Health Care Maintenance in Female Adolescents
2005; Elsevier BV; Volume: 80; Issue: 12 Linguagem: Inglês
10.4065/80.12.1641
ISSN1942-5546
AutoresElizabeth A. Boatwright, Beverly S. Tozer, Deepa P. Verma, Janis E. Blair, Anita P. Mayer, Julia A. Files,
Tópico(s)Primary Care and Health Outcomes
ResumoThe assessment and care of female adolescents by primary care physicians can be facilitated with increased knowledge about this stage of development, the health care risks faced by these patients, and the resources available to aid in their care. With a focus on preventive health maintenance, this concise review addresses these areas as well as how to build relationships with female adolescent patients, conduct age-appropriate interviews and tests, and maintain patient confidentiality. The assessment and care of female adolescents by primary care physicians can be facilitated with increased knowledge about this stage of development, the health care risks faced by these patients, and the resources available to aid in their care. With a focus on preventive health maintenance, this concise review addresses these areas as well as how to build relationships with female adolescent patients, conduct age-appropriate interviews and tests, and maintain patient confidentiality. Female adolescents have unique health care needs. Many internists may be uncomfortable about meeting those needs because of a lack of specific training focused on this age group. Published recommendations by professional health organizations can guide health care practitioners in their approach to adolescent health care (TABLE 1, TABLE 2).1American Medical Association Guidelines for Adolescent Preventive Services (GAPS): Recommendations Monograph. American Medical Association, Chicago, Ill1997Google Scholar, 2American Academy of Pediatrics Guidelines for Health Supervision III. American Academy of Pediatrics, Elk Grove Village, Ill1997Google Scholar With slight variations, these recommendations consist of 4 major categories of preventive services: (1) screening for behavioral and physical conditions, (2) counseling to reduce risks, (3) providing immunizations, and (4) offering anticipatory guidance or general health guidance. In this review, we aim to highlight important health risks of female adolescents and provide internists with practical tools for assessment and care of these patients, using as a framework the Guidelines for Adolescent Preventive Services (GAPS) recommendations of the American Medical Association (AMA),3Elster AB Kuznets NJ AMA Guidelines for Adolescent Preventive Services (GAPS): Recommendations and Rationale. Williams & Wilkins, Baltimore, Md1994Google Scholar modified by more recent screening recommendations from the American Academy of Pediatrics (AAP),2American Academy of Pediatrics Guidelines for Health Supervision III. American Academy of Pediatrics, Elk Grove Village, Ill1997Google Scholar the Bright Futures program,4Green M Palfrey JS Bright Futures: Guidelines for Health Care Supervision of Infants, Children, and Adolescents. 2nd ed, rev. National Center for Education in Maternal and Child Health, Arlington, Va2002: 230-297Google Scholar and other health organizations. Currently, a task force of members from the AMA, AAP, and the Bright Futures program is revising recommendations for adolescent screening and health maintenance. Published recommendations from this joint committee are anticipated in 2006 and 2007, and early recommendations have been incorporated into this review.TABLE 1Resources for Adolescent Services Guidelines for Adolescent Preventive Services (GAPS), American Medical Association www.ama-assn.org/ama/pub/category/1980.html Accessed October 3, 2005 (monograph and adolescent and parent questionnaires can be downloaded free of charge)American Academy of Pediatrics www.aap.org/policy/re9939.html Accessed October 3, 2005Bright Futures Guidelines, Maternal and Child Health Bureau, US Public Health Services www.brightfutures.org/bf2/pdf/index.html Accessed October 3, 2005 (book, pocket guides, anticipatory guidance cards, and family forms can be ordered)US Preventive Services Task Force www.ahrq.gov/clinic/prevenix.htm Accessed October 3, 2005American Academy of Family Physicians www.aafp.org Accessed October 3, 2005Society for Adolescent Medicine, Blue Springs, Mo www.adolescenthealth.org Accessed October 3, 2005Centers for Disease Control and Prevention www.cdc.gov. Accessed October 3, 2005North American Society for Pediatric and Adolescent Gynecology www.naspag.org Accessed October 3, 2005 Open table in a new tab TABLE 2Recommendations for Preventive Health Services for Female Adolescents*Closed circles indicate service to be performed at that age. Dotted lines indicate service to be performed at some time during that stage of development. Body mass index = weight in kilograms divided by height in meters squared (kg/m2); HIV = human immunodeficiency virus; HPV = human papillomavirus; MCV4 = meningococcal conjugate vaccine; MMR = measles-mumps-rubella; O = objective by standard testing; S = subjective by history; Td = tetanus-diphtheria; Tdap = tetanus-diphtheria-pertussis.Modified from Guidelines for Adolescent Preventive Services (GAPS): Recommendations Monograph, copyright 1997, American Medical Association, with permission.1American Medical Association Guidelines for Adolescent Preventive Services (GAPS): Recommendations Monograph. American Medical Association, Chicago, Ill1997Google Scholar Sensory screening data from American Academy of Pediatrics.2American Academy of Pediatrics Guidelines for Health Supervision III. American Academy of Pediatrics, Elk Grove Village, Ill1997Google Scholar 1. Screen once if family history is positive for early cardiovascular disease or hyperlipidemia.2. Screen if positive for exposure to active tuberculosis or lives or works in high-risk situation (eg, homeless shelter or health care facility).3. Screen at least annually if sexually active. HPV screening is by visual inspection and Papanicolaou smear; HPV typing in adolescents is controversial, given the high likelihood of regression over time.4. Screen if at high risk for infection.5. Screen annually if sexually active or if 21 years or older.6. Tdap is recommended as a single booster at the 11- to 12-year visit or at 13 to 18 years of age if not previously given; it can be given as a booster for pertussis if Td was given previously.7. Vaccinate against hepatitis B virus if not yet vaccinated; catch-up vaccination for incompletely immunized adolescents can be given independent of timing of previous dose(s).8. Vaccinate if at risk for hepatitis A infection.9. Vaccinate if no reliable history of chicken pox or previous vaccination. One shot is required for children ≤12 years; adolescents ≥13 years require 2 shots, 1 month apart.10. Vaccinate with MCV4 at age 11 to 12 years or after age 15.†All menstruating adolescents should be screened periodically, with frequency cian, depending on risk factors of laboratory work at the for anemia (eg, heavy menses).‡Urinalysis dipstick for leukocytes suggested yearly in sexually active adolescents.¶Fasting serum glucose recommended every 2 years, starting at age 10 years or with onset of puberty (if earlier than 10 years) for adolescents who are overweight or from high-risk families or ethnic groups.* Closed circles indicate service to be performed at that age. Dotted lines indicate service to be performed at some time during that stage of development. Body mass index = weight in kilograms divided by height in meters squared (kg/m2); HIV = human immunodeficiency virus; HPV = human papillomavirus; MCV4 = meningococcal conjugate vaccine; MMR = measles-mumps-rubella; O = objective by standard testing; S = subjective by history; Td = tetanus-diphtheria; Tdap = tetanus-diphtheria-pertussis. Open table in a new tab 1. Screen once if family history is positive for early cardiovascular disease or hyperlipidemia. 2. Screen if positive for exposure to active tuberculosis or lives or works in high-risk situation (eg, homeless shelter or health care facility). 3. Screen at least annually if sexually active. HPV screening is by visual inspection and Papanicolaou smear; HPV typing in adolescents is controversial, given the high likelihood of regression over time. 4. Screen if at high risk for infection. 5. Screen annually if sexually active or if 21 years or older. 6. Tdap is recommended as a single booster at the 11- to 12-year visit or at 13 to 18 years of age if not previously given; it can be given as a booster for pertussis if Td was given previously. 7. Vaccinate against hepatitis B virus if not yet vaccinated; catch-up vaccination for incompletely immunized adolescents can be given independent of timing of previous dose(s). 8. Vaccinate if at risk for hepatitis A infection. 9. Vaccinate if no reliable history of chicken pox or previous vaccination. One shot is required for children ≤12 years; adolescents ≥13 years require 2 shots, 1 month apart. 10. Vaccinate with MCV4 at age 11 to 12 years or after age 15. †All menstruating adolescents should be screened periodically, with frequency cian, depending on risk factors of laboratory work at the for anemia (eg, heavy menses). ‡Urinalysis dipstick for leukocytes suggested yearly in sexually active adolescents. ¶Fasting serum glucose recommended every 2 years, starting at age 10 years or with onset of puberty (if earlier than 10 years) for adolescents who are overweight or from high-risk families or ethnic groups. Adolescence is a time of great physical, emotional, and social change. It encompasses the ages between 11 and 21 years, although puberty can begin as early as age 7 or 8 years in some girls. Physical pubertal changes occur in a predictable pattern that can be anticipated and monitored.5Marshall WA Tanner JM Variations in pattern of pubertal changes in girls.Arch Dis Child. 