Interval history, including a review of systems, can be obtained according to the health care profession-
al’s preference or style of practice. In most cases, the youth will be alone at the visit. In some situations,
especially if the youth has a special health care need, he may be accompanied by a parent or guardian.
Some clinicians use the HEEADSSS (Home, Education, Eating Activities, Drugs, Sexuality, Suicide, Safety)
or SSHADESS (Strengths, School, Home, Activities, Drugs, Emotions/Eating/Depression, Sexuality, Safety)
mnemonics to help organize the questions for their youth patients.17,18 The following questions may
encourage in-depth discussion to determine changes in health status that would warrant further physicalor emotional assessment:
General Questions for the Youth
■ How do you stay healthy?
■ What are you good at?
■ What do you do to help others?
■ Who are the important adults in your life?
■ What are your responsibilities at home and at school?
■ What do you and your friends like to do together?
■ What health problems, concerns, or questions do you have?
General Questions for the Parent
■ What questions do you have about your child’s physical well-being, growth, or pubertal development?
■ Tell me something your child does really well.
■ What questions or concerns do you have about your child’s emotional well-being, feelings, behavior, or learning?
■ What have you and your child discussed about feelings and behaviors that are contributing to his emotional well-being and a healthy lifestyle?
■ What have you and your child discussed about avoiding risky behaviors? Does your child have any behaviors that you are concerned about?
Past Medical History
■ Has your child received any specialty or emergency care since the last visit?
■ Has your child or anyone in the family, such as parents, brothers, sisters, grandparents, aunts, uncles, orcousins developed a new health condition or died? If the answer is Yes: Ascertain who in the family hasor had the condition, and ask about the age of onset and diagnosis. If the person is no longer living, askabout the age at the time of death.
Risks: Interpersonal violence (fighting, bullying), living situation and food security, family substance use (tobacco, e-cigarettes, alcohol, drugs)
Strengths and protective factors: Connectedness with family and peers, connectedness with community, school performance, coping with stress and decision-making
Surveillance of Development
The developmental tasks of early adolescence can be addressed by asking specific questions, through information obtained in the medical examination, by observation, and through general discussion. The following areas can be assessed to understand the developmental health of the youth. A goal of this assessment is to determine whether the youth is developing in an appropriate fashion and, if not, to pro-vide information, assistance, or intervention. In the assessment, determine whether the youth is making progress on the following developmental tasks19:
■ Forms caring and supportive relationships with family members, other adults, and peers
■ Engages in a positive way with the life of the community
■ Engages in behaviors that optimize wellness and contribute to a healthy lifestyle
– Engages in healthy nutrition and physical activity behaviors
– Chooses safety (wearing bike helmets, using seat belts, avoiding alcohol and drugs)
■ Demonstrates physical, cognitive, emotional, social, and moral competencies (including self-regulation)
■ Exhibits compassion and empathy
■ Exhibits resiliency when confronted with life stressors
■ Uses independent decision-making skills (including problem-solving skills)
■ Displays a sense of self-confidence, hopefulness, and well-being
Review of Systems
The Bright Futures Adolescence Expert Panel recommends a complete review of systems as a part of every health supervision visit. This review can be done through the following questions:
Do you have any problems with
■ Regular or frequent headaches or dizziness
■ Fainting or passing out
■ Eyes or vision
■ Ears or hearing
■ Nose or throat
■ Breathing problems or chest pains
■ Belly aches or pains, throwing up, problems with bowel movements
■ Painful urination or other urine problems
■ Rashes, moles, sunburn
■ Muscle aches, injury, or other problems
■ Fatigue For Girls
■ Have you had your first period?
– If so, when was your last period?
– Do you have any problems with your periods?
– Do you have any itching, burning, or discharge in your vaginal area?
Observation of Parent-Youth Interaction
The parent or guardian of the early adolescent often accompanies the youth to the visit, but the health care professional will spend some time with the youth alone during each Early Adolescence Visit. The health care professional can observe parent-youth interactions, including
■ How comfortably do the youth and parent interact, both verbally and nonverbally?
■ Who asks and answers most of the questions?
■ Does the youth express an interest in managing his own health issues (including youth with special health care needs)?
Cultural norms and values shape parent-youth interactions. To interpret observations accurately, the health care professional should learn about the norms and expectations of the populations served. Different cultures have different norms about how youth and adults interact and whether youth speak directly to adults or offer their own opinions in front of adults.
In addition to observation, the health care professional can help guide the parent and the youth’s interaction to encourage the youth’s participation in his health decisions. For example, if the parent is answering all the questions, then the health care professional can redirect questions straight to the youth with
wording such as, “What are your thoughts on what we are discussing?”
