Adolescent Exam

Adolescence is a time of significant physical change as surges of hormones, including estrogen and testosterone, cause growth in stature and development of secondary sexual characteristics, such as breast and penile maturation.

In addition to the physical changes, adolescence is also a time of marked emotional change, and the combination of these can be distressing and uncomfortable for adolescents. Pediatric providers can play a key role in relieving some of this distress by normalizing the feelings and physical changes that occur during this period. 

In order to build a trusting provider-patient relationship, the provider needs to create an environment where the adolescent feels safe to disclose personal information and concerns. To facilitate this, the adolescent should be treated as a unique individual, with respect, and without preconceived notions about their concerns or goals.

While most of the basic components of the physical exam in adolescents are similar to those in adults, there is added focus on pubertal development through the use of the sexual maturity rating scale.

However, internal examinations, such as bimanual and speculum, and clinical breast examinations are not done as part of routine puberty assessment in adolescents. These examinations may be indicated in specific clinical circumstances, such as pelvic pain, vaginal discharge, or breast masses. 

The discussion of physical changes should be accompanied by adolescent psychosocial screening questions, including environmental safety, mental health, sexual activity, and drug or alcohol use. 

Family connectedness and social support are protective against negative mental health outcomes and high-risk sexual behaviors in adolescents, and is particularly important in sexual minority and gender minority populations.

If requested by the adolescent, help disclose any pertinent information to family members. If the information was disclosed in confidence, do not violate an adolescent's privacy because unsafe disclosure may lead to unintended health and social consequences such as homelessness, abuse, and suicide.

As of 2020, firearm-related injury is the leading cause of death in those under 20 in the United States. 

Access to firearms in the home should be reviewed along with the adolescent's risk of violence, such as the history of physical abuse, gang involvement, use of weapons, and missed school.  Interventions in this area include community mentoring programs and mental health services.

In the United States, motor vehicle collisions are another major cause of mortality in adolescents. Encourage seatbelt use and caution against distracted or impaired driving.

An eventual goal in the care of adolescents is to prepare them for managing their health and healthcare as adults. Physicians can help them to learn these responsibilities by directly addressing adolescents with questions, assigning them responsibility for their own healthcare actions, educating them about their health history, and helping them navigate the healthcare system.

This video focuses on techniques to promote a trusting provider-patient relationship and foster healthcare autonomy as teenagers approach adulthood.  In addition, it also reviews pubertal development of secondary sexual characteristics using the "Tanner Stages", which can be helpful in teaching the patient what is normal and not normal during the physical exam.

Lastly, the SSHADESS assessment is discussed— a strength-focused tool for psychosocial screening in adolescents to promote resilience, intervene early in problem areas, and promote a healthy transition to adulthood.

To begin, set expectations at the start of the visit by describing the role of a healthcare provider as a source of confidential information and support. Also, explain that adolescents are provided with an opportunity to discuss their health privately with the clinician.

If a parent or caregiver accompanies the adolescent, ask them to provide historical or contextual information about the patient's concerns. However, inform the adolescent that they will have the opportunity to have a private talk about any concerns.

Therefore, as a matter of routine, ask the parent to step out while speaking one-on-one with the adolescent. Depending on the clinical situation, private time with the adolescent can range from a small portion of the visit to the entire visit.

Before starting a private conversation, assure the adolescent that the discussion will remain confidential within the healthcare team unless there are concerns about the patient hurting themselves or someone else, a concept called conditional confidentiality.

Work with the adolescent and the parent to allow the patient to gradually take more responsibility when it comes to their health. For example, allowing the adolescent to make medical appointments under supervision will help them learn how to navigate the medical system.

Adolescence is a time of significant physical changes, and it is good practice to try to assess whether the patient is comfortable with their bodily changes. Ask them to share any questions or concerns about how their body is developing.

If the patient expresses any concern, normalize it by saying that such questions are common among teenagers, and they will be taken into account during the physical examination. However, make sure not to offer any reassurance until the assessment is complete.

Offer the patient a chaperone before starting the physical exam, such as a family member or friend who has accompanied them to the visit, or a nurse or medical assistant from the team. Be aware of institutional policies regarding the use of chaperones, especially if an adolescent asks to be examined alone without a chaperone. There may be some circumstances where this is appropriate and preferable for patient comfort and privacy.

In addition to the typical physical exam one would do for adults, a pubertal assessment is an important part of the adolescent physical exam. Start the assessment with an external genital exam. If the adolescent is particularly reluctant to be examined, use the opportunity to understand their concerns and negotiate an acceptable solution, such as providing another appointment date or a different examiner if the exam is not urgent.

When performing the examination, document the patient's sexual maturity stage for pubic hair and genitals, as well as note any external lesions, vaginal or penile discharge, or masses.

The sexual maturity staging system utilized most frequently is that published by Marshall and Tanner – commonly referred to as the "Tanner stages." The Tanner stages show the expected progression of testicular and penile growth in males and the distribution of pubic hair and breast enlargement in females.