1969; 44: 291-303Crossref PubMed Scopus (4464) Google Scholar On average, puberty lasts 3 to 4 years. Breast budding is the first sign of puberty in girls, beginning between ages 7 and 13 years. Growth of pubic hair follows, although in as many as 15% of girls, pubic hair may start growing before breast buds develop. The growth spurt in female adolescents starts during Tanner stage 2, usually 1 year after the onset of puberty, and peaks in Tanner stage 3. Peak height velocity occurs 18 to 24 months earlier in girls than in boys, and the growth spurt lasts as long as 36 months. Growth is completed primarily by the time of menarche, which follows development of breast buds by 2 to 3 years. While major physical changes are occurring, cognitive changes transform a concrete-thinking adolescent into a young adult with the ability to reason abstractly, to anticipate future consequences, and to empathize with others. Cognitive development does not mirror physical maturity, and adolescents may regress during times of stress or illness. As adolescents mature cognitively, they are better able to participate actively in their own health maintenance. Adolescent psychosocial development entails the establishment of a personal identity and self-image, autonomy from parents, and ability to form mature relationships. This psychosocial development has commonly referenced stages (Table 3).TABLE 3Developmental Stages of AdolescentsModified from Joffe,6Joffe A Adolescent medicine.in: Oski FA DeAngelis CD Feigin RD McMillan JA Warshaw JB Principles and Practice of Pediatrics. JB Lippincott Co, Philadelphia, Pa1994: 763-805Google Scholar with permission from Lippincott Williams & Wilkins.CharacteristicStagePsychosocialPsychologicalEarly adolescence (11-13 y) Begin separation from parentsPeer group influence beginsSame-group activitiesComparison of body changes with same-sex peersIntense same-sex friendshipsCrushes Focus on body changes: “Am I normal?”Early formal operation thinkingPoor futurity orientationBeginning of increase in sexual driveImaginary audience behavior, narcissism, egocentrismMiddle adolescence (14-17 y) Peak of conflict with parents; test limitsPeer influence and conformity at highest levelSexual behaviors (both same and opposite sex) increase; experimentation without commitmentRisk-taking behaviors increase Focus on personal and sexual identity: “Who am I?”Autonomy is chief concernMore future orientedFormal operational thinking established (may regress under stress)Acceptance of body changesLate adolescence to young adulthood (18-21 y) Close friendshipsIntimacy issues of increasing importanceReconnection with parentsCareer goals definedMultiple peer groupsPeer group influence wanes Focus on identity in relation to society: “What is my role in relation to society?”Formal operational thinking well establishedFuture-oriented realistic goals Open table in a new tab During the potentially tumultuous period of adolescence, individuals must develop an ideology and a set of values to guide them into adulthood. These values will have strong implications for their overall health far into the future. Physicians are in a unique position to provide non-judgmental purposeful guidance to adolescents, thus helping them to make healthy choices and establish a lifestyle for a successful transition into adulthood. Risk-taking behavior is common in adolescence. Experimentation allows adolescents to try out newly developed skills or physical prowess and to test limits and value systems in order to establish their own. Some risk taking is beneficial because it builds confidence and competence. However, other obviously dangerous risk taking contributes to adolescent mortality and morbidity (Table 4), with approximately 25% of all adolescents being at significant risk of school failure, serious injury, or death.9McMillan JA DeAngelis CD Feigin RD Warshaw JB Oski's Pediatrics: Principles and Practice. Lippincott Williams & Wilkins, Philadelphia, Pa1999Google ScholarTABLE 4Prevalence of Risk-taking Behaviors Among US High School Students in 2003*BMI = body mass index, weight in kilograms divided by height in meters squared (kg/m2).Data from the Centers for Disease Control and Prevention.7Grunbaum JA Kann L Kinchen S et al.Youth risk behavior surveillance: United States, 2003 [published correction appears in MMWR Surveill Summ. 2004;53:536].MMWR Surveill Summ. 2004; 53: 1-96PubMed Google Scholar Voluntary or involuntary first sexual intercourse data from Abma et al.8Abma JC Martinez GM Mosher WD Dawson BS Teenagers in the United States: sexual activity, contraceptive use, and childbearing, 2002.Vital Health Stat 23. 