise of that discretion should be guided by sound ethical principles and the overriding importance of the adolescent’s health and safety. Some of the laws and regulations concerning adolescents’ access to confidential care have been intensely contested at both the federal and state levels, in both legislatures and courts (for specific examples, see Arons, 2000; English and Morreale, 2001; Jones and Boonstra, 2004). Proposed legislative changes are often aimed at requiring parental consent and/or notification for such services as abortion, contraception, treatment for sub- stance use, or even diagnosis and treatment for STIs, but sometimes they are aimed at requiring notification of sexual activity by minors in general (Rudoren, 2006). Numerous national organizations advocate for increased parental involvement and restrictions on confidential access. In summary, as others have pointed out, the body of overlapping and sometimes conflicting statutes, court decisions, and regulations that are rel- evant to adolescent health services is extremely heterogeneous and is subject

CURRENT ADOLESCENT HEALTH SERVICES 183 to ongoing change (U.S. Congress and Office of Technology Assessment, 1991). Nevertheless, the overall trend, with the exception of abortion, has been to protect the confidentiality of adolescents’ health information when they are legally allowed to consent to their own care. When exceptions are made, such as to grant health professionals discretion to disclose informa- tion to parents even when the minor has consented to the care and objects to disclosure, they are usually grounded in the importance of protecting the health of adolescents or others. Findings: •  vidence shows that health services that are confidential increase E the acceptability of services and the willingness of adolescents to seek them, especially for issues related to sexual behavior, repro- ductive health, mental health, and substance use. •  xisting state and federal policies generally protect the confiden- E tiality of adolescents’ health information when they are legally allowed to consent to their own care. SUMMARY This chapter has presented a review of current health services for adolescents and the settings where those services are typically received, with a focus on both the array of mainstream and safety-net primary care services and specialty services. It has also proposed the five objectives of accessibility, acceptability, appropriateness, effectiveness, and equity as a valuable framework for assessing health services and health care models that serve adolescents. Available evidence shows that health services for all adolescents, including those who are particularly vulnerable because of their demographic characteristics or other circumstances, do not reliably and consistently meet these objectives. Evidence also shows the lack of a system that provides coordinated health promotion, disease prevention, and behavioral health services for adolescents—all important elements for ap- propriately and effectively addressing the adolescent health needs discussed in Chapter 2. REFERENCES Aarons, G., Brown, S., Hough, G., Garland, A., and Wood, P. (2001). Prevalence of adolescent substance use disorders across five sectors of care. Journal of American Academy of Child and Adolescent Psychiatry, 40, 419–426. Adebimpe, V. R. (1981). Overview: White norms and psychiatric diagnosis of black patients. American Journal of Psychiatry, 138, 279–285.

184 ADOLESCENT HEALTH SERVICES American Academy of Pediatrics and Division of Child Health Research. (n.d.). Periodic Survey of Fellows (No. 31). Available: www.aap.org/research/periodicsurvey/ps31a.htm [January 22, 2008]. American Medical Association. (1997). Guidelines for Adolescent Preventive Services (GAPS), Recommendations Monograph. Chicago, IL: American Medical Association. Anderson, M. E., Freas, M. R., Wallace, A. S., Kempe, A., Gelfand, E. W., and Liu, A. H. (2004). Successful school-based intervention for inner-city children with persistent asthma. Journal of Asthma, 41, 445–453. Armbruster, P., and Lichtman, J. (1999). Are school based mental health services effective? Evidence from 36 inner city schools. Community Mental Health Journal, 35, 493–504. Arons, J. R. (2000). Misconceived laws: The irrationality of parental involvement require- ments for contraception. William and Mary Law Review, 41, 1093–1131. Barnet, B., Duggan, A. K., and Devoe, M. (2003). Reduced low birth weight for teenagers re- ceiving prenatal care at a school-based health center: Effect of access and comprehensive care. Journal of Adolescent Health, 33, 349–358. Battjes, R. J., Gordon, M. S., O’Grady, K. E., Kinlock, T. W., and Carswell, M. A. (2003). Factors that predict adolescent motivation for substance abuse treatment. Journal of Substance Abuse Treatment, 24, 221–232. Battjes, R. J., Gordon, M. S., O’Grady, K. E., and Kinlock, T. W. (2004). Predicting retention of adolescents in substance abuse treatment. Addictive Behaviors, 29, 1021–1027. Ben-Dror, R. (1994). Employee turnover in community mental health organization: A devel- opmental stages study. Community Mental Health Journal, 30, 243–257. Bennet, R. (1976). Allocation of child medical care decision-making authority: A suggested interest analysis. Virginia Law Review, 62, 285–330. Bethell, C., Klein, J., and Peck, C. (2001). Assessing health system provision of adolescent preventive services: The Young Adult Health Care Survey. Medical Care, 39, 478–490. Bombardieri, M. (2006). Parents strike settlement with MIT in death of daughter. The Bos- ton Globe, April 4. Available: http://www.boston.com/news/local/articles/2006/04/04/ parents_strike_settlement_with_mit_in_death_of_daughter [July 22, 2006]. Brabin, L. (2002). Adolescent Friendly Health Services: An Impact Model to Evaluate Their Effectiveness and Cost. Geneva: World Health Organization. Brannigan, R., Schackman, B. R., Falco, M., and Millman, R. B. (2004). The quality of highly regarded adolescent substance abuse treatment programs: Results of an in-depth national survey. Archives of Pediatrics and Adolescent Medicine, 158, 904–909. Branson, B. M., Handsfield, H. H., Lampe, M. A., Janssen, R. S., Taylor, A. W., Lyss, S. B., and Clark, J. E. (2006). Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. Morbidity and Mortality Weekly Reviews: Recommendations and Reports, 55(RR14), 1–17. Breda, C., and Heflinger, C. (2004). Predicting incentives to change among adolescents with substance abuse disorder. American Journal of Drug and Alcohol Abuse, 30, 251–267. Brindis, C. D., Klein, J., Schlitt, J., Santelli, J., Juszczak, L., and Nystrom, R. J. (2003). School- based health centers: Accessibility and accountability. Journal of Adolescent Health, 32, 98–107. Britto, M. T., Klostermann, B. K., Bonny, A. E., Altum, S. A., and Hornung, R. W. (2001). Impact of a school-based intervention on access to health care for underserved youth. Journal of Adolescent Health, 29, 116–124. Bukstein, O., Bernet, W., Arnold, V., Breitchman, J., Shaw, J., Benson, S., Kinlan, J., McCellan, J., Stock, S., Ptakowski, K., and the Work Group of Quality Issues. (2005). AACAP official action. Practice parameters for the assessment and treatment of children and adolescents with substance use disorders. Journal of the American Academy of Child and Adolescent Psychiatry, 44, 609–621.

