A Systems Perspective

• Five objectives identified by the World Health Organization provide a basis for assessing the quality of current and future systems of health services for adolescents: accessibility, acceptability, appropriateness, effectiveness, and equity.

Primary Care Services

• Evidence shows that while private office-based primary care services are available to most adolescents, those services depend significantly on fee-based reimbursement and are not:
  • accessible to adolescents who are uninsured or underinsured.
  • offered in acceptable settings that foster open communication of sensitive behaviors or health conditions.
  • provided by personnel who are skilled in addressing health conditions and behaviors that are appropriate for this stage of development.
  • effective at fostering health promotion or addressing risky behaviors that are prevalent among adolescents, such as substance use and unsafe sexual activity.

• Evidence shows that safety-net health services for adolescents are
  • accessible to many adolescents who are uninsured or do not find private office-based services acceptable for their needs.
  • frequently more acceptable to adolescents who are uncomfortable with private office-based primary care providers, especially when they can establish relationships with providers who are sensitive to their needs and promote open communication.
  • sometimes able to offer a more appropriate mix of skills and counseling services that address risky behaviors.
  • able to provide effective disease prevention and health promotion services while also addressing issues related to risky behavior. However, such centers often can become unstable during times of fiscal uncertainty and may experience frequent personnel transitions. They also face unique challenges associated with financing of prevention and health promotion services that cannot be reimbursed.
  • important mechanisms for resolving the disparities and inequities that exist within private office-based primary care.

Specialty Care Services

• Evidence shows that specialty care services for the adolescent population are not accessible to most adolescents. Existing specialty services in the areas of mental health, sexual and reproductive health, oral health, and substance use treatment and prevention are generally insufficient to meet the needs of many adolescents. While evidence-based therapies are available in a number of these areas, they are not integrated into many practice settings.
• Even when specialty services are accessible, many adolescents do not find them acceptable because of concerns about disclosure of treatment in sensitive areas (such as substance use or sexual health).
• Many specialty providers lack appropriate training to address the needs of adolescent patients, and certification programs for treating adolescents are frequently unavailable in many specialty areas.
• The lack of appropriate specialty services that are suitable for adolescents means that effective treatment is often delayed, care is of limited duration, and services are poorly reimbursed.
• Limitations in the quality of or access to specialty services are especially prevalent among at-risk adolescents in whom problems in the above areas frequently co-occur, contributing to health care inequities and disparities.

Prevention and Health Promotion

• Routine screening for risk factors and unhealthful behaviors that emerge during adolescence is not available or accessible for most adolescents.
• Many health care providers who treat adolescents fail to adhere to recommended prevention guidelines, to screen for appropriate risk factors and unhealthful behaviors that emerge during adolescence, and to provide effective counseling that would reduce risks and foster health promotion.

Racial and Ethnic Disparities

• Disparities and biases affect the quality of health services for adolescents and deserve serious consideration in any efforts to improve access to appropriate services and reduce inequities in the health system.

Confidential Services

• Evidence shows that health services that are confidential increase the acceptability of services and the willingness of adolescents to seek them, especially for issues related to sexual behavior, reproductive health, mental health, and substance use.
• Existing state and federal policies generally protect the confidentiality of adolescents’ health information when they are legally allowed to consent to their own care.

This chapter introduces a framework for examining the strengths and limitations of current health system approaches for adolescents. This framework comprises five major objectives—accessibility, acceptability, appropriateness, effectiveness, and equity—that serve as criteria for assessing the use, adequacy, and quality of adolescent health services. The chapter then reviews the current array of mainstream and safety-net primary care services, as well as specialty services, that respond to the adolescent health needs identified in Chapter 2; a brief discussion of inpatient hospital services for adolescents is also presented. This review is followed by a discussion of what is known about adolescents’ use of health services. The chapter then considers how context matters—that is, how such factors such as income, race and ethnicity, and community affect access to and utilization of adolescent health services. Next is a discussion of consent and confidentiality and their influence on the acceptability of health services to adolescents. The chapter ends with a summary of the gaps between adolescents’ health service needs and the services and settings that exist to address those needs.

This chapter deals with several important issues: the overall inadequacy of preventive screening, counseling, and health education for adolescents, which are crucial to high-quality care for this population; the value of having health services available in diverse locations; the lack of an integrated health system that recognizes and reflects the particular needs and interests of adolescents; and the importance of confidentiality and privacy of visits between adolescents and providers. Chapter 4 responds to the findings presented in this chapter by exploring elements of improved health services within an adolescent health system that would be more accessible, acceptable, appropriate, effective, and equitable relative to adolescents’ current health status, health service needs, and population variations.

Private Office-Based Care

The majority of adolescents have private insurance through family plans offered by one or both parents’ employers. These adolescents commonly receive their primary medical care from private provider offices, usually a pediatrician, family physician, general internist, or nurse practitioner, or for older female adolescents, a gynecologist. Adolescents with public insurance (such as Medicaid or the State Children’s Health Insurance Program [SCHIP]) also routinely interact with provider offices in the private or public sectors that accept their insurance plans.

Private office-based primary care services frequently cover the following: health maintenance or well-care visits (the scope of which is often guided by local school board policies), basic diagnostic tests (such as height, weight, and blood pressure), vision and hearing screening, and brief consultation on health concerns or health promotion. The administration of recommended vaccines may or may not be included in an annual office visit, depending on local school requirements, state programs for free vaccines, insurance coverage, and reimbursement practices.

Significant variations frequently occur in private and public health plans that limit or influence the nature and duration of services eligible for reimbursement in private office-based primary care settings. For example, traditional plans allow reimbursement for health maintenance visits, laboratory tests, care for certain categories of acute and chronic medical conditions, and prescription medications. They generally do not cover extended or periodic counseling services beyond the brief contact associated with a health maintenance visit, nor do they reimburse many of the counseling or case management expenses associated with treatment of a number of behavioral problems, such as anorexia or bulimia, substance use, sexual or reproductive health practices, trauma, or behavioral or emotional problems that fail to meet the threshold criteria for a clinical disorder (Fox, Limb, and McManus, 2007; Fox, McManus, and Reichman, 2003; see Chapter 6 for more detail).

A review of several studies found that 70 percent of adolescent morbidity and mortality involves consequences from such behavior as unsafe sexual activity, violence, substance use, tobacco use, poor nutritional habits, risky driving, and inadequate physical activity (National Research Council, 1999). Yet even though this age group is at significant risk for the onset of many health conditions that may persist into adulthood, only a minority of adolescents receive developmental or psychosocial services through routine assessment (Chung et al., 2006). While clinician surveys indicate that most private providers perform routine surveillance for risky behaviors, diet, and exercise, fewer than half of adolescents responded affirmatively to survey items asking whether they had spoken with their provider about sexual activity, other risk behaviors, STIs, diet, exercise, and emotional health (Bethell, Klein, and Peck, 2001; Chung et al., 2006; Ellen et al., 1998; Halpern-Felsher et al., 2000; Millstein and Marcell, 2003; Millstein, Igra, and Gans, 1996).