2004; 24: 1-48PubMed Google ScholarFemaleMaleBehavior(%)(%)Never or rarely use seatbelt†In the 30 days before the survey.14.621.5Never or rarely use bike helmet†In the 30 days before the survey.84.287.2Rode with driver who had been drinking alcohol†In the 30 days before the survey.31.129.2Drove after drinking alcohol†In the 30 days before the survey.8.915.0Carried a weapon (gun, knife, club)†In the 30 days before the survey.6.726.9Got into a physical fight‡In the 12 months before the survey.25.140.5Experienced dating violence (hit, slapped, physically hurt by partner)‡In the 12 months before the survey.8.88.9Forced to have sexual intercourse‡In the 12 months before the survey.11.96.1Felt sad or hopeless every day ≥2 weeks in a row‡In the 12 months before the survey.35.521.9Seriously considered suicide‡In the 12 months before the survey.21.312.8Made plan for suicide‡In the 12 months before the survey.18.914.1Attempted suicide‡In the 12 months before the survey.11.55.4Tobacco use Ever58.158.7 Daily for ≥30 days15.815.7 Currently (≥1 within previous 30 days)21.921.8 Before age 13 y16.420.0Alcohol use Ever76.173.7 Current (≥1 in past 30 days)45.843.8 Episodic heavy drinking§Five or more drinks of alcohol on ≥1 occasion within the previous 30 days.27.529.0 Before age 13 y23.332.0Marijuana use Ever37.642.7 Current19.325.1 Before age 13 y6.912.6Cocaine (any form) use Ever or current7.7/3.59.5/4.6Ecstasy (any use ever)10.411.6Methamphetamines (any use ever)6.88.3Inhalant (any use ever)11.4/3.412.6/4.3Illegal corticosteroid (any use ever)5.36.8Injected drug (any use ever)2.53.8Sexual intercourse Ever45.348.0 Before age 13 y4.210.4 ≥4 sex partners11.217.5 Currently sexually active (in past 3 months)34.633.8Condom used during last intercourse57.468.8Alcohol or drug use before last intercourse21.029.8Ever pregnant or fathered child4.93.5Voluntary or involuntary first sexual intercourse Did not want to at that time13.06.0 Mixed feelings52.031.0 Really wanted it to happen at that time33.060.0Dietary behavior ≥5 servings per day of fruit and vegetables in past 7 days20.323.6 ≥3 glasses milk per day in past 7 days11.222.7Physical activity Exercises vigorously or sufficiently (sweats, breathes hard ≥20 minutes on ≥3 of 7 days)55.070.0 Exercises insufficiently (<3 of 7 days or 95th percentile BMI)9.417.4 At risk for being overweight (>85th, <95th percentile BMI)15.315.5 Describes self as overweight36.123.5 Trying to lose weight59.329.1Has tried to lose or control weight Ate less food56.228.9 Exercised65.749.0 Went without eating for 24 hours18.38.5 Used diet pills, powders, or liquids11.37.1 Vomited or used laxatives8.43.7* BMI = body mass index, weight in kilograms divided by height in meters squared (kg/m2).† In the 30 days before the survey.‡ In the 12 months before the survey.§ Five or more drinks of alcohol on ≥1 occasion within the previous 30 days. Open table in a new tab Most deaths in the United States among persons aged 10 to 24 years can be attributed to 4 major causes: motor vehicle accidents (32%), other unintentional injuries (12%), homicide (15%), or suicide (12%).7Grunbaum JA Kann L Kinchen S et al.Youth risk behavior surveillance: United States, 2003 [published correction appears in MMWR Surveill Summ. 2004;53:536].MMWR Surveill Summ. 2004; 53: 1-96PubMed Google Scholar Adolescent male mortality is 2.6 times that of female mortality (Figure 1),10Centers for Disease Control and Prevention Web-based Injury Statistics Query and Reporting System (WISQARS) [Online]. National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, 2004Available at: www.cdc.gov/ncipc/wisqarsGoogle Scholar with motor vehicle accidents the leading cause of death for both.11Department of Health and Human Services Centers for Disease Control Prevention Epidemiology Program Office Division of Health Surveillance and Informatics CDC WONDER.Available at: http://wonder.cdc.govGoogle Scholar As reflected in Table 4, female and male adolescents engage in tobacco use and alcohol use in equal numbers. Female adolescents are less likely than male adolescents to carry a weapon or drive after drinking alcohol but are more likely to be a passenger in an automobile with a driver who has been drinking alcohol. Female adolescents are at higher risk of depression and suicide attempts, although their male counterparts have higher numbers of successful suicides (Table 4; Figure 1). Female adolescents are also more likely than male adolescents to have an eating disorder (Table 4). Substantial morbidity among female adolescents results from sexual activity. This morbidity includes unintended pregnancies and sexually transmitted infections (STIs), including infection with the human immunodeficiency virus (HIV). Female adolescents have the highest prevalence of STIs nationally (except for HIV infection).12Centers for Disease Control and Prevention, National Center for HIV, STD, and TB Prevention, Division of Sexually Transmitted Diseases Prevention 2003 Surveillance Report.Available at: www.cdc.gov/nchstp/dstd/Stats_Trends/Stats_and_Trends.htmGoogle Scholar As reflected in Table 4, female adolescents are more likely than male adolescents to have negative or mixed feelings about initiating sexual activity8Abma JC Martinez GM Mosher WD Dawson BS Teenagers in the United States: sexual activity, contraceptive use, and childbearing, 2002.Vital Health Stat 23. 