CURRENT ADOLESCENT HEALTH SERVICES 185 Burke, P. J., O’Sullivan, J., and Vaughan, B. L. (2005). Adolescent substance use: Brief inter- ventions by emergency care providers. Pediatric Emergency Care, 21, 770–776. Burlew, R., and Philliber, S. (2007). What Helps in Providing Contraceptive Services for Teens. Washington, DC: The National Campaign. The Center for Health and Health Care in Schools. (1993). The Answer Is at School: Bringing Health Care to Our Students. Washington, DC: The George Washington University. Center for Reproductive Health Research Policy. (n.d.). Adolescent Sexuality and Repro- ductive Health. Available: http://reprohealth.ucsf.edu/research/researchareas/as_and_ rh.html#IIID [October 10, 2007]. Chandra, A., Martinez, G. M., Mosher, W. D., Abma, J. C., and Jones, J. (2005). Fertility, family planning, and reproductive health of U.S. women: Data from the 2002 National Survey of Family Growth. National Center for Health Statistics. Vital Health and Sta- tistics, 23(25). Chatterji, P., Caffray, C. M., Crowe, M., Freeman, L., and Jensen, P. (2004). Cost assessment of a school-based mental health screening and treatment program in New York City. Mental Health Services Research, 6, 155–166. Cheng, T. L., Savageau, J. A., Sattler, A. L., and DeWitt, T. G. (1993). Confidentiality in health care: A survey of knowledge, perceptions, and attitudes among high school students. Journal of the American Medical Association, 269, 1404–1407. Child and Adolescent Health Measurement Initiative. (2008). 2003 National Survey of Chil- dren’s Health: Health Care Access and Utilization Indicator 4.5. Available: http://www. nschdata.org/ [May 1, 2008]. Chung, P. J., Lee, T. C., Morrison, J. L., and Schuster, M. A. (2006). Preventive care for children in the United States: Quality and barriers. Annual Review of Public Health, 27, 491–515. Committee on Adolescent Health and American College of Obstetricians and Gynecologists. (2006). ACOG Committee Opinion No. 335. The initial reproductive health visit. Ob- stetrics and Gynecology, 107, 1215–1219. Cooper, L. A., and Powe, N. R. (2004). Disparities in Patient Experiences, Health Care Processes, and Outcomes: The Role of Patient-Provider Racial, Ethnic, and Language Concordance. New York: The Commonwealth Fund. Crespo, R. D., and Shaler, G. A. (2000). Assessment of school-based health centers in a rural state: The West Virginia experience. Journal of Adolescent Health, 26, 187–193. Cuffe, S. P., Waller, J. L., Cuccaro, M. L., Pumariega, A. J., and Garrison, C. Z. (1995). Race and gender differences in the treatment of psychiatric disorders in young adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 34, 1536–1543. Culligan, V. (2002). Connecticut Association of School Based Health Centers. Patient Satisfac- tion Survey Summary. North Haven: Connecticut Association of School-Based Health Centers. Cunningham, P. J., and Nichols, L. M. (2005). The effects of Medicaid reimbursement on the access to care of Medicaid enrollees: A community perspective. Medical Care Research and Review, 62, 676–696. Dailard, C., and Turner Richardson, C. (2005). Teenagers’ access to confidential reproductive health services. Guttmacher Report on Public Policy, 8, 6–11. Deas, D., and Thomas, S. E. (2001). An overview of controlled studies of adolescent substance abuse treatment. American Journal of Addiction, 10, 178–189. Diaz-Perez Mde, J., Farley, T., and Cabanis, C. M. (2004). A program to improve access to health care among Mexican immigrants in rural Colorado. Journal of Rural Health, 20, 258–264. Dobkin, P. L., Chabot, L., Maliantovitch, K., and Craig, W. (1998). Predictors of outcome in drug treatment of adolescent inpatients. Psychological Reports, 83, 175–186.

