Stage of change behavioral assessment tool fails to predict the prevalence of chlamydia in an urban adolescent health clinic.

STUDY OBJECTIVE: Strategies to reduce STI among adolescents and young adults have failed to consistently demonstrate effectiveness. A universal approach may not be appropriate because individuals are at different stages with respect to self-management behaviors. Thus, the Stage of Change Transtheoretical Model has been advocated. This study was conducted to determine whether staging could be accomplished in an urban adolescent clinic and whether it provides a tool to predict STI risk. DESIGN: Participants were interviewed and staged according to a standardized instrument with respect to sexual risk behaviors and contraceptive use. SETTING: Urban adolescent health clinic. PARTICIPANTS: 103 females (ages 18-24). INTERVENTIONS: A physical examination and diagnostic tests for syphilis, HSV, HCV, chlamydia, gonorrhea and HPV were performed. MAIN OUTCOME MEASURES: Stages for behaviors to reduce STI risk and to utilize contraception and STI prevalence. RESULTS: 78% of the participants were in the three earliest stages of behavior (precontemplative, contemplative, and ready for action) with respect to condom use for STI prevention; conversely only 47% were in early stages with respect to birth control practices. Of the participants tested, 12/81 (15%) had chlamydial infection detected by molecular techniques, whereas no participants had gonorrhoeae. Among the subset tested for HPV DNA, 18/45 (40%) were positive. The diagnostic behavior stage for STI prevention did not correlate with the presence of chlamydia. CONCLUSIONS: A staging instrument can be implemented into adolescent health clinic practice, but cannot be used as a risk assessment tool for the presence of chlamydia. Additionally females are more likely to protect themselves against pregnancy than against an STI.

Foster children with special needs: The Children's Aid Society experience.

Children in foster care have many health needs. This article presents the model of the Children's Aid Society (CAS) of New York City in addressing these needs. In addition to their regular foster care program, CAS developed the Medical Foster Care (MFC) in response to the growing number of boarder babies (children with medical conditions who are abandoned at hospitals), and the Therapeutic Foster Care (TFC) for foster children with emotional and behavioral mental health problems. The MFC serves 145 children considered medically fragile, as evidenced by congenital diseases such as heart disease, renal agenesis, cerebral palsy, seizure disorders and mental retardation. The TFC serves 50 children with severe levels of emotional and behavioral symptomatology. As is indicated by the extensive services offered through CAS's regular foster care program, as well as MFC and TFC, these children require specialized treatment. In addition, systems of information maintenance and exchange surrounding the health care of foster children need to be improved. Often agencies are ill-equipped to do adequate background checks on these young people and as a result deliver them to foster care situations where their health needs are not revealed and therefore not addressed. Health care providers also need to stay informed on the overall subject of foster care, as their voices will probably be crucial in ensuring that the extensive needs of these children are adequately represented to government, medical and other service providers.

Obtaining a history of sexual victimization from adolescent females seeking routine health care.

OBJECTIVE: To evaluate the clinical practice of direct physician inquiry of adolescent females during routine history taking and medical examination, with regard to their experience of childhood sexual abuse and/or assault. METHOD: During a one-year period, a female physician directly questioned 146 consecutive female patients, aged 12-22, who were being seen for routine medical histories and physical examinations, as to whether they had ever been sexually victimized. Patients who disclosed histories of sexual victimization were immediately counseled and provided with appropriate on-site mental health referrals. Follow-up of these referrals was conducted to determine if patients complied with referrals to seek mental health services. RESULTS: For 141 of the 146 patients, the physician was unaware of a history of sexual victimization. Of these 141 patients, thirty-two (23%) cases were identified using this clinical strategy. Almost all (93%) of these young women accepted referrals for on-site psychotherapy, and 81% kept their initial appointments for psychotherapy. CONCLUSIONS: The routine medical history and physical examination may be an appropriate setting for health care providers to accurately and comfortably elicit a history of sexual victimization from adolescent females, and provide appropriate referrals for mental health counseling.

Legal and ethical issues facing adolescent health care professionals.

This article reviews the legal standards and ethical dilemmas surrounding the provision of care to adolescent patients. Uncertainty and ambiguity in this area has contributed to the underserving of the adolescent population. Usually, the legal right to consent to treatment resides with the adolescent's parent or legal guardian; however, there are many cases in which adolescents may provide their own consent. The determination that the adolescent is "mature" is one important factor. The law generally upholds a provider's determination of maturity of a patient. Minors also have the right to confidentiality in almost all situations in which they have the right to consent. The issue of confidentiality poses legal and ethical challenges to the provider in five discussed areas. Providers should be aware of the laws specific to their state, while keeping foremost the best interest of their patients. Providers should also encourage parental involvement and communication concerning treatment, while respecting adolescents' right to confidentiality.

CHIP: new opportunities in adolescent health care delivery.

Children's Health Insurance Programs (CHIP), usually targeted to infants, toddlers, and school-aged children, have been expanded to include adolescents. Adolescents need some form of health insurance in order to access needed care. Moreover, programs and services that provide them with health care must be adolescent-friendly, adolescent-focused and adolescent-sensitive, and include specialized training for primary care providers. Translating this philosophy into a successful health care delivery program involves addressing the psychological, institutional and financial barriers that make it difficult for adolescents to access health care. Overcoming these barriers, especially the financial ones, requires that primary care providers advocate for teenagers and take advantage of resources made available for them. CHIP provides a critical opportunity for policy-makers and health care providers to further improve adolescent health care and to more fully integrate adolescents into the health care system.