Comprehensive school-based health care: high school students' use of medical, mental health, and substance abuse services.

OBJECTIVES: To explore adolescent students' use of school based health and medical care and mental health and substance abuse counseling services and to compare adolescents' patterns of use of medical, mental health, and substance abuse services located in school-based and traditional settings. DESIGN: Retrospective analysis of computer-stored, standardized data for all student visits during a 4-year period. SETTING: Three high school-based student health centers. SUBJECTS: A total of 3818 adolescent students who used services provided by the school-based health centers (SBHCs). OUTCOME MEASURES: Frequencies of student visits to medical providers and mental health and substance abuse counselors and frequencies of diagnostic assignments. RESULTS: During a 38-month period, 3818 students attending senior high school made a total of 27 886 visits to three SBHCs. They represented 63% of students enrolled in the SBHCs and approximately 42% of the total school population. There were no significant demographic differences between students attending the SBHCs and the overall student body. However, compared with students who were enrolled in the SBHCs but did not use them, users were more likely to be female and Hispanic. Ninety-four percent of students using the services had visits with medical providers; 25% had visits with mental health counselors; and 8% of students had visits with substance abuse counselors. The total annual mean number of student visits was 4.7, and the annual mean numbers of visits for students who used the following services were: medical, 3.3; mental health, 5.8; and substance abuse, 6.8. An average of 1.4 diagnoses were made per visit. The most common major diagnostic categories were emotional problems (29% of all diagnoses), health supervision (13%), respiratory problems (11%), reproductive health problems (11%), and substance abuse problems (8%). Almost one fourth of the students had contact with more than one of the three categories of service provicer. Visit frequency increased significantly for students who used two categories of provider (13 to 15 mean total visits compared with 4 to 5 mean total visits for students who used just one category of provider) and escalated to a mean of 32 total visits if all three categories of service were used. CONCLUSIONS: Adolescents attending SBHCs had higher rates of visits for health and medical care than adolescents using traditional sources of medical care. The proportions of student users of SBHC mental health and substance abuse counseling services were commensurate with the estimated prevalences of these problems in this country's adolescent population. In addition, the mean numbers of visits to mental health counselors in SBHCs compared favorably with adolescent visit rates for mental health services in other settings. Too little information is available about adolescent use of substance abuse services in non-school-based settings to make similar comparisons. In summary, adolescent users of SBHCs seemed to have a higher use of medical, mental health, and probably substance abuse counseling services than did adolescents in the general populations. These findings are consistent with the interpretation that SBHCs do enhance adolescents' access to care for medical, mental health, and substance abuse problems.

American Academy of Pediatrics. Committee on Substance Abuse. Marijuana: A continuing concern for pediatricians.

Marijuana, the common name for products derived from the plant Cannabis sativa, is the most common illicit drug used by children and adolescents in the United States.(1) Despite growing concerns by the medical profession about the physical and psychological effects of its active ingredient, Delta-9-tetrahydrocannabinol, survey data continue to show that increasing numbers of young people are using the drug as they become less concerned about its dangers.(1)

Violence exposure and emotional trauma as contributors to adolescents' violent behaviors.

OBJECTIVE: To investigate the degree to which violence exposure and symptoms of psychological trauma are related to adolescents' own violent behaviors. DESIGN AND SETTING: Anonymous self-report questionnaire administered to students in 6 public high schools (grades 9-12). PARTICIPANTS: Sixty-eight percent of the students attending the participating schools during the survey participated in the study (N=3735). Ages ranged from 14 to 19 years; 52% were female; and 35% were African American, 33% white, and 23% Hispanic. RESULTS: Multiple regression analysis determined that violence exposure and symptoms of psychological trauma together explained more than 50% of the variance in both male and female self-reported violent behavior. The independent effects of exposure to violence explained about one quarter of the variance in both male and female adolescents' violent behaviors. Anger was found to be the leading trauma symptom. CONCLUSION: Our findings suggest that health clinicians and other professionals who encounter adolescents should routinely screen them for both exposure to violence and symptoms of anger.

