Implementing the Guidelines for Adolescent Preventive Services - includes patient information

Author: Norman J. Montalto
Date: May 1, 1998

Family physicians are primarily responsible for most of the medical care delivered to adolescents in the United States today. Applying the Guidelines for Adolescent Preventive Services (GAPS) is one way for physicians to structure the delivery of care to these unique and challenging patients.

Guidelines for Adolescent Preventive Services

GAPS was first published in December 1993.[1] Members of various interdisciplinary organizations provided input, and the development of these guidelines was promoted by the American Medical Association's Department of Adolescent Health and the Centers for Disease Control and Prevention. Nationally, the promotion of adolescent preventive services has been recommended by numerous authorities, including the Bright Futures[2] project sponsored by the Maternal and Child Health Bureau, the Put Prevention into Family Practice[3] office-based program sponsored by the Office of Disease Prevention and Health Promotion, and the American Academy of Pediatrics.[4] The United States Preventive Services Task Force published an updated version of its recommended interventions for 11- to 24-year-old patients in 1996.[5] All of these organizations suggest similar preventive services.

GAPS consists of 24 recommendations (Figure 1) that encompass health care delivery (recommendation 3), health guidance (recommendation 7), screening (recommendation 13) and immunizations (recommendation 24). The goal of GAPS is to improve health care delivery to adolescents using primary and secondary interventions to prevent and reduce adolescent morbidity and mortality.

FIGURE 1. Guidelines for Adolescent Preventive Services, STD = sexually transmitted disease; HIV = human immunodeficiency; ELISA = enzyme-linked immunosorbent assay.

Recommendation 1

From ages 11 to 21 all adolescents should have an annual routine

health visit.

Recommendation 2

Preventive service should be age and developmentally appropriate,

and should be sensitive to individual and sociocultural

differences.

Recommendation 3

Physicians should establish office policies regarding

confidential care for adolescents and the way parents will

be involved in that care. These policies should be made clear to

adolescents and their parents.

Recommendation 4

Parents or other adult caregivers of adolescents should receive

health guidance at least once during early adolescence, once

during middle adolescence and, preferably, once during late

adolescence.

Recommendation 5

All adolescents should receive health guidance annually to

promote better understanding of their physical growth, their

psychosocial and psychosexual development, and the

importance of becoming actively involved in decisions regarding

their health care.

Recommendation 6

All adolescents should receive health guidance annually to

promote the reduction of injuries.

Recommendation 7

All adolescents should receive health guidance annually about

dietary habits, including the benefits of a healthy diet and

ways to achieve a healthy diet and safe weight management.

Recommendation 8

All adolescents should receive health guidance annually about

the benefits of exercise and should be encouraged

to engage in safe exercise on a regular basis.

Recommendation 9

All adolescents should receive health guidance

annually regarding responsible sexual behaviors, including

abstinence. Latex condoms to prevent sexually transmitted

diseases (including HIV infection) and appropriate methods of

birth control should be made available with instructions on ways

to use them effectively

Recommendation 10

All adolescents should receive health guidance annually to

promote avoidance of tobacco, alcohol and other abusable

substances, and anabolic steroids.

Recommendation 11

All adolescents should be screened annually

for hypertension according to the protocol developed by the

National Heart, Lung, and Blood Institute's Second Task Force on

Blood Pressure Control in Children.

Recommendation 12

Selected adolescents should be screened to determine their risk of

developing hyperlipidemia and adult coronary heart disease,

following the protocol developed by the Expert Panel on Blood

Cholesterol Levels in Children and Adolescents.

Recommendation 13

All adolescents should be screened annually for eating disorders

and obesity by determining weight and stature, and asking about

body image and dieting patterns.

Recommendation 14

All adolescents should be asked annually about their use of

tobacco products, including cigarettes and

smokeless tobacco.

Recommendation 15

All adolescents should be asked annually

about their use of alcohol and other abusable substances, and

about their use of over-the-counter or prescription drugs,

including anabolic steroids, for nonmedical purposes.

Recommendation 16

All adolescents should be asked annually

about involvement in sexual behaviors that may result in

unintended pregnancy and STDs, including HIV infection.

Recommendation 17

Sexually active adolescents should be screened for STDs.

Recommendation 18

Adolescents at risk for HIV infection should be offered

confidential HIV screening with the ELISA and a confirmatory

test.