Several factors account for the lack of appropriate private office-based health services for adolescents that are tailored to their behavioral and developmental needs. For example, insurance reimbursements are often inadequate to compensate for the time it takes to offer adequate health promotion or disease prevention services for adolescents (McManus, Shejavali, and Fox, 2003; O’Connor, Johnson, and Brown, 2000). This and other finance issues are discussed in more detail in Chapter 6.

Another challenge involves the nature and skills of the workforce that is available to address the health needs of adolescents. According to the National Medical Ambulatory Survey and the National Hospital Ambulatory Medical Care Survey, 40 percent of health visits for adolescents aged 11–14 were to pediatricians during 1994–2003. As adolescents matured and reached adulthood, they encountered a more diverse array of providers, moving from pediatricians to family physicians, internal medicine physicians, and gynecologists. For example, among females and males aged 18–21, only 4 percent and 7 percent, respectively, had met with pediatricians. For the two age groups, 22 percent and 29 percent of visits, respectively, were to family physicians. Half of female and 70 percent of male health maintenance visits in the older age group were to family physicians. After age 18, females were more likely to visit obstetricians/gynecologists than any other type of physician (Rand et al., 2007).

In some cases, adolescents are able to interact with a specialist in adolescent medicine in a private office-based primary care setting. An ado lescent medicine specialist has received extensive training in the particular health conditions and concerns of adolescents, as discussed later in this chapter and further in Chapter 5. These specialists may be more prepared than other practitioners to address multiple health problems faced by adolescents, identify specific behavioral disorders, and offer guidance on health promotion and disease prevention. But access to adolescent specialists is severely limited, since these practitioners are commonly available only in academic health centers. According to one recent estimate, just 466 certificates in adolescent medicine were issued from 1996 to 2005 (for a population of about 40 million people aged 10–19), compared with 2,839 certificates issued in geriatric medicine during the same period (Hoffman, 2007).

In addition to difficulties associated with insurance conditions and the shortage of specialists, opportunities to engage adolescents in discussions pertinent to their particular needs and circumstances and to monitor their general health status are severely constrained by a lack of continuity with a clinician or place of care, a lack of privacy, a lack of clinical awareness or skill, racial and ethnic barriers, language-related barriers, clinician and patient gender-related barriers, and a lack of time to provide comprehensive preventive care even if adolescents attend their recommended visits (Chung et al., 2006). In their review of the literature, Chung and colleagues (2006) found that fulfilling only the most conservative (i.e., evidence- and cost/benefit-based) counseling recommendations of the U.S. Preventive Care Task Force would take an average clinician nearly 40 minutes per adolescent per year. Both national surveys of pediatricians and case studies have found that insurance reimbursements are inadequate to cover the necessary time (McManus, Shejavali, and Fox, 2003; O’Connor, Johnson, and Brown, 2000).

Several group plans and managed care organizations have recognized the importance of offering primary care services tailored to the needs of adolescents. These plans and organizations tend to provide greater opportunity for adolescents and their parents to engage with providers who are specially equipped to address their concerns and are skilled in discussing sensitive health issues, such as pubertal changes, sexual activity, behavioral and mental health conditions, and substance use.

More commonly, however, providers in private office-based primary care settings believe they are inadequately trained in adolescent health, and they are uncomfortable with discussing sensitive health issues of particular concern to adolescents and their families (as discussed further in Chapter 5). Moreover, few of these providers are aware of the Guidelines for Adolescent Preventive Services (discussed in Chapter 4) or the Healthy People 2010 objectives for adolescents and young adults (described in Chapter 2) (American Medical Association, 1997; U.S. Department of Health and Human Services, 2007). They fail to recognize the importance of incorporating health promotion and disease prevention as a fundamental part of routine health services for adolescents. Most providers practice in environments that fail to encourage adolescents to ask health questions, express their health concerns, or explore disease prevention strategies that might prepare them to address significant risks and vulnerabilities that often emerge in adolescence (such as the use of tobacco, alcohol, and drugs; sexual activity; risky driving; and violent behavior) (Klein and Wilson, 2002).

One study of ambulatory care for children in different settings found that few medical practitioners are able to provide comprehensive, coordinated, or sensitive health services tailored to adolescent needs (Mangione-Smith et al., 2007). Likewise, adolescent disease prevention services received the lowest score for quality among clinical services for children and youths (as measured by eight indicators): 4.5 percent as compared with 92 percent for treatment of upper respiratory tract infections and 85.3 percent for treatment of allergic rhinitis (Mangione-Smith et al., 2007).

In summary, while many adolescents have access to private office-based primary care services, such services are not suited to the particular behavioral and developmental needs of this stage of life. The lack of reimbursement for counseling and case management services, as well as the diversity of health care providers who are involved in the care of adolescents, creates unique challenges that affect both the availability and acceptability of prevention and health promotion services. Even when effective services are available, they are frequently not integrated into routine primary care settings.

Furthermore, few centers are specifically focused on the primary care needs of special subpopulations of adolescents, such as those who are in the foster care system, in families that have recently immigrated, or LGBT. The lack of quality private office-based primary care services for these groups creates service gaps that constitute basic disparities and inequities in the health care system. These special subpopulations rely on safety-net centers for their health care, as discussed in the following section.

Findings:

• Evidence shows that while private office-based primary care ser vices are available to many adolescents, those services depend significantly on fee-based reimbursement and are not:
  • accessible to adolescents who are uninsured or underinsured.
  • offered in acceptable settings that foster open communication of sensitive behaviors or health conditions.
  • provided by personnel who are skilled in addressing health conditions and behaviors that are appropriate for this stage of development.
  • effective at fostering health promotion or addressing risky be haviors that are prevalent among adolescents, such as substance use and unsafe sexual activity.

Safety-Net Primary Care Services

Many adolescents are uninsured or underinsured and are therefore ineligible to receive primary care services from private office-based providers. Other adolescents may not have an established relationship with a primary care provider or may be concerned about the confidentiality of visits with their primary care provider. These young people often rely on safety-net providers, defined as “those providers that organize and deliver a significant level of health care and other health-related services to uninsured, Medicaid, and other vulnerable patients” (Institute of Medicine, 2000, p. 21). Core safety-net providers have two distinguishing characteristics: (1) they have a legal mandate or explicit mission to “maintain an ‘open door,’ offering access to services to patients regardless of their ability to pay; and (2) a substantial share of their patient mix is uninsured, Medicaid, and other vulnerable patients” (Institute of Medicine, 2000, pp. 3–4).