186 ADOLESCENT HEALTH SERVICES Donovan, C., Mellanby, A., Jacobson, L., Taylor, B., and Tripp, J. (1997). Teenagers’ views on the general practice consultation and provision of contraception. British Journal of General Practice, 47, 715–718. Dougherty, D. (2007). Adolescent Research: Effectiveness, Quality and Costs of Community- and School-based Health Programs/Settings. Presentation at the Research Workshop on Adolescent Health Care Services and Systems, January 22, Washington, DC. Drug Strategies. (2003). Treating Teens: A Guide to Adolescent Drug Programs. Washington, DC: Drug Strategies. Dryfoos, J. (1994). Medical clinics in junior high school: Changing the model to meet de- mands. Journal of Adolescent Health, 15, 549–557. Ellen, J. M., Franzgrote, M., Irwin, C. E., Jr., and Millstein, S. G. (1998). Primary care phy- sicians’ screening of adolescent patients: A survey of California physicians. Journal of Adolescent Health, 22, 433–438. Elster, A., Jarosik, J., VanGeest, J., and Fleming, M. (2003). Racial and ethnic disparities in health care for adolescents: A systematic review of the literature. Archives of Pediatric and Adolescent Medicine, 157, 867–874. English, A. (1999). Health care for the adolescent alone: A legal landscape. In J. Blustein, C. Levine, and N. N. Dubler (Eds.), The Adolescent Alone: Decision Making in Health Care in the United States (pp. 78–99). Cambridge, UK: Cambridge University Press. English, A., and Ford, C. A. (2004). The HIPAA privacy rule and adolescents: Legal questions and clinical challenges. Perspectives on Sexual and Reproductive Health, 36, 80–86. English, A., and Kenny, K. (2003). State Minor Consent Laws: A Summary (2nd Ed.). Chapel Hill, NC: Center for Adolescent Health and the Law. English, A., and Morreale, M. (2001). A legal and policy framework for adolescent health care: Past, present, and future. Houston Journal of Health Law and Policy, 1, 63–108. Fairbrother, G., Scheinmann, R., Osthimer, B. J. D., Dutton, M. J., Newell, K. A., Fuld, J., and Klein, J. D. (2005). Factors that influence adolescent reports of counseling by physicians ������������������������������������������������������������������������������ on risky behavior. Journal of Adolescent Health, 37, 467–476. Fisher, M., and Kaufman, M. (1996). Adolescent inpatient units: A position statement of the Society for Adolescent Medicine. Journal of Adolescent Health, 18, 307–308. Flores, G., and Ngui, E. (2006). Racial/ethnic disparities and patient safety. Pediatric Clinics of North America, 53, 1197–1215. Ford, C. A., and English, A. (2002). Limiting confidentiality of adolescent health services: What are the risks? Journal of the American Medical Association, 288, 752–753. Ford, C., Millstein, S., Halpern-Felsher, B., and Irwin, C. E. (1997). Influence of physician confidentiality assurances on adolescents’ willingness to disclose information and seek future health care: A randomized control trial. Journal of the American Medical Associa- tion, 278, 1029–1034. Fox, H. B., and Limb, S. J. (2008). State Policies Affecting the Assurance of Confidential Care for Adolescents (Fact Sheet No. 5). Washington, DC: Incenter Strategies. Fox, H. B., McManus, M. A., and Reichman, M. B. (2003). Private health insurance for ado- lescents: Is it adequate? Journal of Adolescent Health, 32(6), 12–24. Fox, H. B., Limb, S. J., and McManus, M. A. (2007). Preliminary Thoughts on Restructuring Medicaid to Promote Adolescent Health (Issue Brief No. 1). Washington, DC: Incenter Strategies. Frost, J., and Bolzan, M. (1997). The provision of public-sector services by family planning agencies in 1995. Family Planning Perspectives, 29, 6–14. Gance-Cleveland, B., Costin, D. K., and Degenstein, J. A. K. (2003). School-based health centers. Statewide quality improvement program. Journal of Nursing Care Quality, 18, 288–294.