Recommendation 19

Female adolescents who are sexually active

and women 18 or older should be screened annually for cervical

cancer by use of a Papanicolaou test.

Recommendation 20

All adolescents should be asked annually

about behaviors or emotions that indicate recurrent or severe

depression or risk of suicide.

Recommendation 21

All adolescents should be asked annually about a history of

emotional, physical or sexual abuse.

Recommendation 22

All adolescents should be asked annually about learning or

school problems.

Recommendation 23

Adolescents should receive a tuberculin skin

test if they have been exposed to active tuberculosis, have lived

in a homeless shelter, have been incarcerated, have lived in or

come from an area with a high prevalence of tuberculosis, or

currently work in a health care setting.

Recommendation 24

All adolescents should receive prophylactic

immunizations according to the guidelines established by the

federally convened Advisory Committee on Immunization

Practices.

Decisions about ways to apply GAPS during interactions with adolescents in the office setting are the responsibility of the physician. The use of GAPS enables the physician to restructure the visit from a focus on traditional assessment of wellness to identification and treatment of at-risk behaviors such as drinking, unprotected sex, nicotine use or thoughtless/careless approaches to life. Historically, traditional medical care for adolescents has produced much smaller decreases in morbidity and mortality when compared with traditional medical care in other age groups. This finding is related to the fact that rates of injury and violence are higher today than they were 50 years ago.[6,7]

Three out of four adolescent deaths are caused by unintentional injury (e.g., motor vehicle accidents, drownings, poisonings, burns) and violence (e.g., homicide, suicide).[8,9] This finding provides evidence that most mortality in adolescents and young adults may be attributed to unhealthy or risky behaviors. In 1993, approximately three fourths of adolescent deaths were considered preventable.[5]

The 1995 Youth Risk Behavior Surveillance Survey, a national survey of students in grades nine through 12, revealed that 72 percent of all deaths among school-aged youth were the result of four primary causes: motor vehicle accidents, other unintentional injury, homicide and suicide.[10] Similar data from patients five to 21 years of age identified the same causes of mortality,[11] indicating a need for physicians to focus on accidents and violence in preventive care.

There has been some success in reducing teenage mortality. The overall death rates for persons from 10 to 24 years of age decreased 11.7 percent from 1979 to 1988. "Other injury" and motor vehicle crashes (35.7 percent and 15.5 percent, respectively) both declined but were offset by an increase in absolute rates of suicide and homicide (7.9 percent and 6.7 percent).[8]

From 1979 to 1991, mortality from all causes in 15- to 24-year old young people decreased by 12.8 percent, and unintentional injuries decreased by 32.9 percent. Absolute increases in homicide and suicide (54.5 percent and 5.6 percent, respectively) indicate that prevention in these areas should be emphasized.[12]

Physicians may be able to delegate some of the preventive services to office staff. Office personnel can obtain screening information, measure blood pressure, record body mass index, provide health guidance and distribute age-appropriate information. In addition, scheduled laboratory values and immunizations can be highlighted by the staff and ordered, with little time required on the part of the physician. As with other services provided in the office setting, delivery systems should facilitate physician time with the patient, allowing for a more detailed history or for problem-focused health guidance, if required.

Prioritizing Recommendations

In 1995, 65 percent of all adult deaths were caused by heart disease, cancer and stroke. Developers of the Youth Risk Behavior Surveys believe that the behaviors leading to these outcomes in adults were "initiated during adolescence."[10] In general terms, they classify six areas of behavior that result in premature morbidity and mortality. They are: behavior that contributes to unintentional and intentional injuries, tobacco use, alcohol and other drug use, sexual behaviors, unhealthy dietary behaviors and physical inactivity.

The behaviors causing both adult and adolescent mortality are included in the GAPS recommendations. Specifically, these include tobacco use, inadequate use of bicycle and motorcycle helmets, lack of seat belt use, use of marijuana or alcohol, riding in a car with a driver who has used these substances, carrying a weapon, engaging in physical fighting, homicide and suicide. Avoiding drugs, exercising, maintaining an ideal body weight, making proper nutritional choices, and avoiding or delaying sexual activity during adolescence may reduce premature adult mortality. Interventions that identify and target these behaviors may be the most important risk factors for physicians to evaluate.