The state of adolescent health: looking back and planning ahead.

PURPOSE: A decade has passed since the 1986 Health Futures of Youth policy-making conference was held. The present study aimed to examine perceived changes in the field of adolescent health since this conference, as a basis for further planning in adolescent health and consideration of a possible follow-up conference. METHODS: The study included two parts: (a) a mailed survey which was completed by 68 of 90 conference participants; and (b) telephone interviews with a sample of leaders from federal agencies and major foundations and one professional organization serving youth in the United States. RESULTS: Respondents perceived that small to moderate improvements have occurred for 10 key recommendations made at the 1986 conference. There appears to be increased recognition of the special needs of youth and a greater understanding of the period of adolescence. Improvements in health-related activities and in research of health behaviors have occurred. However, perceived setbacks have occurred at the intersection of health and social welfare. The conference was viewed by respondents as having had a moderate influence on the field of adolescent health and on the participants' own work and working relationships. In addition, policy-making conferences were listed as the strongest source of influence on the agenda of national agencies and foundations serving youth. CONCLUSION: A follow-up conference is recommended and should focus on both health-related topics and issues of social welfare.

Relationship of AIDS-related attitudes to sexual behavior changes in adolescents.

The impact of the acquired immunodeficiency syndrome (AIDS) epidemic on a group of adolescents was investigated by surveying 197 sexually active, predominantly African-American, urban high school students. Reported sexual behavior changes were evaluated in relation to AIDS-related knowledge and attitudes. Over 50% of the students decreased their frequency of sexual activity, increased their condom use, and/or decreased their number of partners. These students had significantly higher scores on a measure of worry about vulnerability to human immunodeficiency virus (HIV) infection than those whose behavior had not changed. AIDS knowledge, AIDS beliefs, and AIDS-related anxiety interacted with gender to affect sexual behavior change. Male students reporting decreased frequency of sexual activity, for example, had more accurate beliefs about AIDS than males reporting no decrease. Among female students, however, those reporting decreased frequency had less accurate beliefs than those reporting no decrease. These results highlight the importance of considering gender and specific sexual behaviors when designing AIDS education interventions.

Changes in adolescents' knowledge and attitudes about AIDS over the course of the AIDS epidemic.

We compared AIDS-related attitudes of junior and senior high school students from 1988 to 1991 and across grade level to examine how effectively schools are addressing AIDS. Attitudes measured included knowledge and social anxiety about AIDS, as well as perceptions of vulnerability to HIV infection. Junior high school students (grades 7-9) were sampled three times, from 1989 to 1991. High school students (grades 10-12) were sampled four times, from 1988 to 1991. The 1991 junior high school sample had lower AIDS knowledge scores than the 1989 sample. Conversely, the 1991 high school sample had more accurate knowledge than earlier groups. With respect to grade level, 9th graders had more accurate knowledge than 7th and 8th graders, but knowledge did not increase from 10th through 12th grade. Anxiety about interacting with a person with AIDS and perceptions of vulnerability to HIV infection were unrelated to either sampling time or grade level. It is concluded that it will be important to redouble efforts to educate adolescents about AIDS and that particular attention needs to be paid to young adolescents.

Interviewing guidelines for the clinical evaluation of adolescent substance abuse.