CURRENT ADOLESCENT HEALTH SERVICES 187 Ginsburg, K., Slap, G., Avital, C., Forke, C., Balsley, C., and Rouselle, D. (1995). Adolescents’ perceptions of factors affecting their decisions to seek health care. Journal of the Ameri- can Medical Association, 273, 1913–1918. Godley, S. H., Jones, N., Funk, R., Ives, M., and Passetti, L. L. (2004). Comparing outcomes of best-practice and research-based outpatient treatment protocols for adolescents. Journal of Psychoactive Drugs, 36, 35–48. Godley, M. D., Kahn, J. H., Dennis, M. L., Godley, S. H., and Funk, R. R. (2005). The stabil- ity and impact of environmental factors on substance use and problems after adolescent outpatient treatment for cannabis abuse or dependence. Psychology of Addictive Behav- iors, 19, 62–70. Godley, M. D., Godley, S. H., Dennis, M. L., Funk, R. R., and Passetti, L. L. (2007). The effect of assertive continuing care on continuing care linkage, adherence, and abstinence following residential treatment for adolescents with substance use disorders. Addiction, 102, 81–93. Grella, C. E., and Joshi, V. (2003). Treatment processes and outcomes among adolescents with a history of abuse who are in drug treatment. Child Maltreatment, 8, 7–18. Grunbaum, J. A., Kann, L., Kinchen, S., Ross, J., Hawkins, J., Lowry, R., Harris, W. A., McManus, T., Chyen, D., and Collins, J. (2004). Youth risk behavior surveillance— United States, 2003. Morbidity and Mortality Weekly Report. Surveillance Summaries, 53, 1–96. Guagliardo, M. F., Teach, S. J., Huang, Z. J., Chamberlain, J. M., and Joseph, J. G. (2003). Racial and ethnic disparities in pediatric appendicitis rupture rate. Academy of Emer- gency Medicine, 10, 1218–1227. Guo, J. J., Jang, R., Keller, K. N., McCracken, A. L., Pan, W., and Cluxton, R. J. (2005). Impact of school-based health centers on children with asthma. Journal of Adolescent Health, 37, 266–274. Halpern-Felsher, B. L., Ozer, E. M., Millstein, S. G., Wibbelsman, C. J., Fuster, C. D., Elster, A. B., and Irwin, C. E., Jr. (2000). Preventive services in a health maintenance organi- zation: How well do pediatricians screen and educate adolescent patients? Archives of Pediatric and Adolescent Medicine, 154, 173–179. Heron, S. L., Stettner, E., and Haley, L. L. (2006). Racial and ethnic disparities in the emer- gency department: A public health perspective. Emergency Medicine Clinics of North America, 24, 905–923. Hoffman, J. (2007). Treating the awkward years. The New York Times, p. F1, April 24. Hser, Y. I., Grella, C. E., Hubbard, R. L., Hseieh, S. C., Fletcher, B. W., Brown, B. S., and Anglin, M. D. (2001). An evaluation of drug treatments for adolescents in 4 US cities. Archives of General Psychiatry, 58, 689–695. Institute for Clinical Systems Improvement. (2007). Health Care Guideline: Preventive Ser- vices for Children and Adolescents. Bloomington, MN: Institute for Clinical Systems Improvement. Institute of Medicine. (1997). Schools and Health: Our Nation’s Investment. Washington, DC: National Academy Press. Institute of Medicine. (2000). America’s Health Care Safety Net: Intact but Endangered. Washington, DC: National Academy Press. Institute of Medicine. (2001). Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press. Institute of Medicine. (2003). The Future of the Public’s Health in the 21st Century. Wash- ington, DC: The National Academies Press. Johnson, P. (1998–1999). Refusal of treatment by children and the mature minor doctrine. Quality of Care Newsletter, 74(Fall–Winter). Available: http://www.cqcapd.state.ny.us/ newsletter/74cclong.htm [May 29, 2008].

188 ADOLESCENT HEALTH SERVICES Jones, C. A., Clement, L. T., Hanley-Lopez, J., Morphew, T., Kwong, K. Y., Lifson, F., Opas, L., and Guterman, J. J. (2005). The Breathmobile Program: Structure, implementation, and evolution of a large-scale, urban, pediatric asthma disease management program. Disease Management, 8, 205–222. Jones, R. K., and Boonstra, H. (2004). Confidential reproductive health services for minors: The potential impact of mandated parental involvement for contraception. Perspectives on Sexual and Reproductive Health, 36, 182–191. Jones, R. K., Purcell, A., Singh, S., and Finer, L. B. (2005). Adolescents’ reports of parental knowledge of adolescents’ use of sexual health services and their reactions to mandated parental notification for prescription contraception. Journal of the American Medical Association, 293, 340–348. Juszczak, L., Schlitt, J., Odium, M., Baragon, C., and Washington, D. (2003). School-Based Health Centers National Census School Year 2001–2002. Washington, DC: National As- sembly on School-Based Health Care. Available: http://www.nasbhc.org/atf/cf/{CD9949F2- 2761-42FB-BC7A-CEE165C701D9}/EQ_2001census.pdf [January 9, 2008]. Juszczak, L., Schlitt, J., and Moore, A. (2007). School-Based Health Centers. National Cen- sus School Year 2004–2005. Washington, DC: National Assembly on School-Based Health Care. Available: http://www.nasbhc.org/atf/cf/%7BCD9949F2-2761-42FB-BC7A- CEE165C701D9%7D/Census2005.pdf [October 11, 2007]. Kaiser Family Foundation. (2007). Key Facts: Race, Ethnicity, and Medical Care. Menlo Park, CA: Kaiser Family Foundation. Kalafat, J., and Illback, R. J. (1998). A qualitative evaluation of school-based family resource and youth service centers. American Journal of Community Psychology, 26, 573–604. Kalivas, P. W., and Volkow, N. D. (2005). The neural basis of addiction: A pathology of mo- tivation and choice. American Journal of Psychiatry, 162, 1403–1413. Kang, M., Bernard, D., Booth, M., Quine, S., Alperstein, G., Usherwood, T., and Bennett, D. (2003). Access to primary health care for Australian young people: Service provider perspectives. British Journal of General Practice, 53, 947–952. Key, J. D., Washington, E. C., and Hulsey, T. C. (2002). Reduced emergency department utilization associated with school-based clinic enrollment. Journal of Adolescent Health, 30, 273–278. Kinzie, S. (2006). GWU suit prompts questions of liability. The Washington Post, p. A01, March 10. Kisker, E. E., and Brown, R. S. (1996). Do school-based health centers improve adolescents’ access to health care, health status, and risk-taking behavior? Journal of Adolescent Health, 18, 335–343. Klein, J. D., and Wilson, K. M. (2002). Delivering quality care: Adolescents’ discussion of health risks with their providers. Journal of Adolescent Health, 30, 190–195. Klein, J. D., Wilson, K. M., McNulty, M., Kapphahn, C., and Collins, K. S. (1999). Access to medical care for adolescents: Results from the 1997 Commonwealth Fund Survey of the Health of Adolescent Girls. Journal of Adolescent Health, 25, 120–130. Klein, J. D., Sesselberg, T. S., Gawronski, B., Handwerker, L., Gesten, F., and Schettine, A. (2003). Improving adolescent preventive services through state, managed care, and com- munity partnerships. Journal of Adolescent Health, 32, 91–97. Knight, J. R., Sherritt, L., Shrier, L. A., Harris, S. K., and Chang, G. (2002). Validity of the CRAFFT substance abuse screening test among adolescent clinic patients. Archives of Pediatrics and Adolescent Medicine, 156, 607–714. Knight, J. R., Sherritt, L., Harris, S. K., Gates, E., and Chang, G. (2003). Validity of brief alcohol screening tests among adolescents: A comparison of the AUDIT, POSIT, CAGE, and CRAFFT. Alcoholism: Clinical and Experimental Research, 27, 67–73.