If the patient's development does not align with the timing and expected progression of pubertal stages, hormonal testing may be indicated to establish the etiology of delayed or early puberty.

This part of the exam is an opportunity to teach the patient about normal and abnormal breast and genital findings, which will help them learn about their own body and the changes they can expect as they progress through puberty.

In the case of a young girl starting puberty, inform her that hair growth occurs under the arms and in the pubic region, which is a normal and expected process in adolescents.

Breast exams for adolescents without specific concerns related to breast health are typically limited to brief inspection and palpation to assess for sexual maturing staging. Also, explain the onset of menstruation which indicates that the body is ready to support a child.

For a boy starting puberty, let him know that his penis and testicles will get larger, and he will have erections when aroused, which is a normal and expected part of his development.

The complex biologic transitions of puberty often impact the psychosocial aspects of an adolescent's life and are an important part of the evaluation.

The SSHADESS assessment is a psychosocial interview tool that allows for assessing high-risk behaviors while emphasizing the identification of strengths. Healthy development is more likely to occur when adolescents feel valued and empowered.

Start the assessment by asking the adolescent what activities they are good at, or about something they are proud of. Identifying strengths within their life experience helps to build a therapeutic alliance and promotes their resilience.

Continue the assessment by asking about school, grades, and relationships with friends and family. Healthy development is promoted when adolescents form healthy social connections within their home and community. Therefore, any potential for abuse, neglect, or bullying should be addressed.

Next, ask about their daily activities, with a particular focus on social media. This is an opportunity to educate families about digital literacy, open family communication, and boundary setting on content and display of personal information.

Doctor: "Any extracurricular activities you have been doing?"

Patient: "Yea, I do dance."

Doctor: "You do? Ok, great! Is there like all kinds of dance or…"

Patient: "It's mostly modern dance. It's like an afterschool"

Doctor: "Oh, fine! That sounds like a very good form of exercise. That's nice."

Patient: "It is!"

Doctor: "Yea"

The American Academy of Pediatrics recommends that clinicians screen adolescents for substance use and, if applicable, provide brief intervention, do follow-up, and consider referral for weekly or more frequent use.

Adolescence can be a time of complex emotional changes which can manifest in various ways that could negatively affect health. Mental health disorders can emerge during this time, and indeed suicide is the third leading cause of death in teenagers.

The AAP and USPSTF recommend routine screening for depression in adolescents with the use of standardized instruments such as the Patient Health Questionnaire, or PHQ-A. The AAP also recommends screening for eating disorders.

Doctor: "Camellia, tell me how you've been sleeping lately?"

Patient: "Pretty good, yea. I wake up pretty early for high school, but other that, pretty well"

Doctor: "Ok. So, what time do you usually go to bed at night?"

Patient: "Umm, Elevenish, eleven."

Doctor: "Eleven? OK. And then, what time are you waking up?"

Patient: "It's like seven, seven-thirty"

Doctor: "So good eight hours!"

Patient: "Yea, I try."

Counsel the adolescent on pregnancy risk, healthy relationships, and contraception. Assess sexual behaviors, including the number of sexual partners, condom use, and history of sexually transmitted diseases, with annual screens for gonorrhea and chlamydia in sexually active females less than 24 years or more frequently if they are at high risk. Abstinence, if practiced, should be reinforced.

Inquire about safety at home, school, and in the community. Do not make assumptions about sexual orientation and gender identity, and create a safe and inclusive environment with gender-inclusive questioning.

Doctor: "Umm, so there is a few kinds of more sensitive questions that I do ask all the teenage patients, just to make sure that you're safe."

Patient: "Hmm, hmm."

Doctor: "Are you in a relationship with anyone?"

Patient: "Yes"

Doctor: "You are, ok. Can I ask what's his name?"

Patient: "Yea, his name is Ryan."

Doctor: "Ryan, Ok. And do you know him from school or…."

Patient: "He did go to UConn, but we met afterward, after he graduated"

Doctor: "Ok, good. And how long how you guys been together?"

Patient: "It's two years now."

Doctor: "Two years. OK. That's great, so you probably know each other pretty well."

Patient: "Yea"

Doctor: "Good. And you guys feel like you have a pretty respectful relationship with one another?"

Patient: "Yeah, for sure."

Doctor: "You feel safe with him? He respects you?"

Patient: "Oh, yeah."

Doctor: "Good. And are you guys sexually active at all?"

Patient: "Yes"

When finished with the interview and exam, ask the adolescent if they have any questions or concerns that were not addressed. Remind them that pediatric providers are safe and confidential resources if any concerns arise about their physical or mental health. 

Also, ensure that the adolescent knows how to get in contact with the pediatrician if they need to. Some adolescents may prefer to access care through secure electronic portals and related mobile apps, and this information should be provided to them.