As noted in earlier IOM studies, the safety net consists of public hospital systems; academic health centers; community health centers or clinics funded by federal, state, and local public health agencies; and local health departments. An additional feature of the safety net for adolescents is the presence of school-based health centers. The organization and delivery of safety-net services vary widely from state to state and community to community.

A literature review presented at a workshop convened in January 2007 as part of this study revealed that many reports focused on improving services and outcomes for adolescents frequently omit safety-net health services (see, for example, National Research Council and Institute of Medicine, 2002). Studies of the quality of adolescent safety-net health services vary in methodological rigor; randomized studies are rare; extensive variations exist in populations, settings, topics, and time; single-site studies predominate; and a meta-analysis or synthesis of essential components is not possible given the quality of the available research (Dougherty, 2007). Overall, the review presented in the study workshop was striking in revealing the absence or low quality of the existing evidence on safety-net sites of care for adolescents (see Table 3-2).

TABLE 3-2

Studies Evaluating the Delivery of Adolescent Health Services in School-Based and Community Health Centers.

School-Based Health Centers

One important source of primary care for adolescents is schools, especially those with school-based health centers. Almost 30 years ago, New York State launched the first state-funded grant program to support school-based health centers (Brindis et al., 2003). By last count, the number of such centers nationwide had reached 1,709 in 45 states (Juszczak, Schlitt, and Moore, 2007). While school-based health centers serve students from kindergarten through high school, more than 50 percent serve mainly adolescents.

Since schools are where most school-aged adolescents spend a significant portion of their time, school-based health centers appear to be a logical means of improving access, efficiency, and economies of scale in adolescent health services. Significant debate has persisted, however, about the relative merits and disadvantages of a population-based versus a selective high-risk approach to offering primary care services in school-based health centers. As noted in the 1997 IOM report Schools and Health: Our Nation’s In vestment (Institute of Medicine, 1997), the population-based approach can have a large impact on the population as a whole, but the benefits for selected individuals may be small. Most adolescents in school already have access to and utilize mainstream primary care services. Yet many high-risk adolescents—a significant and growing segment of the population according to the 1997 IOM study—may be better served by providers in school-based health centers if they lack access to other community health personnel or do not find their local providers to be sensitive to their needs.

While no single model exists for school-based health centers, many share certain common characteristics. Centers are located inside the school building or on the school campus. Philip J. Porter, MD, an early architect of school-based health centers, once said, “Health services need to be where students can trip over them. Adolescents do not carry appointment books, and school is the only place where they are required to spend time” (The Center for Health and Health Care in Schools, 1993). In most instances, the centers are sponsored by mainstream health organizations. One study found that hospitals were the leading organizers of school-based health centers, sponsoring 32 percent of the total number. Health departments and federally funded community health centers each sponsored 17 percent, school districts 15 percent, and community-based nonprofit organizations 12 percent (Juszczak et al., 2003).

Students receive care in school-based health centers from a multidisciplinary team of professionals. Typically, a medical assistant supports a nurse practitioner or physician assistant. More than half of the centers provide mental health services, most frequently through a master’s-level social worker, psychologist, or substance abuse counselor. A part-time pediatrician or family physician may also be part of the staff. A center may have access to part-time professionals as well, including nutritionists, health educators, social services case managers, dentists, dental hygienists, substance abuse counselors, and others, depending on the needs of the students and the resources available in the community (Juszczak, Schlitt, and Moore, 2007).

The fundamental reason school-based health centers have drawn support is their capacity to increase access to basic health care for low-income children and adolescents. Data on large numbers of such centers document their acceptability to students and families, as well as their capacity to address the critical needs of the adolescents they serve (Dryfoos, 1994; Institute of Medicine, 1997). And because the centers can be targeted to schools that enroll large numbers of underserved racial and ethnic minorities, they have the potential to foster equity in access to care and to improve in health outcomes among the most vulnerable populations.

Despite this evidence that school-based health centers have moved from the margin to the mainstream, however, two issues—funding and debate about the role and mission of the centers and their place in community health systems—represent a potential constraint on their growth.

Funding remains an issue because state governments subject to pay-as-they-go constraints are reluctant to create new programs that require annual infusions of large amounts of state funds. The tendency is to hope that programs can be funded through existing public revenues, most commonly Medicaid. The experience thus far has been that patient care revenues are insufficient to support school-based health centers, and additional core grants are required to sustain quality programs.

The other major challenge in developing primary care services for adolescents in school-based health centers lies in the relationship between the U.S. health system, which is predominantly private, and the U.S. education system, which is publicly financed through local and state funds. The low levels of financing for school-based health centers restrict their ability to attract the necessary providers, and conversely, local providers are frequently not aware of or well integrated into the centers’ system of care. The fundamental mismatch and lack of engagement between the health and education systems remains a source of persistent concern. Table 3-3, drawn from the above-mentioned IOM report (Institute of Medicine, 1997) and a study by Santelli and colleagues (1995), highlights the strengths and shortcomings of school-based health centers.

TABLE 3-3

Potential Strengths and Weaknesses of School-Based Health Centers.

Mental Health

As noted in Chapter 2, mental disorders are common among adolescents and may impose a tremendous health burden for this population.² Emotional and behavioral symptoms often co-occur with other health problems seen in the health system and in the juvenile justice and foster care systems (see Chapter 2). Traditionally, the mental health sector has been responsible for treatment of adolescents with mental disorders. This sector comprises a diverse workforce of psychiatrists, psychologists, social workers, and other, lesser-trained individuals organized into loose networks of providers. The reimbursement system for mental health services has traditionally focused on the severely and persistently mentally ill, and has limited capacity to address emerging mental illness and adolescents who are functioning but not healthy. In case studies in four major cities, mental health providers reported that insurers rarely covered telephone calls to parents, teachers, and primary care providers; team conferences; or care coordination. In addition, these mental health providers reported that few insurers accepted diagnostic codes for psychosocial problems not yet considered diagnosable mental disorders (McManus, Shejavali, and Fox, 2003).