CURRENT ADOLESCENT HEALTH SERVICES 189 Kolbe, L. J., Kann, L., and Collins, J. L. (1993). Overview of the Youth Risk Behavior Surveil- lance System. Public Health Reports, 108(Suppl. 1), 2–10. Kulig, J. W., and Committee on Substance Abuse. (2005). Tobacco, alcohol, and other drugs: The role of the pediatrician in prevention, identification, and management of substance abuse. Pediatrics, 115, 816–821. Lee, E. J., and O’Neal, S. (1994). A mobile clinic experience: Nurse practitioners providing care to a rural population. Journal of Pediatric Health Care, 8, 12–17. Leonard, M. B., Stablein, D. M., Ho, M., Jabs, K., and Feldman, H. I. (2004). Racial and cen- ter differences in hemodialysis adequacy in children treated at pediatric centers: A North American Pediatric Renal Transplant Cooperative Study (NAPRTCS) Report. Journal of the American Society of Nephrology, 15, 2923–2932. Leshner, A. I. (1997). Addiction is a brain disease and it matters. Science, 278, 45–47. Liddle, H. A., and Dakof, G. A. (1995). Family-based treatment for adolescent drug use: State of the science. NIDA Research Monographs, 156, 218–254. Lieberman, H. M. (1974). Evaluating the quality of ambulatory pediatric care at a neighbor- hood health center. Clinical Pediatrics (Philadelphia), 13, 52–55. Ma, J., Wang, Y., and Stafford, R. S. (2005). U.S. adolescents receive suboptimal preventive counseling during ambulatory care. Journal of Adolescent Health, 36, 441.e1–441.e7. Macek, M. D., Manski, R. J., Vargas, C. M., and Moeller, J. F. (2002). Comparing oral health care utilization estimates in the United States across three nationally representative sur- veys. Health Services Research, 37, 499–521. Macfarlane, A., and Blum, R. (2001). Do we need specialist adolescent units in hospitals? British Medical Journal, 322, 941–942. MacKay, A. P., and Duran, C. (2007). Adolescent Health in the United States, 2007. Hyatts- ville, MD: National Center for Health Statistics. Mangione-Smith, R., DeCristofaro, A. H., Setodji, C. M., Keesey, J., Klein, D. J., Adams, J. L., Schuster, M. A., and McGlynn, E. A. (2007). The quality of ambulatory care delivered to children in the United States. New England Journal of Medicine, 357, 1515–1523. Manski, R. J., and Brown, E. (2007). Dental Use, Expenses, Private Dental Coverage, and Changes, 1996 and 2004. MEPS Chartbook No. 17. Rockville, MD: Agency for Health- care Research and Quality. Marcin, J. P., Pretzlaff, R. K., Whittaker, H. L., and Kon, A. A. (2003). Evaluation of race and ethnicity on alcohol and drug testing of adolescents admitted with trauma. Academy of Emergency Medicine, 10, 1253–1259. Martin, T. W. (1993). White therapists’ differing perceptions of black and white adolescents. Adolescence, 28, 281–289. Maternal and Child Health Bureau. (2005). The Oral Health of Children: A Portrait of States and the Nation, 2005. Rockville, MD: U.S. Department of Health and Human Services, Health Resources and Services Administration. Maternal and Child Health Bureau. (2008). The National Survey of Children with Special Health Care Needs Chartbook 2005–2006. Rockville, MD: U.S. Department of Health and Human Services. Mayberry, R. M., Mili, F., and Ofili, E. (2000). Racial and ethnic differences in access to medi- cal care. Medical Care Research and Review, 57(Suppl.), 108–145. McAndrews, T. (2001). Zero tolerance policies (ERIC Documentation Reproduction Service No. ED451579). ERIC Digest, 146, 1–7. McKay, J. (2006). Continuing care in the treatment of addictive disorders. Current Psychiatry Reports, 8, 355–362. McLellan, A. T., and Meyers, K. (2004). Contemporary addiction treatment: A review of systems problems for adults and adolescents. Biological Psychiatry, 56, 764–770.