Final Comment

GAPS recommendations can be applied in a busy clinical practice. By making use of the HSR form, understanding the GAPS recommendations and employing two simple mnemonics, physicians can improve the way they provide adolescent preventive services. Following the GAPS recommendations will enable physicians to increase time spent with these patients. In addition to the immediate benefit adolescent patients may derive from increased communication with their physician, they may also build more constructive and positive relationships with other health care professionals that may promote good health habits and prevent future illness and injury. There may be no other group of patients in our practices where small interventions may have such valuable long-term outcomes.

REFERENCES

[1.] Elster AB, Kuznets NJ, eds. AMA guidelines for adolescent preventive services (GAPS): recommendations and rationale. Baltimore: Williams & Wilkins, 1994.

[2.] Green M, ed. Bright futures: guidelines for health supervision of infants, children, and adolescents. Arlington, Va.: National Center for Education in Maternal and Child Health, 1994:196-259.

[3.] Put prevention into family practice (Kit and handbook). Kansas City, Mo.: American Academy of Family Physicians, 1994.

[4.] Committee on Practice and Ambulatory Medicine. Recommendations for preventive pediatric health care. Pediatrics 1995;96:373-4.

[5.] U. S. Preventive Services Task Force. Guide to clinical preventive services: report of the U.S. Preventive Services Task Force. 2d ed. Baltimore: Williams & Wilkins, 1996.

[6.] Fingerhut LA. Trends and current status in childhood mortality, United States, 1900-1985. Vital & health statistics, series 3, no. 26. Hyattsville, Md.: National Center for Health Statistics 1989; DHHS publication no. (PHS) 89-1410.

[7.] Mortality. In: Vital statistics of the United States, 1987. Vol. II. Part A. Washington, D.C.: U.S. Government Printing Office, 1989; DHHS publication no. (PHS) 90-1101.

[8.] National Center for Health Statistics. Health, United States, 1991, and prevention profile. Washington, D.C.: Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, 1992; DHHS publication no. (PHS) 92-1232.

[9.] Mortality trends and leading causes of death among adolescents and young adults--United States, 1979-1988. MMWR Morb Mortal Wkly Rep 1993;42:459-62 [Published erratum appears in MMWR Morb Mortal Wkly Rep 1993;42:615].

[10.] Centers for Disease Control and Prevention. Youth risk behavior surveillance, United States, 1995. MMWR Morb Mortal Wkly Rep 1996;45(SS-4):1-84.

[11.] National Center for Health Statistics. Advance reports of final mortality statistics, 1993. Hyattsville, Md.: Department of Health and Human Services, Public Health Service, 1996. Mon Vital Stat Rep 1996;44(7 Suppl).

[12.] National Center for Health Statistics. Advance report of final mortality statistics, 1991. Mon Vital Stat Rep 1993;42(Suppl 2):364-96.

[13.] Stevens NG, Lyle S. Guidelines for adolescent preventive services: a critical review. J Am Board Fam Pract 1994;7(5):421-30.

[14.] Adolescent Medicine Committee. Adolescent health questionnaires. Special Ohio Academy of Family Physicians news insert. Columbus, Ohio: August, 1989.

The author thanks Jerry Spiegler M.S., for technical assistance, and Tara Tolliver and Cindy Wentz for help in preparing the manuscript

Figure 1 adapted with permission from Elster AB, Kuzsets NJ, eds. AMA guidelines for adolescent preventive services (GAPS). Recommendations and rationale. Baltimore: Williams & Wilkins, 1994. Figure 2 adapted with permission from Goldenring JM, Lohen E Getting into adolescent heads. Contemp Pediatr 1988;00:75-90. Figure 3 adapted with permission from Schubiner H. Preventive health screening in adolescent patient. Prim Care 1989; 16:211-30.

NORMAN J. MONTALTO, D.O., is an associate professor in the Department of Family Medicine at Robert C. Byrd Health Sciences Center of West Virginia University, Charleston. He is also director of the Freedom from Tobacco Program at the Charleston Area Medical Center. Dr. Montalto graduated from the University of Osteopathic Medicine and Health Sciences in Des Moines, Iowa, and completed a residency at Ohio State University, Columbus.

Address correspondence to Norman J. Montalto, D.O., Family Medicine Center of Charleston, 1201 Washington St. East, Suite 108, Charleston, WV 25301. Reprints are not available from the author.

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