Residency · Residency · Medicine-Pediatrics
Adolescent Medicine: The Med-Peds Sweet Spot
Introduction
Adolescents (ages 10-24) occupy the unique intersection of pediatric and adult medicine. Med-peds physicians are ideally positioned to address the complex physical, psychological, and social changes of this population. Adolescent medicine encompasses puberty, risk-taking behaviors, mental health, reproductive health, and the transition to adult care.
The HEEADSSS Assessment
| Domain | Letter | Key Questions | Risk Indicator |
|---|---|---|---|
| Home | H | Who lives at home? Feel safe? Conflict? | Instability, abuse, homelessness |
| Education/Employment | E | Grades? Suspensions? Future plans? | Declining performance, absenteeism |
| Eating | E | Body image? Dieting? Purging? | Disordered eating behaviors, weight changes |
| Activities | A | Friends? Sports? Screen time? | Isolation, excessive screen use |
| Drugs | D | Tobacco? Alcohol? Marijuana? Vaping? | Frequent use, use alone, functional impairment |
| Sexuality | S | Orientation? Activity? Contraception? STIs? | Unprotected sex, coercion, early onset |
| Suicide/Depression | S | Mood? Self-harm? Suicidal ideation? | PHQ-A positive, prior attempts, plan |
| Safety | S | Seatbelts? Helmets? Guns? Violence? Bullying? | Firearms access, DV, cyberbullying |
The HEEADSSS psychosocial interview is the foundation of the adolescent visit:
Home: Living situation, family relationships, safety. Education/Employment: School performance, future plans. Eating: Diet, body image, disordered eating behaviors. Activities: Hobbies, exercise, screen time, peer relationships. Drugs: Tobacco, alcohol, marijuana, other substances. Sexuality: Sexual orientation, gender identity, sexual activity, contraception. Suicide/Depression: Mood, self-harm, suicidal ideation. Safety: Seatbelts, helmets, violence exposure, bullying, firearms.
Confidentiality
Explain confidentiality and its limits at the start of each visit. Spend time alone with the adolescent (without parent) Know your state-specific minor consent laws for reproductive health, mental health, and substance use treatment.
Puberty and Growth
Normal Pubertal Development
Girls: Thelarche (breast budding, Tanner stage 2) typically age 8-13; menarche approximately 2-2.5 years after thelarche. Boys: Testicular enlargement (>4 mL) typically age 9-14. Growth spurt: Girls peak at Tanner 2-3; boys peak at Tanner 3-4.
Pubertal Concerns
Precocious puberty: Secondary sexual characteristics before age 8 (girls) or 9 (boys) Delayed puberty: No breast development by age 13 (girls) or no testicular enlargement by age 14 (boys) Evaluation includes bone age, LH, FSH, estradiol/testosterone, and pelvic/testicular ultrasound.
Reproductive and Sexual Health
Contraception
Provide comprehensive, nonjudgmental counseling. LARC methods (IUDs, implants) are first-line for adolescents per AAP and ACOG. Emergency contraception: Discuss availability and indications. STI screening: Chlamydia and gonorrhea annually for sexually active females under 25.
Gender-Affirming Care
Use correct names and pronouns; Understand the spectrum of gender identity; Puberty blockers (GnRH agonists) may be considered for gender dysphoria; Multidisciplinary approach: mental health, endocrinology, primary care.
Mental Health
Depression and Anxiety
Screen with PHQ-A (Patient Health Questionnaire for Adolescents) at annual visits. Depression prevalence: ~13% of adolescents; higher in LGBTQ+ youth. First-line treatment: CBT and/or fluoxetine (FDA-approved for ages 8+) Monitor closely for suicidality, especially in first weeks of SSRI initiation.
Eating Disorders
Anorexia nervosa, bulimia nervosa, avoidant/restrictive food intake disorder (ARFID) Screen with questions about body image, weight control behaviors, menstrual irregularity. Medical complications: bradycardia, electrolyte abnormalities, bone density loss. Multidisciplinary management with therapy, nutrition, and medical monitoring.
Substance Use
Screening: CRAFFT tool validated for adolescents; Vaping/e-cigarettes: Nicotine exposure, lung injury risk; Marijuana: Impacts on developing brain, particularly executive function; Brief motivational interviewing is effective for mild-moderate use; Refer for specialized treatment when indicated.
Common Medical Concerns
Acne
Mild: Topical retinoids, benzoyl peroxide. Moderate: Add topical or oral antibiotics. Severe/Nodulocystic: Isotretinoin (requires iPLEDGE program; pregnancy prevention mandatory)
Sports Medicine
Preparticipation physical evaluation. Concussion recognition and return-to-play protocols. Overuse injuries and relative energy deficiency in sport (RED-S)
Chronic Disease in Adolescence
Type 1 diabetes self-management. Asthma adherence. IBD, epilepsy, and other chronic conditions requiring transition planning.
Transition to Adult Care
Begin transition planning at age 12-14; Use tools like Got Transition Six Core Elements framework; Assess readiness for self-management; Transfer medical summary, emergency plan, and specialist contacts.
Clinical Pearls
Always see adolescents alone for part of the visit; this is where the real conversation happens. LARC methods are safe and highly effective in adolescents; dispel myths about IUD use in nulliparous patients. The CRAFFT tool is a quick, validated substance use screen that takes under 2 minutes. Eating disorders have the highest mortality of any psychiatric illness; early identification is critical. Med-peds physicians bridge the gap between pediatric and adult systems, making them ideal adolescent medicine providers.
References
- Goldenring JM, Rosen DS. Getting into adolescent heads: An essential update. Contemp Pediatr. 2004;21(1):64-90.
- Committee on Adolescence, American Academy of Pediatrics. Contraception for adolescents. Pediatrics. 2014;134(4):e1244-e1256.
- Knight JR, Sherritt L, Shrier LA, et al. Validity of the CRAFFT substance abuse screening test among adolescent clinic patients. Arch Pediatr Adolesc Med. 2002;156(6):607-614.
- White PH, Cooley WC. Supporting the health care transition from adolescence to adulthood in the medical home. Pediatrics. 2018;142(5):e20182587.
For the intern
When you admit a 16-year-old at 3am, stabilize acute medical issues first—but remember that psychosocial screening often reveals the underlying problem. A "drug overdose" may be a suicide attempt; "abdominal pain" may be pregnancy or sexual abuse. Ask about home safety and suicidal ideation even in the middle of the night. The full HEEADSSS assessment and contraception counseling can wait until morning rounds when you can speak with the patient alone. Document parental presence during sensitive discussions. Know your hospital's policy on confidential STI (sexually transmitted infection) testing and reproductive services for minors—these vary by state and you'll need this information before morning.
Common pitfalls
- Conducting the entire visit with parents present. You'll miss drug use, sexual activity, abuse, and suicidal ideation. Send parents out for at least 10-15 minutes, even if the patient initially declines private time.
- Forgetting state-specific minor consent laws. A 15-year-old may legally consent to contraception and STI treatment in your state, but you must know the rules before prescribing or you risk liability and broken trust.
- Starting with sexuality and drugs. Build rapport first with less threatening topics (Home, Education, Activities). Adolescents will shut down if you lead with "Do you have sex or use drugs?"
- Dismissing somatic complaints as "just anxiety." Adolescents with frequent headaches or abdominal pain need organic workup before attributing symptoms to stress, but also screen for depression and trauma.