190 ADOLESCENT HEALTH SERVICES McManus, M. A., Shejavali, K. I., and Fox, H. B. (2003). Is the Health Care System Work- ing for Adolescents? Perspectives from Providers in Boston, Denver, Houston, and San Francisco. Washington, DC: Maternal and Child Health Policy Research Center. Mensinger, J. L., Diamond, G. S., Kaminer, Y., and Wintersteen, M. B. (2006). Adolescent and therapist perception of barriers to outpatient substance abuse treatment. American Journal on Addictions, 15(Suppl. 1), 16–25. Millstein, S. G., and Marcell, A. V. (2003). Screening and counseling for adolescent alcohol use among primary care physicians in the United States. Pediatrics, 111, 114–122. Millstein, S. G., Igra, V., and Gans, J. (1996). Delivery of STD/HIV preventive services to adolescents by primary care physicians, Journal of Adolescent Health, 19, 249–257. Morral, A. R., McCaffrey, D. F., Ridgeway, G., Mukherji, A., and Beighley, C. (2006). The Rel- ative Effectiveness of 10 Adolescent Substance Abuse Treatment Programs in the United States (RAND Technical Report No. 346). Santa Monica, CA: RAND Corporation. National Center for Injury Prevention and Control. (2007). Leading Causes of Death and Fatal Injury Reports (2004 data). Available: http://www.cdc.gov/ncipc/wisqars/ [July 30, 2007]. National Institute of Dental and Craniofacial Research. (1994). NIDCR CDC Oral Health Data Query System. Available: http://apps.nccd.cdc.gov/dohdrc/dqs/entry.html [June 6, ������������������������������������������������������������������� 2007]. National Institute on Drug Abuse. (1999). Principles of Drug Addiction Treatment: A Research-Based Guide (NIH Publication No. 00-4180). Bethesda, MD: National Insti- tutes of Health. National Institute on Drug Abuse. (2006). Principles of Drug Abuse Treatment for Criminal Justice Populations: A Research-Based Guide (NIH Publication No. 06-5316). Bethesda, MD: National Institutes of Health. National Research Council. (1999). Risks and Opportunities: Synthesis of Studies of Adoles- cence. M. D. Kipke (Ed.). Washington, DC: National Academy Press. National Research Council and Institute of Medicine. (2002). Community Programs to Pro- mote Youth Development. J. Eccles and J. A. Gootman (Eds.). Washington, DC: National Academy Press. Nawar, E. W., Niska, R. W., and Xu, J. (2007). National Hospital Ambulatory Medical Care Survey: 2005 emergency department summary. Advance Data from Vital and Health Statistics, 386(June 29). O’Connor, K. G., Johnson, J., and Brown, R. T. (2000). Barriers to Providing Health Care for Adolescents: The Pediatrician’s View. Presented at the Association for Health Ser- vices Research Annual Meeting, June, Los Angeles, CA. Available: http://www.aap.org/ research/periodicsurvey/ps42ahsr.htm [March 8, 2008]. O’Connor, R. E., and Haley, L. (2003). Disparities in emergency department health care: Systems and administration. Academy of Emergency Care, 10, 1193–1198. Olson, A. L., Kelleher, K. J., Kemper, K. J., Zuckerman, B. S., Hammond, C. S., and Dietrich, A. J. (2001). Primary care pediatrician’s roles and perceived responsibilities in the iden- tification and management of depression in children and adolescents. Ambulatory Pedi- atrics, 1, 91–98. Orso, C. L. (1979). Delivering ambulatory health care: The successful experience of an urban neighborhood health center. Medical Care, 17, 111–126. Owens, P. L., Thompson, J., Elixhauser A., and Ryan, K. (2003). Care of Children and Ado- lescents in U.S. Hospitals. HCUP Fact Book No. 4; AHRQ Publication No. 04-0004. Rockville, MD: Agency for Healthcare Research and Quality. Ozer, E. M., Adams, S. H., Lustig, J. L., Gee, S., Garber, A. K., Gardner, L. R., Rehbein, M., Addison, L., and Irwin, C. E., Jr. (2005). Increasing the screening and counseling of adolescents for risky health behaviors: A primary care intervention. Pediatrics, 115, 960–968.