Treatment for adolescents with mental disorders generally involves the use of psychotropic medication and/or psychotherapy. Effective therapeutic interventions with fewer adverse effects have emerged in both areas over the last two decades. Unfortunately, despite the lack of effectiveness of usual clinical care, most routine community practices fail to incorporate evidence-based therapies for mental health problems into their delivery systems (Weisz, Hawley, and Doss, 2004; Weisz et al., 1995, 2005). In other words, community practices rarely incorporate effective care for mental disorders as assessed through randomized trials; therefore, the benefits of effective therapeutic interventions are not available to the majority of adolescents and families seeking care for mental health problems within their communities. In most communities, effective treatment is also hampered by severe shortages of trained professionals, limited coverage of useful care, and poor coordination among providers from different disciplines (Ben-Dror, 1994; McManus, Shejavali, and Fox, 2003). These factors have contributed to long waiting lists, low levels of satisfaction, and little evidence of effectiveness for routine community mental health services.

An analysis of 2003 data from the National Survey of Children’s Health reveals that a significant percentage of adolescents need but fail to receive mental health or counseling services. On a national basis, 36 percent of adolescents aged 12–17 with current behavioral problems that require treatment or counseling do not receive mental health services; this percentage ranges from 63 percent in Texas to 10 percent in Wyoming (Child and Adolescent Health Measurement Initiative, 2008).

Sexual and Reproductive Health

The American Medical Association and the American College of Obstetricians and Gynecologists, among others, recommend that adolescents receive guidance and counseling on responsible sexual behavior, including abstinence, methods of birth control, and prevention of STIs and HIV infection (American Medical Association, 1997; Committee on Adolescent Health and American College of Obstetricians and Gynecologists, 2006). Current guidelines recommend that adolescents who have had sexual intercourse be screened for STIs.

According to data from the 2002 National Survey of Family Growth, approximately half (49 percent) of all adolescent girls aged 15–19 had visited a medical provider for reproductive health services³ in the previous year (Suellentrop, 2006b). This proportion varies according to age and race or ethnicity. As young adolescents mature, their use of reproductive health services increases. Slightly more than one-third (38 percent) of adolescent females aged 15–17 reported receiving reproductive health services in the past year, increasing to 65 percent for those aged 18–19 (Chandra et al., 2005; Suellentrop, 2006b). Non-Hispanic black and non-Hispanic white adolescent females were more likely than Hispanic adolescent females to report the use of reproductive health services in the past year (57 percent, 49 percent, and 41 percent, respectively). Eight of ten sexually experienced adolescent females had visited a provider in the past year for reproductive health services (Suellentrop, 2006b). Female adolescents who had received reproductive health services in the past year reported that they had visited private doctors or managed care providers (55 percent) at around the same rate as clinics (53 percent). Older adolescents (aged 18–19), however, were significantly more likely than younger adolescents (aged 15–17) to report going to a private doctor or managed care organization as opposed to a clinic (Suellentrop, 2006b).

A Pap test and birth control were the most commonly reported reproductive health services. Almost three-quarters of adolescent females (71 percent) reported receiving a Pap test in the past year. Hispanic adolescent females were much less likely than non-Hispanic black adolescent females and non-Hispanic white adolescent females to have received a Pap test in the past year (55 percent, 80 percent, and 72 percent, respectively) (Suellentrop, 2006b). Approximately two-thirds of adolescent females who had used reproductive health services (64 percent) had received birth control or a prescription for birth control in the past year. Almost half reported receiving counseling or information about birth control (Suellentrop, 2006b).

Counseling on different methods of birth control is particularly important for adolescent girls and may be helpful in reducing the proportion of girls who discontinue using their method of contraception. In 2002, almost one-third of sexually experienced adolescent girls indicated that they had ever stopped using a method of contraception, and more than half reported that they had stopped using a method because of side effects (53 percent). A majority of the adolescent girls who reported that they had stopped using a method of contraception were using the pill (Suellentrop, 2006c).

Adolescent boys have particularly low rates of use of primary care—1.7 visits annually reported in 2000, compared with 2.2 visits annually for adolescent females (Ma, Wang, and Stafford, 2005). According to the National Survey of Family Growth, almost one-third of adolescent boys reported that they had received no health services in the past year. Among those who had visited a health care provider in the past year, approximately one-quarter had received counseling or advice from their provider about methods of birth control, STIs, or HIV/AIDS. Close to one in five adolescent boys reported that they had visited a family planning clinic for health services. Sexually experienced adolescent boys were more likely than inexperienced adolescent boys to report having visited a family planning clinic (Suellentrop, 2006a).

Studies evaluating the effectiveness of clinic services tailored specifically to adolescents have found that clinic interventions can increase adolescents’ use of contraception, reduce rates of adolescent pregnancy, and increase adolescents’ knowledge about sexual and other reproductive health issues (Burlew and Philliber, 2007). In 1995, approximately two-thirds of all family planning agencies (such as Planned Parenthood) are estimated to have provided one service specifically tailored to adolescents (Frost and Bolzan, 1997). Such tailoring usually involves offering longer appointment times, having specific counseling appointments, offering a variety of support services, or spreading a visit over two appointments (the first for counseling and the second for a pelvic exam). The convenience of a clinic in terms of location, hours of operation, types of services offered, and costs also affects its use by adolescents. Research suggests that adolescents are more inclined to rely on clinics when they offer a wide range of services in addition to family planning, when the services are provided at little or no cost, and when confidentiality is ensured. In a recent study, 59 percent of adolescent girls (under age 18) who were attending a Planned Parenthood clinic indicated that they would refuse family planning services and delay STI testing and treatment if their parents were notified that they were being prescribed oral contraceptives (Reddy, Fleming, and Swain, 2002). (See the section on confidentiality and privacy later in this chapter.)

Active outreach strategies are also important to draw adolescent clients to a clinic and ensure that the right services are being offered. Such strategies include forming partnerships with other organizations in the community, maintaining a presence at community events, and inviting adolescents to refer their peers to the clinic. Clinic personnel, especially those interested in and dedicated to working with adolescents, can also influence the clinic’s success (Burlew and Philliber, 2007).

Oral Health

Dentistry has significantly different characteristics from medicine that directly influence the quantity, quality, accessibility, and affordability of dental services for adolescents. Service characteristics associated with oral health also result in environmental constraints that impede coordination of care with other basic medical and developmental health services; foster varying systems of professional education and training, financing, staffing, service delivery, accreditation, licensure, and professional governance; and contribute to differing involvement in government health programs and sometimes profound differences in professional culture, mores, and norms. As a result, observations and recommendations based on the medical professions typically cannot easily be extrapolated to dental services.

