Well-child visit (adolescent): Clinical sciences

The well-child visits for an adolescent between 11 and 21 years of age is a yearly check-up that promotes physical, mental, and social health while building trust between caregivers, adolescents, and the healthcare provider. Each visit includes a comprehensive history and physical exam, followed by an interview about general self-care, administration of immunizations; and finally, a one-on-one interview with the adolescent, using the “HEADSSS” assessment.

When a pediatric patient presents for an adolescent well child visit, begin with a comprehensive history and physical exam. First, review the interval history, taking note of any changes in health since the last office visit; and ask the family or caregiver to share any questions or concerns they might have. During the physical exam, first, consider the patient’s general appearance and then perform a full body exam, including chaperoned genitourinary and breast exams, if applicable.

Next, review the patient’s growth chart, which trends the height, weight, and calculated body mass index, or BMI; and don’t forget to measure the blood pressure to screen for hypertension. Adolescents also receive routine hearing screens once between 11 to 14 years, once between 15 to 17 years, and once between 18 to 21 years of age , and vision screens at 12 and 15 years of age.

Finally, you should assess puberty-related changes using the sexual maturity rating, or SMR, which is also called Tanner staging. SMR is used to track the development of secondary sex characteristics in biologically male and female patients.

Now, here’s a high yield fact! SMR starts with Stage 1, which is prepubertal, and ends at Stage 5, which is complete sexual maturity. This scale consists of two independent criteria, including the appearance of pubic hair in both sexes; and either the increase in testicular volume and penis size and length in biological males; or the breast development in biological females.

Okay, your next step is to talk to the caregiver and the adolescent, beginning with topics related to self-care. Self-care includes a discussion about health-related routines, such as healthy eating, physical activity, and sleep. Also ask about oral hygiene habits, which should include twice-daily toothbrushing, daily flossing, and biannual visits to the dentist. If the adolescent is biologically female, ask about menstruation, including regularity, flow, and symptoms like cramping.

For patients 9 to 11 and 17 to 21 years of age, order a lipid test to screen for dyslipidemia. Additionally, order a hemoglobin to screen for anemia if your patient has risk factors, such as a diet that’s low in iron or a heavy menstrual flow.

Now that you’re done with discussing self-care, it’s time to focus on immunization. Before you do, talk with the family or caregiver about recommended vaccines, and answer any questions they may have while advocating for vaccination and addressing any vaccine hesitancy.

All adolescents 11 to 12 years of age should receive tetanus, diphtheria, and acellular pertussis, or Tdap vaccine; HPV vaccine, as well as the meningococcal ACWY vaccine. Adolescents should also receive a second dose of the meningococcal ACWY at 16 years of age and Meningococcal B between 16 and 18 years of age. Finally, the influenza and COVID-19 vaccines are recommended annually, for all ages.

Alright, your next step is to interview the teen separately. Explain to the family that a one-on-one interview provides space for the teen to build autonomy, strengthen the physician-patient relationship, and ask questions they might otherwise be reluctant to ask.

Next, explain that confidential conversations provide a nonjudgmental and supportive environment for adolescents to openly express concerns about sensitive issues. Keep in mind that laws and regulations regarding adolescent privacy and the ability to independently consent to health care services vary significantly among US states. Finally, assure your patient that you will keep their information confidential unless something they communicate indicates that they might be a danger to themself or others.

A core aspect of the adolescent interview is the HEADSSS assessment, which is a mnemonic you can use to remember topics to address. As a brief overview, HEADSSS stands for Home; Education and Employment; Activities; Drugs and substance use; Sexuality, Gender Identity, and Relationships; Self-harm and Depression; and Safety.

Here’s a clinical pearl! You may also encounter an alternative to HEADSSS called SSHADESS, which stands for Strengths, School, Home, Activities, Drugs and substance use, Emotions and eating, Sexuality, and Safety.