CURRENT ADOLESCENT HEALTH SERVICES 191 Rand, C. M., Shone, L. P., Albertin, C., Auinger, P., Klein, J. D., and Szilagyi, P. G. (2007). National health care visit patterns of adolescents. Implications for delivery of new ado- lescent vaccines. Archives of Pediatrics and Adolescent Medicine, 161, 252–259. Reddy, D. M., Fleming, R., and Swain, C. (2002). Effect of mandatory parental notification on adolescent girls’ use of sexual health care services. Journal of the American Medical Association, 288, 710–714. Rounds-Bryant, J. L., Kristiansen, P. L., and Hubbard, R. L. (1999). Drug abuse treatment outcome study of adolescents: A comparison of client characteristics and pretreatment behaviors in three treatment modalities. American Journal of Drug and Alcohol Abuse, 25, 573–591. Rudoren, J. (2006). Judge blocks law to report sex under 16. The New York Times, April 19. Available: http://www.nytimes.com/2006/04/19/us/19kline.html [July 19, 2006]. Samargia, L., Saewyc, E., and Elliott, B. (2006). Foregone mental health care and self-reported access barriers among adolescents. Journal of School Nursing, 22, 17–24. Santelli, J., Morreale, M., Wigton, A., and Grason, H. (1995). Improving Access to Primary Care for Adolescents: School Health Centers as a Service Delivery Strategy (MCH Policy Research Brief). Baltimore, MD: The Johns Hopkins University School of Hygiene and Public Health. Schuchter, J., and Fairbrother, G. (2008). Health Services Utilization among Adolescents from the 2005 NHIS. An analysis of 2005 National Health Interview Survey data. Report to the Institute of Medicine Committee on Adolescent Health Care Services and Models of Care for Treatment, Prevention, and Health Development. Available: http://www. cincinnatichildrens.org/assets/0/78/1067/1395/1833/1835/1849/1853/960a6652-5045- 4946-ba64-191c919cefb7.pdf [March 19, 2008]. Schultz, S. T., Shenkin, J. D., and Horowitz, A. M. (2001). Parental perceptions of unmet dental need and cost barriers to care for developmentally disabled children. Pediatric Dentistry, 23, 321–325. Shields, A. E., Finkelstein, J. A., Comstock, C., and Weiss, K. B. (2002). Process of care for Medicaid-enrolled children with asthma: Served by community health centers and other providers. Medical Care, 40, 303–314. Slade, E. P. (2002). Effects of school-based mental health programs on mental health service use by adolescents at school and in the community. Mental Health Services Research, 4, 151–166. Slesnick, N., Kang, M. J., Bonomi, A. E., and Prestopnik, J. L. (2008). Six- and twelve- month outcomes among homeless youth accessing therapy and case management services through an urban drop-in center. Health Services Research, 43, 211–229. Strakowski, S. M., Lonczak, H. S., Sax, K. W., West, S. A., Crist, A., Mehta, R., and Thienhaus, O. J. (1995). The effects of race on diagnosis and disposition from a psychi- atric emergency service. Journal of Clinical Psychiatry, 56, 101–107. Strakowski, S. M., Keck, P. E., Jr., Arnold, L. M., Collins, J., Wilson, R. M., Fleck, D. E., Corey, K. B., Amicone, J., and Adebimpe, V. R. (2003). Ethnicity and diagnosis in pa- tients with affective disorders. Journal of Clinical Psychiatry, 64, 747–754. Substance Abuse and Mental Health Services Administration. (2006a). Characteristics of young adults (aged 18–25) and youth (aged 12–17) admissions: 2004. The DASIS Re- port, 21. Substance Abuse and Mental Health Services Administration. (2006b). Substance use treat- ment need among adolescents: 2003–2004. The NSDUH Report, 24. Suellentrop, K. (2006a). Adolescent boys’ use of health services. Science Says, 26. Washington, DC: National Campaign to Prevent Teen Pregnancy. Suellentrop, K. (2006b). Adolescent girls’ use of health services. Science Says, 28. Washington, DC: National Campaign to Prevent Teen Pregnancy.

192 ADOLESCENT HEALTH SERVICES Suellentrop, K. (2006c). Teen contraceptive use. Science Says, 29. Washington, DC: National Campaign to Prevent Teen Pregnancy. Szapocznik, J., Lopez, B., Prado, G., Schwartz, S. J., and Pantin, H. (2006). Outpatient drug abuse treatment for Hispanic adolescents. Drug and Alcohol Dependence, 84, S54–S63. Tang, S. S., Yudkowsky, B. K., and Davis, J. C. (2003). Medicaid participation by private and safety net pediatricians, 1993 and 2000. Pediatrics, 112, 368–372. Tatelbaum, R., Adams, B., Kash, C., McAnarney, E., Roghmann, K., Coulter, M., Charney, E., and Plume, M. (1978). Management of teenage pregnancies in three different health care settings. Adolescence, 13, 713–728. Thorndike, A. N., Ferris, T. G., Stafford, R. S., and Rigotti, N. A. (1999). Rates of U.S. physi- cians counseling adolescents about smoking. Journal of the National Cancer Institute, 91, 1857–1862. Todd, K. H., Deaton, C., D’Adamo, A. P., and Goe, L. (2000). Ethnicity and analgesic practice. Annals of Emergency Medicine, 35(1), 11–16. Tomlinson, K. L., Brown, S. A., and Abrantes, A. (2004). Psychiatric comorbidity and sub- stance use treatment outcomes of adolescents. Psychology of Addictive Behaviors, 18, 160–169. Tylee, A., Haller, D. M., Graham, T., Churchill, R., and Sanci, L. A. (2007). Youth-friendly primary-care services: How are we doing and what more needs to be done? Lancet, 369, 1565–1573. U.S. Congress and Office of Technology Assessment. (1991). Adolescent Health (OTA-H-466, 467, and 468). Washington, DC: U.S. Government Printing Office. U.S. Department of Health and Human Services. (2000). Healthy People 2010 (2nd Ed.). Washington, DC: U.S. Government Printing Office. U.S. Department of Health and Human Services. (2007). 21 Critical Health Objectives for Adolescents and Young Adults. Centers for Disease Control and Prevention. Available: http://www.cdc.gov/HealthyYouth/AdolescentHealth/NationalInitiative/pdf/21objectives. pdf [October 17, 2007]. U.S. Preventive Task Force and Agency for Healthcare Research and Quality. (2004). Screening for Family and Intimate Partner Violence. Available: http://www.ahrq.gov/clinic/uspstf/ uspsfamv.htm [March 11, 2008]. U.S. Surgeon General. (2001). Youth Violence: A Report of the Surgeon General. Washington, DC: U.S. Department of Health and Human Services. Van Hook, S., Harris, S. K., Brooks, T., Carey, P., Kossack, R., Kulig, J., Knight, J. R., and New England Partnership for Substance Abuse Research. (2007). The “Six T’s”: Barri- ers to screening adolescents for substance abuse in primary care. Journal of Adolescent Health, 40, 456–461. Vargas, C. M., and Ronzio, C. R. (2002). Relationship between children’s dental needs and dental care utilization: United States, 1988–1994. American Journal of Public Health, 92, 1816–1821. Veit, F. C., Sanci, L. A., Coffey, C. M., Young, D. Y., and Bowes, G. (1996). Barriers to effective primary health care for adolescents. The Medical Journal of Australia, 165, 131–133. Volkow, N. D., and Li, T. K. (2005). Drugs and alcohol: Treating and preventing abuse, ad- diction, and their medical consequences. Pharmacological Therapy, 108, 3–17. Waldron, H. B., and Kaminer, Y. (2004). On the learning curve: The emerging evidence supporting cognitive-behavioral therapies for adolescent substance abuse. Addiction, 99(Suppl. 2), 93–105. Watson, S. (1998). A ward of their own. Nursing Standard, 12, 12–13.