Growth chart (section already on the paper)
Screening (section already on the paper)
Immunization (section already on paper)
Anticipatory Guidance (must answer 3 for this child)
- Risks: Living Situation and Food Security
Families in difficult living situations or with limited resources may have concerns about their ability to acquire adequate housing and sufficient food. Questions on this topic, especially those directed to the youth, can be sensitive. If the family has housing difficulties, refer the family to community housing resources.
Increased caloric needs during the adolescent growth spurt make food security a critical issue in early adolescence. If the family is having difficulty obtaining nutritious food, provide information about the Special Nutrition Assistance Program (SNAP), the Commodity Supplemental Food Program, local food shelves, and local community food programs.
Ask the Parent
Tell me about your living situation. Do you have enough heat, hot water, and electricity? Do you have appliances that work? Do you have problems with bugs, rodents, or peeling paint or plaster? In the past 12 months, did you worry that your food would run out before you got money to buy more? In the past 12 months, did the food you bought not last and you did not have money to buy more?
For the Parent
■ The people at community agencies have expertise in housing issues and can get you the help you need. Would you like me to help you get in touch with them?
■ Community food and nutrition programs and resources, like food banks, food pantries, and community food programs, are available to help you and your family. You also may be eligible for programs like SNAP, the program formerly known as Food Stamps.
- Risks: Family Substance Use (Tobacco, E-cigarettes, Alcohol, Drugs)
Exposure to tobacco smoke remains an important environmental risk. Although the long-term health effects of e-cigarettes have not yet been established, exposure to secondhand vapor from them likely car-ries health risks. Youth with family members and peers who use e-cigarettes (also called vaping) are more likely to begin using these devices themselves, and youth who use e-cigarettes are more likely to start using conventional cigarettes. Worrying about a family member with a substance use or mental health problem may be a source o significant stress.
Ask the Youth
Does anyone in your house or other places where you spend a lot of time smoke cigarettes or vape with e-cigarettes?
Ask the Parent
Is there anyone in your child’s life whose alcohol or drug use concerns you?
For the Youth
■ It’s not always possible, but, when you can, avoid spending time indoors or in cars where people are smoking cigarettes or vaping with e-cigarettes.
■ If someone in your family smokes, they have probably tried to stop many times. Nicotine from cigarettes and e-cigarettes is one of the most addicting drugs we know. That’s why it’s so hard to quit. That’s also why your family and I don’t want you to start using tobacco or e-cigarettes.
■ If you are worried about any family members’ drug or alcohol use problems, you can talk with me.
- Strengths and Protective Factors: School Performance
An opportunity to develop academic competence in school also is a strength and protective factor for youth; school performance and engagement with school personnel and activities are key. The transition from elementary school to middle school and then to high school is an exciting time because it brings new experiences and responsibilities and increased freedom. It also has its difficult moments, as youth grapple with new social and academic situations and challenges. Success in school is associated with a reduced number of risky behaviors and it increases positive social relationships. Poor academic achievement may be a sign of depression, anxiety, attention, or learning problems. Chronic absenteeism, which is frequently defined as missing at least 10% of school days, is a very frequent problem, especially in areas of poverty, either rural or urban. Among states that currently measure it, rates across a state range from about 11% on the low end to as high as 24%. Chronic absenteeism is a leading harbinger of dropping out of school, regardless of reason. Rates start to increase during middle school. Emphasizing to parents and to patients the importance of attending school every day is extremely important.21
Ask the Youth
How are you doing in school? What do you enjoy at school? What is your favorite subject? Are you having particular difficulty with any subjects? Do you get any therapies in school or extra help with any particular subjects?
Ask the Parent
Is your child getting to school on time? How is your child doing in school? Is she completing her homework?
How are her grades? Has she missed more than 2 days of school in any month?
For the Youth
■ Take responsibility for getting your homework done and getting to school on time.
■ If you are having any difficulty at school, talk with your parent or another trusted adult about it.
For the Parent
■ Emphasize the importance of school.
■ Praise positive efforts.
■ Recognize success and achievements.
■ Monitor and guide your child as she assumes more responsibility for her schoolwork.
■ Many youth need help with organization and setting priorities as they transition through middle school and into high school.
■ Encourage reading by helping your child find books and magazines about subjects that interest her.
■ Have her bring a book when you know she’ll be waiting somewhere or in a situation requiring patience.
Address the following in narrative form:
● What new learnings did you gain from completing this case study?
● What was challenging for you in this case study?
● What worked well for you as you completed the developmental assessment?
● What would you do differently in future developmental assessments and work with pediatric clients?