Pediatricians can learn to assess adolescent patients' use of drugs and alcohol. Their most important task is to determine whether use of chemicals is causing behavioral impairment. A general psychosocial assessment of an adolescent's functioning is the most important component of an evaluation for substance abuse. It provides the foundation for determining whether behavioral dysfunction exists. The pediatrician should address several topical areas: family relationships, school performance and attendance, peer relationships, legal difficulties, leisure activities and employment, and self-perception. The chemical use history helps the pediatrician in two ways. In general, it helps to provide focus to the pediatrician's educational counseling about the risks of chemical use. It also helps the pediatrician to determine whether substance abuse is the cause of any behavioral dysfunction that the pediatrician may have discovered during the general psychosocial assessment. Strategies to enhance more accurate disclosure of substance use by adolescents include postponing this section of the interview until rapport has been developed with the teenager, ordering questions so that illicit substances are addressed later, exploring peer involvement with chemicals as an antecedent to discussing the adolescent's personal use, and using an historical perspective, so that the teenager is asked to describe his or her initial experience with each substance class prior to addressing current use patterns. Dysfunctional consequences of chemical use may present an opportunity for adolescents and their families to accept intervention. If the pediatrician believes that an adolescent patient would benefit from a formal treatment program, the following steps help to ensure successful completion of the referral. The pediatrician should first summarize information learned during the evaluation that is relevant to the problem behaviors. Try to outline the dysfunctional behavior in the context of chemical use. Communicate concern for the teenager's well-being. Provide information without moralizing or lecturing. Clarify your role as pediatrician. Try to personalize the referral process to prevent feelings of rejection by the adolescent and family. If necessary, provide concrete assistance to the family to facilitate the referral process.

How children perceive the medical evaluation for suspected sexual abuse.

This study investigated how 99 children who were examined for suspected sexual abuse (SSA) perceived their own medical evaluation experiences. Each child was interviewed about the degree of pain and fear associated with the experience, the kindness of the doctor, general fear of doctor visits, and degree of fear associated with a hypothetical second examination. The majority of children did not perceive their SSA examination to be strongly negative. However children did report greater fear associated with the SSA evaluation compared to an ordinary doctor visit. Using multiple regression, general fear of doctor visits and fear and pain associated with the SSA examination contributed to the prediction of intensity of fear about a hypothetical second SSA evaluation. Perceived kindness of the doctor, patient sex and age, and physician sex and age did not contribute to the regression equation. The relatively low reported rate of intense distress associated with medical evaluation of SSA suggests that fear and pain can be minimized and effectively managed for many children. The results of the regression analysis suggest that previous negative medical experiences may play an important role in determining how a child interprets the experience of an SSA medical evaluation.

Genital human papillomavirus infections in adolescents: implications for evaluation and management.

Genital infections caused by human papillomaviruses (HPV) have become the most prevalent sexually transmitted disease in the United States. Rates of infection with these agents are particularly high among adolescents. The most common clinical expression of genital HPV infection is condyloma acuminata, a condition that dermatologists are frequently called on to treat. The identification of external genital warts in a teenager raises questions that impact directly on the patient's evaluation and management. Issues of importance include the likelihood that occult infection exists at other sites in the genital tract, the risks associated with HPV infection, and the need, if any, for further diagnostic assessment, including that necessary to detect the presence of coexisting sexually transmitted infections. This article examines these and associated issues and provides information that will be of value to the dermatologist caring for adolescent patients with genital warts.

Rapid diagnosis of common sexually transmitted diseases in adolescents: a review.

Sexually transmitted diseases (STDs) represent a significant health problem for adolescents in the United States. As a result, clinicians from a number of disciplines, among them pediatrics and dermatology, may be called on to evaluate teenage patients with these infections. Traditionally, the diagnosis of many STDs has relied on isolation of the causative organisms in culture. While such procedures typically offer optimal diagnostic accuracy, they are often time consuming and expensive, and may not be widely available. In an attempt to remedy this, culture-independent techniques have been developed to permit more rapid and economical diagnosis of these important pathogens. The strengths and limitations of these methods must be understood, however, for the tests to be used effectively.

The psychosocial effects of acne on adolescents.

To describe the psychosocial impact of acne on adolescents, and, in particular, to assess whether self-concept is affected by medical treatment, we evaluated 39 teenagers presenting for care to a community-based dermatologist. Prior to and following treatment, subjects completed a self-assessment questionnaire, the Piers-Harris self-concept scale, and underwent an objective assessment of acne severity. Fifty-eight percent of subjects were dissatisfied with their facial appearance and this in turn was correlated with feelings of embarrassment and social inhibition (for each, r = 0.48, P less than or equal to 0.005). Subjects' rating of acne severity, but not the dermatologist's, was correlated with dissatisfaction with facial appearance (r = 0.45, P less than or equal to 0.005). Despite these findings, the mean Piers-Harris total t-score (55.4 +/- 7.4) was within the normal range. Fourteen subjects (36%) returned for follow-up and 71% of these were judged by both the dermatologist and themselves to have improved. Following therapy, significant reductions in the adverse consequences of acne were observed with 42% of subjects reporting that their facial appearance was more acceptable to peers, 50% being less embarrassed, and 58% feeling less socially inhibited. Minimal improvement in mean Piers-Harris total t-score was observed (54.6 to 57.4, P = 0.004, paired t-test). Our data demonstrate that acne is perceived by adolescents to have important negative personal and social consequences, and that improvement in these areas may accompany medical treatment.