Dental services are used with approximately the same frequency as medical services among adolescents (see Table 3-4). Orthodontic and aesthetic concerns generate dental visits, and dental pathologies are both common and often symptomatic among adolescents. This frequent contact gives dentists both opportunities and responsibilities to engage their adolescent patients in promoting salutary health behaviors, to detect eating disorders and risky behaviors, and to identify health conditions that require referral. Despite the frequency with which adolescents visit dentists, however, the dental profession and its pediatric specialty have until recently focused relatively little on adolescence beyond orthodontic issues.

TABLE 3-4

Doctor and Dentist Visits by Children and Adolescents (aged 6–17) in Last 12 Months.

While 80 percent of adolescents’ parents report that they obtained a dental visit in a year on the National Health and Nutrition Examination Survey (NHANES) in Table 3-4, overreporting of dental services is a well-recognized problem that is evidenced by discrepancies between federal surveys (Macek et al., 2002). This may result from the social expectation that all children should receive two preventive dental visits each year, an expectation that is not shared with medical care. Because of its more intensive surveillance approach, the Medical Expenditure Panel Survey (MEPS) is regarded as the most reliable national data source on adolescents’ use of dental services. MEPS reports that 53 percent of adolescents ages 6 through 20 received at least one dental visit in the year 2004, virtually unchanged from 51 percent reported in 1996 (Manski and Brown, 2007). A variety of recognized barriers to dental care, including coverage inadequacies, workforce shortages, and adolescents’ failure to use dental services (as occurs with medical services), combine to reduce utilization of dental care among adolescents. The percentages of adolescents who report dental care needs reflect compromised oral health status among the adolescent population: half of those aged 10–19 (53.5 percent) are reportedly in need of dental care (National Institute of Dental and Craniofacial Research, 1994, NHANES III data 1988–1994).

National surveys reveal higher levels of unmet need among racial and ethnic minorities relative to whites. For children aged 6–18, parents report rates of unmet need that are 1.6 times higher for blacks and 2.1 times higher for Mexican Americans than for whites (Vargas and Ronzio, 2002). Minority status may be confounded by other characteristics of social disadvantage, such as parental educational attainment. Two to three times more parents with only or less than a high school education (3.0 times and 2.3 times, respectively) than parents with more than a high school education report that their children aged 6–18 have unmet needs for dental care. Parents of children and adolescents with special health needs also report higher unmet dental needs (Schultz, Shenkin, and Horowitz, 2001). Data compiled by Schuchter and Fairbrother (2008) reveal increases in unmet need for dental care with advancing age, as well as variations by race or ethnicity and gender (see Table 3-5). Unmet need for preventive dental care among children and adolescents who have not seen a dentist in the past year increases steadily by age to one in five adolescents aged 12–17 (Maternal and Child Health Bureau, 2005).

TABLE 3-5

Unmet Dental Needs, Last 12 Months.

Substance Use Treatment and Prevention

Studies of referral patterns for alcohol and drug treatment centers indicate that schools infrequently detect substance use disorders among adolescents and make referrals for treatment. In 2004, only 11 percent of admissions to alcohol and drug treatment for adolescents aged 12–17 were due to school referrals (Substance Abuse and Mental Health Services Administration, 2006a). Schools may be more likely to handle drug use by punishing students than to refer them to or provide treatment (McAndrews, 2001).

Rates of substance use are particularly high among adolescents who are engaged with certain institutional sectors. For example, in one county in California, Aarons and colleagues (2001) found high proportions of adolescents (under age 18) with substance use disorders in the juvenile justice system (62 percent), the mental health system (41 percent), and the foster care system (19 percent). Prevalence rates for older youths aged 18–25 in institutional care are thought to be even higher. The criminal justice system is the major source of referrals for adolescent substance use treatment. In 2004, for example, the criminal justice system accounted for 52 percent of referrals for admission to treatment among adolescents aged 12–17, and the same percentage was reported for older adolescents aged 18–21 (Substance Abuse and Mental Health Services Administration, 2006a).

According to data from the National Survey on Drug Use and Health (2003–2004), 6.1 percent of adolescents aged 12–17 needed treatment for alcohol use, and 5.4 percent needed treatment for illicit drug use (Substance Abuse and Mental Health Services Administration, 2006b). Of those ado lescents who needed treatment for alcohol use, however, only 7.2 percent had received specialty treatment (including inpatient hospitalization, treatment in a rehabilitation facility, or treatment in a mental health center) in the past year. The corresponding figure for treatment for illicit drug use was 9.1 percent.

Many adolescents, however, do not perceive a need for or seek treatment and may not volunteer information about their use of substances unless they have established a rapport with a health professional or counselor. In the National Survey on Drug Use and Health (2003–2004), among those who were classified as needing treatment but had received no specialty treatment in the past year, only 2.2 percent perceived a need for treatment for alcohol use problems and only 3.5 percent for drug use problems (Substance Abuse and Mental Health Services Administration, 2006b). Similar findings were reported in the Cannabis Youth Treatment Study: 80 percent of adolescents saw no need for treatment (Mensinger et al., 2006). Adolescents who experience more negative consequences from their substance use show more motivation to change (Battjes et al., 2003; Breda and Heflinger, 2004).

Several studies have identified certain characteristics associated with successful treatment outcomes for adolescents who use substances. These characteristics include severity and comorbidity (Dobkin et al., 1998; Grella and Joshi, 2003; Hser et al., 2001; Rounds-Bryant, Kristiansen, and Hubbard, 1999; Tomlinson, Brown, and Abrantes, 2004) and longer periods of time in treatment (Hser et al., 2001), especially for those with comorbid psychiatric disorders. Recent research suggests that substance use may affect neural systems that are important for reward and for self-regulation and inhibition. If adolescents suffer from these substance use–related changes in neural systems, sufficient duration of treatment may be important for addressing these problems (Kalivas and Volkow, 2005; Leshner, 1997; Volkow and Li, 2005). While duration is important, however, providers frequently have difficulty retaining adolescents in treatment programs. Retention in treatment is predicted by the presence of fewer deviant peers, the absence of emotional problems due to substance use, and a positive assessment of the counselor’s skills on the part of the patient (Battjes et al., 2004). Treatment success is also associated with characteristics of the post-treatment environment, such as not being involved with others who engage in risky behavior (family substance use, peer networks), taking part in support groups (e.g., Alcoholics Anonymous or Narcotics Anonymous), and participating in substance-free leisure activities (Godley et al., 2005).

One problem with the delivery of substance use treatment may be a lack of professional training and certification in working with adolescents. As of 2002, for example, no U.S. state had adolescent-specific provider certification for such treatment. And as of 2004, the certification program of the National Association of Alcoholism and Drug Abuse Counselors had no adolescent-specific requirements (McLellen and Meyers, 2004). Another problem is that, despite their availability, appropriate screening instruments and treatment guidelines are not routinely incorporated into substance use treatment programs for adolescents (see the discussion of screening later in this chapter). One study of 144 “highly regarded programs” found that the average program score for these elements was 23.8 out of a possible 45 (Brannigan et al., 2004).