CURRENT ADOLESCENT HEALTH SERVICES 193 Weisz, J. R., Donenberg, G. R., Han, S. S., and Kauneckis, D. (1995). Child and adolescent psychotherapy outcomes in experiments versus clinics: Why the disparity? Journal of Abnormal Child Psychology, 23, 83–106. Weisz, J. R., Hawley, K. M., and Doss, A. J. (2004). Empirically tested psychotherapies for youth internalizing and externalizing problems and disorders. Child and Adolescent Psychiatric Clinics of North America, 13, 729–815. Weisz, J. R., Sandler, I. N., Durlak, J. A., and Anton, B. S. (2005). Promoting and protecting youth mental health through evidence-based prevention and treatment. The American Psychologist, 60, 628–648. West, J. C., Herbeck, D. M., Bell, C. C., Colquitt, W. L., Duffy, F. F., Fitek, D. J., Rae, D., Stipec, M. R., Snowden, L., Zarin, D. A., and Narrow, W. E. (2006). Race/ethnicity among psychiatric patients: Variations in diagnostic and clinical characteristics reported by practicing clinicians. Focus, 4, 48–56. White, M., White, W. L., and Dennis, M. L. (2004). Emerging models of effective adolescent substance abuse treatment. Counselor, The Magazine for Addiction Professionals, 5, 24–28. Williams, R. J., Chang, S. Y., and the Addiction Centre Research Group. (2000). A comprehen- sive and comparative review of adolescent substance abuse treatment outcome. Clinical Psychology: Science and Practice, 7, 138–166. Winters, K. C. (1999). Treating adolescents with substance use disorders: An overview of practice issues and treatment outcome. Substance Abuse, 20, 203–225. Winters, K. C., Stinchfield, R. D., Opland, E., Weller, C., and Latimer, W. W. (2000). The effectiveness of the Minnesota Model approach in the treatment of adolescent drug abusers. Addiction, 95, 601–612. Wissow, L., Fothergill, K., and Forman, J. (2002). Confidentiality for mental health concerns in adolescent primary care. Bioethics Forum, 18, 43–54. World Health Organization. (1999). Programming for Adolescent Health and Development: Report of a WHO/UNFPA/UNICEP Study Group on Programming for Adolescent Health (WHO Technical Report Series 886). Geneva: World Health Organization. World Health Organization. (2001). Global Consultation on Adolescent Health Services. A Consensus Statement. Geneva: Department of Child and Adolescent Health and Develop- ment, World Health Organization.

Next: 4 Improving Systems of Adolescent Health Services »
Adolescent Health Services: Missing Opportunities Get This Book
×
Buy Hardback | $59.95 Buy Ebook | $47.99
MyNAP members save 10% online.
Login or Register to save!
Download Free PDF

Adolescence is a time of major transition, however, health care services in the United States today are not designed to help young people develop healthy routines, behaviors, and relationships that they can carry into their adult lives. While most adolescents at this stage of life are thriving, many of them have difficulty gaining access to necessary services; other engage in risky behaviors that can jeopardize their health during these formative years and also contribute to poor health outcomes in adulthood. Missed opportunities for disease prevention and health promotion are two major problematic features of our nation's health services system for adolescents.

Recognizing that health care providers play an important role in fostering healthy behaviors among adolescents, Adolescent Health Services examines the health status of adolescents and reviews the separate and uncoordinated programs and services delivered in multiple public and private health care settings. The book provides guidance to administrators in public and private health care agencies, health care workers, guidance counselors, parents, school administrators, and policy makers on investing in, strengthening, and improving an integrated health system for adolescents.

  1. ×

    Welcome to OpenBook!

    You're looking at OpenBook, NAP.edu's online reading room since 1999. Based on feedback from you, our users, we've made some improvements that make it easier than ever to read thousands of publications on our website.

    Do you want to take a quick tour of the OpenBook's features?

    No Thanks Take a Tour »
  2. ×

    Show this book's table of contents, where you can jump to any chapter by name.

    « Back Next »
  3. ×

    ...or use these buttons to go back to the previous chapter or skip to the next one.

    « Back Next »
  4. ×

    Jump up to the previous page or down to the next one. Also, you can type in a page number and press Enter to go directly to that page in the book.

    « Back Next »
  5. ×

    To search the entire text of this book, type in your search term here and press Enter.

    « Back Next »
  6. ×

    Share a link to this book page on your preferred social network or via email.

    « Back Next »
  7. ×

    View our suggested citation for this chapter.

    « Back Next »
  8. ×

    Ready to take your reading offline? Click here to buy this book in print or download it as a free PDF, if available.

    « Back Next »
Stay Connected!