2004; 24: 1-48PubMed Google Scholar and they are more likely to experience abuse or victimization. Rates of sexual activity among adolescents have declined during the past decade; nationally, 46.7% of high school students reported ever having sexual intercourse when surveyed in 2003, compared with 53% in 1993.13Kann L Warren CW Harris WA et al.Youth risk behavior surveillance: United States, 1993.MMWR CDC Surveill Summ. 1995; 44: 1-56PubMed Google Scholar This trend is encouraging, and ongoing investigations of the reasons for the trend will likely influence future adolescent practice guidelines. In contrast to adolescent mortality, two thirds of all deaths among adults older than 25 years of age result from cardiovascular disease (39%) or cancer (24%).7Grunbaum JA Kann L Kinchen S et al.Youth risk behavior surveillance: United States, 2003 [published correction appears in MMWR Surveill Summ. 2004;53:536].MMWR Surveill Summ. 2004; 53: 1-96PubMed Google Scholar, 11Department of Health and Human Services Centers for Disease Control Prevention Epidemiology Program Office Division of Health Surveillance and Informatics CDC WONDER.Available at: http://wonder.cdc.govGoogle Scholar Strikingly, the behaviors considered risk factors for these conditions (eg, tobacco use, unhealthy eating, and lack of exercise) often begin during adolescence (Table 4). Awareness of these prevalent high-risk behaviors can enable physicians to more easily tailor the patient interview to include important psychosocial questions. The importance of asking focused questions aimed at screening for behavioral health risks has been stressed by many professional organizations.2American Academy of Pediatrics Guidelines for Health Supervision III. American Academy of Pediatrics, Elk Grove Village, Ill1997Google Scholar, 3Elster AB Kuznets NJ AMA Guidelines for Adolescent Preventive Services (GAPS): Recommendations and Rationale. Williams & Wilkins, Baltimore, Md1994Google Scholar, 4Green M Palfrey JS Bright Futures: Guidelines for Health Care Supervision of Infants, Children, and Adolescents. 2nd ed, rev. National Center for Education in Maternal and Child Health, Arlington, Va2002: 230-297Google Scholar, 14Summary of Policy Recommendations for Periodic Health Examinations. Revision 5.7. American Academy of Family Physicians, Leawood, Kan2005Google Scholar The AMA's GAPS3Elster AB Kuznets NJ AMA Guidelines for Adolescent Preventive Services (GAPS): Recommendations and Rationale. Williams & Wilkins, Baltimore, Md1994Google Scholar are detailed in Table 2. One of the most challenging aspects of providing care to adolescents is effectively conducting the adolescent interview. Various resources exist to help the internist with this task (Table 1). Questionnaires have been created by many professional organizations to aid in the initial task of collecting information from both the adolescent and the parent. Acronyms can serve as helpful interview prompts, the most common of which addresses the areas of home, education/employment, activities, drugs, sex, and suicide (HEADSS) (Table 5). The use of acronyms makes it easier to remember important adolescent issues to discuss at each office encounter; even an office visit for a minor complaint should be viewed as an opportunity for the physician to uncover risk-taking behavior.TABLE 5Adolescent Interview: HEADSS*An approach to the psychosocial interview that allows the practitioner to move from less to more sensitive or intimate subjects. Home Composition of household; family dynamics, relationships with adolescent; living situation; guns in the homeEducation/Employment School attendance; absences; attitude toward school; ever failed or skipped a grade; suspension; favorite and most difficult subjects; goals: vocational/technical school, college, careerActivities How time is spent when not in school; sports, exercise, clubs, hobbies; television viewing; job; friendships; driving; weapon carrying and fightingDrugs Cigarettes or smokeless tobacco (age at first use, packs per day); alcohol or drugs (use at school or parties, use by friends and self, type and quantity)Sex Dating; sexual feelings (opposite or same sex); sexual intercourse (age at first intercourse, number of lifetime partners, recent change in partners, type of contraception and frequency of use); history of sexually transmitted disease; prior pregnancies, abortions; history of nonconsensual intimate physical contact or sex; history of trading sex for money or drugsSuicide or depression Feelings about self; history of depression or feeling blue; sleep pattern; thoughts of hurting self; prior suicide attempts; history of other mental illness* An approach to the psychosocial interview that allows the