The low levels of availability, accessibility, and acceptability of effective treatment services for adolescents with substance use disorders are particularly disturbing in light of evidence demonstrating the effectiveness of such interventions (Brannigan et al., 2004). Positive treatment effects for significant reductions in marijuana use, heavy drinking, and other illicit drug use have been found for many different types of interventions, including multisystemic therapy, family therapy, contingency management, cognitive-behavioral therapy, 12-step programs, and motivational enhancement therapy (Williams, Chang, and the Addiction Centre Research Group, 2000). More time in treatment is associated with better outcomes (Hser et al., 2001).

Although a number of treatment approaches are promising (Deas and Thomas, 2001; Liddle and Dakof, 1995; Szapocznik et al., 2006; Waldron and Kaminer, 2004; Winters et al., 2000), studies of the relative effectiveness of a limited number of adolescent substance use treatment programs have been unable to demonstrate that one particular program or approach consistently works better than others (Godley et al., 2004; Morral et al., 2006; White, White, and Dennis, 2004). In the absence of evidence-based studies supporting the choice of any one treatment method, government and professional organizations have identified key principles of effective treatment that can serve as the basis for adolescent treatment strategies (Bukstein et al., 2005; Drug Strategies, 2003; National Institute on Drug Abuse, 1999). Examples of these principles include adapting treatment interventions to individual needs; continuing treatment for an adequate period of time; continuously monitoring for possible drug use; using developmentally appropriate programs; and attending to individuals’ multiple needs, not just their drug use.

Positive outcomes for certain treatment strategies generally involve short-term effects, and relapse rates remain high (Winters, 1999). Some forms of relapse may be related to the above-noted structural changes in the brain that involve inhibition and reward centers (Kalivas and Volkow, 2005). Treatment regimens may therefore best be derived from a chronic disease management rather than an acute care model (National Institute on Drug Abuse, 2006; Volkow and Li, 2005). Important lessons for treatment and prevention services for adolescents can be drawn from treatments for diabetes and hypertension in older populations (which involve chronically relapsing and remitting disorders with major challenges of adherence to treatment regimens).

At present, aftercare for adolescents with substance use disorders remains inadequate, and comorbid mental health problems receive insufficient attention. One review of 53 studies found that fewer than half of adolescents discharged from treatment programs (38 percent) remained abstinent from substance use after 6 months, even when aftercare plans were in place (Williams, Chang, and the Addiction Centre Research Group, 2000). Data reported by Godley and colleagues (2007) for some aftercare models, such as “assertive” continuing care (in which the clinician rather than the patient has responsibility for linkage and retention), suggest that these models can improve linkage to aftercare for adolescents who have received residential drug treatment. However, while the authors found that substance use decreased as expected when these models were employed, the results were not significant (low statistical power, which limited conclusions). A recent (as yet untested) approach is for aftercare programs to implement “adaptive” interventions, which vary in focus and intensity in response to changes in individual needs (McKay, 2006).

Summary

Evidence-based therapies are available for adolescents in the specialty areas of mental health, sexual and reproductive health, oral health, and substance use treatment and prevention. Yet these interventions are commonly not integrated into routine health care practices, particularly for those who depend on public financing for their routine care. Many adolescents have difficulty gaining access to specialized services because of financial restrictions, shortages of skilled personnel, and the lack of appropriate or convenient settings that are suitable for their stage of development. Adolescents with comorbid conditions (such as mental health, sexual, and substance use conditions) are especially difficult to serve within the current fragmented array of health care services and settings.

Findings:

• Evidence shows that specialty care services for the adolescent popu lation are not accessible to most adolescents. Existing specialty services in the areas of mental health, sexual and reproductive health, oral health, and substance use treatment and prevention are generally insufficient to meet the needs of many adolescents. While evidence-based therapies are available in a number of these areas, they are not integrated into many practice settings.
• Even when specialty services are accessible, many adolescents do not find them acceptable because of concerns about disclosure of treatment in sensitive areas (such as substance use or sexual health).
• Many specialty providers lack appropriate training to address the needs of adolescent patients, and certification programs for treating adolescents are frequently unavailable in many specialty areas.
• The lack of appropriate specialty services that are suitable for ado lescents means that effective treatment is often delayed, care is of limited duration, and services are poorly reimbursed.
• Limitations in the quality of or access to specialty services are especially prevalent among at-risk adolescents in whom problems in the above areas frequently co-occur, contributing to health care inequities and disparities.

Usual Sources of Medical Care

Most adolescents (aged 11–17) have a usual source of medical care—92 percent according to parental reports—while 75 percent of young people aged 18–21 report that they have a usual source of care (Schuchter and Fairbrother, 2008⁴ ) (see Figure 3-1). This is an important sign of access to health services and is a key indicator to monitor.

FIGURE 3-1

Percentage of adolescents with a usual source of care, 2005 National Health Interview Survey. NOTE: Percents may not add to 100 because of rounding and small categories of less than 1 percent. Adolescents aged 18 and over answer for themselves; parents (more...)

Adolescents who have a usual source of medical care rely predominantly on a doctor’s office or managed care organization (approximately 77 percent) or a clinic or health center (a little over 20 percent). Privately insured adolescents aged 11–17 are more likely than publicly insured adolescents to report a doctor’s office or managed care organization as their usual source of care (85 percent versus 66 percent) (see Table 3-6) (Schuchter and Fairbrother, 2008). These rates remain generally consistent as adolescents grow older, as indicated in Figure 3-2.

TABLE 3-6

Usual Source of Care (%), by Age and Insurance Type, 2005 National Health Interview Survey.

FIGURE 3-2

Usual source of care for adolescents (%), by age and setting, 2005 National Health Interview Survey. NOTES: ED = Emergency Department, HMO = health maintenance organization, OPD = Outpatient Departments. Those aged 18 and over answer for themselves; parents (more...)

Publicly insured adolescents are more likely than their privately insured counterparts to name a clinic or health center as their usual source of medical care (30 percent versus 14 percent) (Schuchter and Fairbrother, 2008). Low reimbursement rates in public insurance programs (Medicaid and SCHIP) may cause many providers to limit the number of publicly insured patients they see, contributing to these disparities (Cunningham and Nichols, 2005; Tang, Yudkowsky, and Davis, 2003). A very small proportion of adolescents report nontraditional sites, such as school-based health centers, hospital emergency departments, or family planning centers, as their usual source of medical care (about 1 percent in each category) (Schuchter and Fairbrother, 2008). Almost half of uninsured adolescents (aged 10–17) have at least one unmet health service need (MacKay and Duran, 2007).