Adolescents' exposure to violence and associated symptoms of psychological trauma.

OBJECTIVE: To examine the extent to which adolescents are exposed to various types of violence as either victims or witnesses, and the association of such exposure with trauma symptoms; specifically, the hypotheses that exposure to violence will have a positive and significant association with depression, anger, anxiety, dissociation, posttraumatic stress, and total trauma symptoms. DESIGN AND SETTING: The study employed a survey design using an anonymous self-report questionnaire administered to students (grades 9 through 12) in six public high schools during the 1992-1993 school year. PARTICIPANTS: Sixty-eight percent of the students attending the participating schools during the survey participated in the study (N = 3735). Ages ranged from 14 to 19 years; 52% were female; and 35% were African American, 33% white, and 23% Hispanic. RESULTS: All hypotheses were supported. Multiple regression analyses of the total sample revealed that violence exposure variables (and to a lesser extent, demographic variables) explained a significant portion of variance in all trauma symptom scores, including depression (R2 = .31), anger (R2 = .30), dissociation (R2 = .23), posttraumatic stress (R2 = .31), and total trauma (R2 = .37). CONCLUSIONS: A significant and consistent association was demonstrated linking violence exposure to trauma symptoms within a diverse sample of high school students. Our findings give evidence of the need to identify and provide trauma-related services for adolescents who have been exposed to violence.

Use of enzyme immunoassay for the rapid diagnosis of Chlamydia trachomatis endocervical infection in female adolescents.

Enzyme immunoassay (EIA) has been proposed as an alternative to tissue culture for the detection of Chlamydia trachomatis in cervical specimens. The diagnostic efficacy of EIA was compared to tissue culture in 113 teenaged females attending an adolescent reproductive health program. Infection was diagnosed by tissue culture in 16% of subjects. Compared with tissue culture, EIA demonstrated a sensitivity of 100%, specificity of 88%, positive predictive value of 62%, and a negative predictive value of 100%. These data indicate that EIA is an acceptable alternative to tissue culture when screening for C. trachomatis endocervical infection in adolescent females.

Knowing someone with AIDS: the impact on adolescents.

Tested 25 adolescents who reported knowing a person with AIDS or HIV (PWA) and were matched by gender, race, grade, school type, and academic achievement with 25 adolescents who reported not knowing a PWA. The groups were compared with respect to their knowledge, beliefs, and social anxiety about AIDS and with respect to their worries about personal vulnerability to HIV infection. Social anxiety was significantly lower in those reporting knowing someone with AIDS than in the matching group. No significant differences between the two groups were found for knowledge, beliefs, or vulnerability worries. The implications of these findings for research on AIDS interventions with adolescents are discussed.

High school athletes and the use of ergogenic aid.

To determine high school athletes' attitudes toward and use of ergogenic aids, we surveyed 295 students presenting for preparticipation examinations. In general, young athletes believed that steroids and amphetamines were not efficacious in enhancing sports performance and that their use was potentially harmful. Subjects reported minimal use of steroids (1%) and amphetamines (2%), and only a minority would consider their use. As a group, however, male athletes were more likely to believe that steroids were effective (32% vs 13%) and to consider the future use of these agents (14% vs 0) compared with female athletes. The majority of high school athletes believed that supplemental protein or vitamins could improve performance and that their use caused little or no health risk. These data suggest that young athletes may require information regarding the limited benefits and potential risks associated with the use of ergogenic aids.