practitioner to move from less to more sensitive or intimate subjects. Open table in a new tab Paper questionnaires and acronyms are useful tools for obtaining information. However, they are limited in scope and lack the crucial relational aspect of the interview that engenders trust in an adolescent and elicits honest responses. Thus, physicians must develop an “adolescent-friendly” approach to build rapport and encourage open and honest communication. An accepting atmosphere is created initially in the waiting room, with the display of age-appropriate literature and a reception staff that treats adolescents with respect. Also, a longer appointment time for the first visit will facilitate interaction with both the adolescent and the parent. The first few minutes with the adolescent often determine whether a trusting relationship can be established; these minutes are well spent in showing genuine interest in the adolescent and by conversing in a relaxed informal manner. The dual relationship forged by the physician with both the adolescent and the parent will provide an understanding of family dynamics, and it will also help enlist the parent as an ally to promote the adolescent's health. The physician should initially interview the parent and adolescent together and then meet with the adolescent alone. Periodic group meetings can then be scheduled as needed. By including the parent initially, the clinician can discuss issues of confidentiality and the expected transition from parental oversight to adolescent responsibility for health maintenance. The parent can provide essential details about the patient's personal and family medical history and can voice any concerns before being dismissed so that the adolescent can talk with the physician alone. Allowing the adolescent to express herself openly enables the physician to gain important information about the patient's concerns and her understanding of health issues. The adolescent's primary concern may be different from the physician's, and she will feel more respected by a physician who actively listens. The physician should be alert for any hidden agenda. For example, a patient may complain of a sore throat but actually be worried about having an STI. A primary goal of adolescent medicine is to instill a sense of responsibility in adolescents for their own health maintenance. This approach differs from the pediatric model, in which the child experiences health care through the mediation of a parent. Ideally, adolescent patients will establish a direct relationship with their physician, which will give them a sense of having their “own” physician. Keeping this goal in mind can help physicians clarify their role. The female adolescent's physician is neither a surrogate parent nor “one of the gang.” Instead, physicians of adolescents are in a unique position as adults with authority who serve as advocates for adolescents while encouraging them to make healthy choices. Describing the physician's role can be an effective way to begin asking sensitive questions and counseling adolescents about developing a healthy lifestyle. A crucial aspect of gaining the trust of any adolescent is an assurance of confidentiality, which should be discussed openly during the initial interview. In general, health care delivery to a minor (<18 years) requires parental consent. However, in some situations, obtaining parental consent may represent a barrier to care.15Ford CA Millstein SG Halpern-Felsher BL Irwin Jr, CE Influence of physician confidentiality assurances on adolescents' willingness to disclose information and seek future health care: a randomized controlled trial.JAMA. 1997; 278: 1029-1034Crossref PubMed Google Scholar, 16Sigman G Silber TJ English A Epner JE Confidential health care for adolescents: position paper of the Society for Adolescent Medicine.J Adolesc Health. 1997; 21: 408-415Abstract Full Text PDF PubMed Scopus (78) Google Scholar, 17Cheng TL Savageau JA Sattler AL DeWitt TG Confidentiality in health care: a survey of knowledge, perceptions, and attitudes among high school students.JAMA. 1993; 269: 1404-1407Crossref PubMed Scopus (277) Google Scholar Thus, federal and state laws, as well as many professional organizations, recognize exceptions. Sources of legal requirements in adolescent health care include the US Constitution and state constitutions, federal statutes and regulations (eg, the HIPAA [Health Insurance Portability and Accountability Act] privacy rule, the Title X family planning program, federal drug and alcohol programs, protection of human subjects in research), and state statutes and regulations.18English A Reproductive health services for adolescents: critical legal issues.Obstet Gynecol Clin North Am. 2000; 27: 195-211Abstract Full Text PDF PubMed Google Scholar State statutes and regulations determine issues of rights and duties of pa
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