Those with special health conditions, such as chronic illnesses or acute injuries, may have frequent encounters with health professionals. The usual source of care for these adolescents may not embody all aspects of a medical home; for example, a recent analysis from the Child and Adolescent Health Measurement Initiative 2005–2006 found that fewer than half of adolescents with special health needs experienced all facets of a medical home (Maternal and Child Health Bureau, 2008).

Visits with Health Care Providers

While the majority of adolescents visit a health care provider during the course of a year, the proportion decreases with age, especially in later adolescence as young people move into young adulthood. The sharpest decrease occurs at age 18, as adolescents age out of public insurance. Significant differences in utilization rates are also seen by gender.

In 2005, according to the NHIS, 83 percent of adolescents aged 10–19 reported having seen a doctor or other health care provider in the past year (MacKay and Duran, 2007). Males aged 18–19 were much less likely to have made a recent health visit than their younger counterparts; in contrast, health care utilization was much more consistent across the adolescent and young adult age spectrum for females. More than 34 percent of males aged 18–19 reported not having a health care visit in the past 12 months compared with 16 percent of females in the same age group (MacKay and Duran, 2007).

Especially noteworthy are adolescents’ reported high rates of use of hospital emergency departments for routine as well as emergency care, rates that increase with age among both male and female adolescents. Adolescents frequently rely on emergency departments for both urgent and nonurgent health conditions, and their rates of utilization for routine, nonurgent health services in emergency settings are higher than those of any other age group (Nawar, Niska, and Xu, 2007).

Summary

Most adolescents have a usual source of medical care and see a health care provider annually. The types of settings where adolescents receive health services vary with their insurance plans: those with private insurance are more likely to receive health services in a private provider’s or managed care office, while adolescents with public insurance are more likely to see providers in a local clinic or health center. A very small proportion of adolescents report nontraditional sites, such as school-based health centers, hospital emergency departments, or family planning centers, as their usual source of care (about 1 percent in each category).

As adolescent males grow older, their annual visits to health care providers decline significantly. The sharpest decrease occurs at age 18, a time when many adolescents age out of insurance, both public and private. Older adolescent females show much less of a decline in annual health care visits.

Current Status of Prevention and Health Promotion Services for Adolescents

Standardized screening instruments, structured tools, and professional guidelines are available to address risky adolescent behaviors, as is discussed in more detail in Chapter 4. Despite the availability of these resources, studies have shown that practitioners fail to provide the recommended screening, counseling, and health education services. Health personnel frequently rely on adolescents or their parents to initiate discussions of health concerns that may involve the use of alcohol, tobacco, or other substances; risky sexual practices; or other problematic behaviors. The frequent practice in some domains, such as mental health, is simply to ask whether there are any general areas of concern during annual health maintenance visits or routine physical examinations or to use specific trigger questions around a particular topic (Olson et al., 2001). This lack of communication about high-risk issues may be especially problematic for adolescents who are marginalized or perceive themselves to be socially distant from health care providers, such as those who are LGBT. For example, there are clear differences in the identification and treatment of mental disorders among racial and ethnic groups, and rates of identification are lower for those who perceive greater social distance from their physicians (Cuffe et al., 1995; Strakowski et al., 1995).

In a review of preventive care for children and adolescents, Chung and colleagues (2006) found that in most studies, fewer than half of children had received developmental or psychosocial screening, and fewer than half of adolescents had been asked about various health risks or screened for chlamydia. Bethell and colleagues (2001) report that only 18 percent of adolescents aged 14–18 said they had received counseling on risky behavior (such as smoking, use of alcohol or street drugs, sexual/physical abuse, and violence); 23 percent had received preventive screening and counseling on emotional health and relationship issues; and 36 percent had received preventive screening and counseling on sexual activity and STIs. Furthermore, despite the national concern about obesity, only half of adolescents said they had received preventive screening regarding weight, diet, and exercise (Bethell, Klein, and Peck, 2001).

Adolescents generally do not receive routine preventive services for substance use, even though the guidelines of national professional organizations, such as the American Academy of Pediatrics, suggest that they should be screened for drug, alcohol, and cigarette use (Institute for Clinical Systems Improvement, 2007; Kulig and Committee on Substance Abuse, 2005). A 1995 survey of pediatricians showed that fewer than 50 percent screened adolescents for substance use (American Academy of Pediatrics and Division of Child Health Research, n.d.). Another survey from 1991–1996 showed that only a minority of physicians counseled adolescents about smoking (Thorndike et al., 1999).

While several studies have found that routine screening is uncommon for adolescents, providers do target counseling to the highest-risk adolescents, a finding that indicates a relationship between engagement of adolescents in risky behavior and receipt of counseling for that behavior (Bethell, Klein, and Peck, 2001; Fairbrother et al., 2005; Klein and Wilson, 2002). Many at-risk adolescents, however, do not receive counseling. A survey by Klein and Wilson (2002) found that 71 percent of adolescents engaged in one of eight behaviors with potential health risks. Among this at-risk group, 63 percent had not spoken to their doctor about any of these risks. Fairbrother and colleagues (2005) found that approximately one-third of low-income adolescents in New York City who reported having sexual intercourse had not been counseled about STIs. Even more striking, among adolescents reporting symptoms of depression, almost 70 percent had not been counseled about these feelings.

There are a number of reasons for the lack of preventive screening and counseling. First, routine screening requires the use of reliable screening instruments and standardized screening measures. Several such instruments are available for primary care settings (e.g., for substance use—Knight et al., 2002, 2003), yet they are absent or infrequently used in many practices that provide adolescent health care. Second, reimbursement for screening and counseling is inadequate (as discussed in Chapter 6). Third, studies demonstrate that some physicians may avoid screening because they regard it as too time-consuming or fear alienating patients. In the case of substance use, physicians may be unaware of positive treatment outcomes or lack information on treatment resources for adolescents (Kulig and Committee on Substance Abuse, 2005; Van Hook et al., 2007).

Another barrier to routine screening for risky and unhealthful behaviors in adolescents may be the lack of training in screening and counseling among health care providers. Research has demonstrated that educational interventions can improve providers’ screening and counseling of adolescents. One project, for example, offered training and tools for providers to improve their screening and counseling regarding tobacco, alcohol, and drug use; sexual behavior; and safety. The study found significantly increased screening and counseling rates among providers who had received the intervention compared with those who continued to provide their usual standard of care. The average proportion of adolescents screened and counseled increased from 58 percent to 83 percent and from 52 percent to 78 percent, respectively, while no significant increases occurred in the comparison group during the same period. The authors report that the training appeared to account for most of this increase, with the tools sustaining the effects of the training (Ozer et al., 2005). Yet while significant increases in screening may occur as a result of such training programs, they are often difficult to sustain for the reasons outlined above.

