One of the biggest trends in health care today is the focus on specialties, and almost every health care practitioner specializes in something. An obstetrician may not just focus solely on pregnancies – but on high-risk pregnancies or fertility treatments, nurses can become experts in geriatric nursing, and family care practitioners can focus on adolescent health. This chapter will direct your attention to the increasing availability of various health services in the United States for adolescents due to the awareness that adolescent needs have largely been ignored and the overall increasing size of the adolescent population.
In fact, according to The National Adolescent Health Information Center’s “Demographics: Children and Adolescents,” the population of adolescents ages 10-19 was 38.8 million in 1998, and this population is expected to grow to nearly 50 million by the year 2040. Not only is the size of the adolescent population changing, but so are the demographics. The proportion of the adolescents who are very poor is also increasing, with 18.9% of all those under age 18 living below the Federal Poverty Line (FPL)* in 1998. This statistic in and of itself should raise some concern about access and availability of health care for adolescent now and in the future.
However adolescent health itself is a broad specialty, encompassing behavioral health, nutrition, alcohol and drug abuse, cigarette smoking, sexual and reproductive health, and mental health – just to name a few! Although these are all issues that need to be discussed, it would be impossible to discuss them all adequately in one chapter. Instead, this chapter will focus on sexual and reproductive health, mental health, health insurance and access to care, and finally the great debate – whether or not specialized adolescent health care is better than treating adolescents in a general, primary health care setting.
There has been a dramatic rise in the proportion of adolescents who have had sexual intercourse, with 56% of females and 73% of males between the ages of 15-19, and 20% of females and 33% of males before the age of 15 (http://youth.ucsf.edu/nahic/product.html). The overall teenage pregnancy rate has risen with over one million females becoming pregnant. Approximately three million teenagers are infected with a sexually transmitted disease each year (Baker, et al. 2001). With these increased numbers of sexually active adolescents and such staggering statistics comes the need for appropriate health care. There are a wide variety of services offered to adolescents (female and male) for pregnancy prevention and education, pregnancy, abortion (in some states), and treatment of STD’s such as Planned Parenthood and local health departments – but access to such services, cost, and confidentiality definitely play a role in the utilization of these services.
For an adolescent to actually realize they need such services and to carry out the action of going to a family planning clinic requires transportation, potential cost, awareness of confidentiality, and a certain comfort level to be able to express various concerns with a health care professional. For a female adolescent, going to a gynecologist can be an anxiety-ridden experience, as well as scary, painful, and embarrassing (Bodden-Heidrich, et al. 2000). Any health care professional who is dealing with a young woman in such a setting needs to be aware of these feelings and make efforts to alleviate any concerns they may have. However, such experiences are not exclusive to young women, and more attention needs to be paid to the younger male adolescents. Adolescence is just as scary a time for boys as it is for girls, and yet adequate efforts are not made to improve their use of health services. Marcell, et al (2001) estimates that male adolescent visits are lower than females at all adolescent-specific programs: hospitals (33% vs. 67%) and community/health departments (25% vs. 75%), and yet school-based clinics see the highest proportion of males. Equality of health care among male and female adolescents does not exist, which in all probability accounts for the increasing rates of pregnancy and STD’s.
Vast improvements in general mental health care have occurred in the United States due to the integration of behavioral health care into general medical health care. Now insurance companies may pay for clinical visits to a psychiatrist or counselor (although oftentimes those visits are limited). Physicians are now gaining a better understanding of the genetic and biological base for mental illnesses, as well as social environmental factors, which will improve the overall treatment of the individual. Understanding the effects of social and environmental events on a child’s mental and emotional well-being has great implications for the way they are treated in a mental health setting. Increased exposure to violence (through home and media exposure), physical and sexual abuse, neglect and stress are just a few of the numerous social and environmental factors that put a child at risk for developing depression, mood disorders, anxiety disorders, eating disorders, learning problems and behavioral problems. Through early diagnosis and treatment (psychotherapy and pharmacological therapy), a child can learn the skills they need to understand and manage various life events.