In dealing with adolescents’ risky behaviors, health care providers may need to interact with the education, legal, and/or social service sectors. Addressing another level of coordination, one project sought to improve adolescent screening and counseling through a broad community-level initiative involving partnerships among state Medicaid, managed care plans, and community leaders. Increases in screening and counseling for use of tobacco and other substances for Medicaid populations and improved HIV counseling for all populations were reported, although the gains were more modest than those seen with the training intervention described above (Klein et al., 2003).

Differences in the prevalence of unhealthful and risky behaviors among different populations of adolescents raise important questions about the extent to which all adolescents should be screened for use of selected substances or unhealthful practices. Given the specificity and sensitivity of many screening instruments, it is necessary to determine whether they are appropriate for use in a general or selected population. Some screening instruments may produce a high number of false positives or false negatives that would discount their value in many clinical settings. For example, the Centers for Disease Control and Prevention has provided new guidelines (Branson et al., 2006) for all health care providers in various primary care settings regarding routine screening for HIV in adolescents, especially those participating in risky behaviors leading to exposure to HIV. Moreover, some instruments may be more or less appropriate for diverse populations served in primary care settings. While several screening tools are available in many languages and in both audio and printed formats, others are more limited. Understanding the demographics of the primary care panel is critical to any screening process.

Summary

Health maintenance visits and health supervision are important components of primary care services for adolescents. As noted earlier in this chapter, most adolescents visit health care providers annually. Yet few providers screen adolescents for risk factors and unhealthful behaviors, and most providers fail to offer services or resources that could help adolescents improve their future health status as young adults.

Findings :

• Routine screening for risk factors and unhealthful behaviors that emerge during adolescence is not available or accessible for most adolescents.
• Many health care providers who treat adolescents fail to adhere to recommended prevention guidelines, to screen for appropriate risk factors and unhealthful behaviors that emerge during adolescence, and to provide effective counseling that would reduce risks and foster health promotion.

Existing Disparities in Adolescent Health Services

The 2001 U.S. Surgeon General’s report emphasized adolescent health needs, with particular attention to violence and health care disparities. Other than this report, little attention has been directed toward strategies for reducing health service disparities among adolescents.

A review of racial and ethnic disparities and patient safety by Flores and Ngui (2006) focused on mental health among adolescents. The study found that white psychotherapists who were presented with identical case scenarios rated black less likely than white adolescents to display pathological behavior and that providers were less distressed by minority youths’ reporting aggressive, deviant behavior or hating their mothers. This study reaffirmed earlier research indicating that black adolescents are underdiagnosed for depression and other mental health concerns (Adebimpe, 1981; Martin, 1993; Strakowski et al., 2003).

In a review of the literature on disparities in emergency department care, Heron, Stettner, and Haley (2006) found that Hispanic and black adolescents presenting with trauma had an increased rate of testing for drugs and alcohol compared with white adolescents (Marcin et al., 2003). The more frequent testing rates could not be clinically justified as there was no difference in the frequency of positive results. This same review documented disparities in the care for Hispanic adolescents who presented to the emergency department for brain injuries (O’Connor and Haley, 2003). The authors found health care disparities for all pediatric age groups in areas including asthma management (Heron, Stettner, and Haley, 2006).

Over the last 5 years, there has been an increase in studies examining disparities in health service delivery. In reviewing data from California and New York, Guagliardo and colleagues (2003) found racial and ethnic disparities in the rate of appendix rupture. Compared with white children and adolescents aged 4–18, Hispanic and Asian children and adolescents had higher odds (1.30 [1.14–1.48] and 1.21 [0.92–1.58], respectively) of a rupture in California; in New York, Asian and black adolescents had higher odds (2.09 [1.36–3.21] and 1.44 [1.07–1.95], respectively). The authors conclude that immigrant groups were more at risk for delayed emergency care in these communities as adjustments for other demographic factors did not fully explain the disparities.

Disparities have also been reported for a population of adolescents undergoing hemodialysis. A substantial proportion of minority adolescents (averaging age 12) had received inadequate hemodialysis (Leonard et al., 2004). Similarly, these findings could not be explained by such factors as center size, age, or renal diagnosis.

In a review of 31 studies that spanned asthma services, mental health care, reproductive health services, and primary care, racial and ethnic disparities that could not be explained by socioeconomic status were found in all service areas (Elster et al., 2003). The authors offer four findings: (1) there is less utilization of health services among racial and ethnic minority adolescents, after controlling for insurance status and socioeconomic status; (2) despite the absence of differences in the prevalence of mental disorders among black, Hispanic, and white adolescents, there is less utilization of mental health services among minority adolescents; (3) minority youths receive more reproductive health services than white adolescents; and (4) socioeconomic status has a modest impact on health service delivery but does not completely account for the disparities seen.

Summary

Health disparities and biases are a persistent feature of the health care delivery system for racial and ethnic minority adolescents, although little research has been focused on this particular age group. Disparities have been reported in studies of mental health services and emergency department care, as well as in research on adolescents who receive hemodialysis and asthma treatment. While social and economic differences account for some of these disparities, researchers have found that these differences alone cannot explain significant variations in rates of utilization of health services and health outcomes.

Finding:

• Disparities and biases affect the quality of health services for ado lescents and deserve serious consideration in any efforts to improve access to appropriate services and reduce inequities in the health system.

Acceptability

Various studies have examined the role of confidentiality generally in adolescents’ willingness to seek health care and disclose information to health care professionals. Ford and colleagues (1997) found through a randomized controlled trial that increased assurance of confidentiality produced an increase in adolescents’ willingness to provide information about sexuality, mental health, and substance use (from 39 percent to 46.5 percent). Such candor with health care professionals who are taking a health history is critical to adolescents’ receiving the most appropriate care. Other positive outcomes, such as willingness to make a return visit, were noted as well. These findings are consistent with those of an earlier statewide survey (Cheng et al., 1993) in which substantial numbers of adolescents in Massachusetts cited deep concern regarding confidentiality that affected how and when they sought care. Further, studies have examined the impact of limiting confidentiality on adolescents’ use of specific health services, such as those addressing sexual and reproductive health, mental health, and substance use.

Accessibility

In addition to the importance of confidentiality to adolescents’ willingness to seek health services and disclose information to health care providers, it is necessary to ensure access to these confidential services.