In 1997, suicide accounted for 12% of all deaths for young adults ages 10-24, which makes suicide the third leading cause of death for adolescents and young adults There are also gender differences in suicide rates: while adolescent males have a consistently higher suicide rate than females, adolescent females are twice as likely as adolescent makes to attempt suicide. Among high-school students in 1997, 27.1% of females seriously considered suicide compared to 15.1% of males, and 83.8% of all suicides among 15-19 year olds in the United States were committed by males (http://youth.ucsf.edu/nahic/products.html). The good news is that since the early 1990’s, suicide rates have fallen sharply for most adolescents. Increased attention to adolescent mental health has probably contributed to these decreased numbers, and hopefully these numbers will continue to decrease as awareness of mental health/illness in the adolescent population increases. However, the stigma surrounding mental illness still remains, and views surrounding treatment for mental illness for adolescents as well as adults in the U.S. will not change until the stigma is eliminated.
In 1995, 4.2 million adolescents ages 10-18 were not insured. Currently, one in seven adolescents lacks health insurance coverage and older adolescents are the most likely population to be uninsured. According to Brindis et al., adolescents without insurance use fewer health services, have longer intervals between doctors visits, and are less likely to have their health problems treated and less likely to receive medical care from a physician when necessary. Insurance coverage obviously makes a significant difference in whether adolescents have access to quality health care, and adolescents who are uninsured visit a physician’s office 1.5 times a year, compared to those who are insured who make visits nearly three times a year (http://www.ahcpr.gov/research/chsr2ado.htm). Despite Medicaid expansions in the past decade, this statistic has remained relatively the same.
The State Children’s Health Insurance Program (CHIP) will hopefully allow states to break down the barriers to care for low-income and uninsured adolescents and adolescents with special needs. This program will expand an adolescents’ health insurance coverage, but will not guarantee that adolescents will receive services. The states that are involved have benefits packages with varying degrees of coverage including reproductive, mental health, substance abuse, and dental services. Reproductive services continues to be a never-ending political debate and states struggle with the need for these services. Some of the areas in which CHIP tries to meet the needs of adolescents are through outreach and enrollment, access to care, access to confidential services, access for those with special needs (e.g. cystic fibrosis), school-based clinics, quality of care, and links with other services in the community. Policy development creates opportunities to promote adolescent health, and without access to services (including access to insurance) adolescent health will never improve.
Currently, the greatest debate is whether specialized adolescent health care provides more comprehensive services than primary care, and is therefore better. For many adolescents, they have grown up seeing a pediatrician, and by the time they hit puberty they no longer want to go to a doctor that treats “babies” and want to go to a doctor that will treat them as an adult and provide strict confidentiality. In truth, adolescents are no longer the children their parents and pediatricians think they are, but they still have special needs that must be managed, and many general practitioners may not be used to screening and treating such things. The onset of adolescence brings about many changes – physically, emotionally, and socially – and as a result new medical needs need to be met.
And yet, continuity of care becomes an issue when a child switches from a pediatrician to an adolescent physician, and then to a general practitioner or internist when they reach adulthood, not to mention the many changes that may occur after adulthood due to change in insurance or moving to a new city. An adolescent who is 19 years old and has been seeing his/her physician (who specializes in adolescent health) may have formed a significant relationship with that doctor and may have difficulty going to someone who they are not comfortable with and does not know them or their needs. But does that mean that a general practitioner who treats adolescents cannot understand their needs? Definitely not, and changing doctors may provide quite a challenge when it is time for the adolescent to move on to a general practitioner.
The focus of this chapter has been the needs of adolescents and the treatment of these needs through specialized services. Teenagers need to be screened for high risk behavioral, sexual, and physical factors – and any doctor who treats an adolescent should be able to do that, and should be educated on communicating with adolescents and understanding their diverse needs. However, all doctors have time constraints in their clinics, and oftentimes the clinic support staff (nurses, social workers, educators) is the key factor in treating any adolescent, no matter if they are going to a physician who specializes in adolescent health or a general practitioner.
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