Caring for hospitalized adolescents

I. Problem/Challenge.

Adolescence is generally recognized as the period of life where one transitions from childhood to adulthood. This entails development in biological, social, emotional, and intellectual spheres. These often are asynchronous and nonlinear. Easy categorization of an adolescent is, therefore, quite difficult.

From a purely physical standpoint, one could describe adolescence as the period beginning with the appearance of secondary sexual characteristics, and ending with epiphyseal fusion. In the United States (US), 99% of boys will have one secondary sexual characteristic by age 14 years, and 99% of girls by age 13 years. Somatic growth for boys ends on average at 18 years old and for girls at 16 years old.

Of note, the term “puberty” refers more specifically to a period of sexual maturation, correlating with the time period beginning with gonadarche and culminating in sexual fertility. In addition, after epiphyseal fusion, there continues to be physiologic development often called the “transition” life phase. This includes increase in muscle mass, increase in the size of the pelvic inlet in women, increase of bone mass, and other physiologic changes correlating with development to adult physiologic homeostasis.

Adolescence is typically a period of good physical health. There are, however, disease processes, both biologic and behavioral, which afflict adolescents more commonly than other age groups. Improvement in the care of chronic childhood diseases has led to a growing population of adolescents with chronic severe illnesses that have a high likelihood of hospitalization.

II. Identify the Goal Behavior

Caring for an adolescent in the hospital requires consideration of a complex interplay of physiologic, psychosocial and legal issues. One must consider diseases that are endemic to the adolescent population, due to either biologic processes or behaviors manifested more commonly in this age group. The rapidly changing body size, composition and physiology of the adolescent also requires adjustment of pharmacologic interventions, medical equipment, supportive technologies, and treatment protocols.

Legal issues surrounding consent and privacy in this age group are complex and typically are specific to each state. In general, encouraging the adolescent to voluntarily involve parents/legal guardians in some aspects of their care is desirable. This goal should be tempered, however, by the reality that lack of confidentiality can reduce the chances that adolescents will seek care and fully disclose details of their health.

In addition, one must be aware of abusive family dynamics, which may place the safety of an adolescent in jeopardy. Finally, consideration of the need to transition the adolescent to adult systems of care in order to prevent readmission due to lack of follow-up is critical in the older adolescent.

III. Describe a Step-by-Step approach/method to this problem.

Should I be taking care of an adolescent?

Hospitals and health care systems are inconsistent in whether admitting privileges are granted on the basis of a specific age group. You should be aware of whether a specific age group is specified in your admitting privileges. If this is not the case, consideration needs to be given not only to the comfort level and privileging of the admitting physician, but also covering physicians and allied health professionals involved with inpatient care of the adolescent.

Consideration of your medical training, ongoing experience in this age group and comfort level with this population is critical in determining whether an adolescent should be under your care. If you are part of a group of physicians, having a defined policy as to whether your group will care for adolescents (and clearly defining the age group you consider to be an “adolescent”) should be considered to ensure that coverage of adolescents is continuous and consistent in the hospital.

Can an adolescent consent to my care?

Unless the patient does not have the capacity to make medical decisions due to neurologic or psychiatric disease, once an adolescent reaches the age of majority, they are able to make all decisions regarding their medical care. The age of majority for most US territories and states is 18 years old, with the exception of Alabama (19), Mississippi (21), Nebraska (19), Pennsylvania (21), and Puerto Rico (21).

More recently, some states have begun to legally recognize “mature minors.” In these states, mature minors are defined as being individuals 16 years old or older who have the cognitive maturity to give informed consent, even if they are living at home as a dependent. Mature minors can provide consent to general medical care and procedures that are not deemed “serious.”

This doctrine exists as a statute in Arkansas and Nevada, and as a law in Massachusetts, Maine, Pennsylvania, Tennessee, and Illinois. Conversely, in Mississippi and Utah, state laws mandate parental consent for minors, thereby preventing any consideration of “mature minor” status.

In states where statutes or laws do not exist (with the exception of Mississippi and Utah), it has become generally recognized that adolescents 16 years old or older who fit the definition of mature minors can give informed consent to general medical care. There have been no reported cases where a physician has been held liable solely for failing to obtain parental consent for care provided to a mature minor. Providing care to a mature minor outside of states where it is legally sanctioned, however, is a personal decision for each physician based on individual beliefs and opinions.

Adolescents can apply to courts for a legal status of “emancipated minor,” whereby the minor is able to make all legal and medical decisions without involving a parent or legal guardian. Although conditions in individual states vary, most states mandate that the following requirements must be met before a court would consider legal emancipation:

The minor is 16 years old or older
The minor is financially self-sufficient and living away from home

It is in the best interests of the minor to be emancipated from their parent(s)/legal guardian(s). In addition, emancipation for medical consent (without full legal emancipation) can be granted by court order for minors 16 years old or older where there is no parent or guardian available to give consent.

Without a court order, a minor can be considered emancipated for medical care consent in the following conditions:

Current or prior marriage
Active duty in the armed forces
Fifteen years old or older and living separately from parent(s)/legal guardian(s) and managing his/her own financial affairs

Decision-making capacity in these adolescents extends to medical care only, unless they have also achieved a legal status of “emancipated minor.” It can also be voluntarily granted by the parent, guardian or related caregiver. In some states, medical emancipation independent of full emancipation can occur at a specific age (Oregon at 15, Alabama at 14) or after graduation from high school (Pennsylvania).

There are also special situations where minors can consent to care without a parent or legal guardian. These situations can be categorized generally as reproductive health, mental health, substance abuse treatment, and emergency care.

Reproductive health

Treatment of sexually transmitted infections (STIs) is a common situation in the inpatient setting. In all fifty states and the District of Columbia, minors are explicitly allowed to consent to treatment, with some states requiring an age of 12 or 14 years old before allowing consent. In all states this includes human immunodeficiency virus (HIV) testing and treatment, although in one state (Iowa), a positive HIV test requires parental notification.

Allowing minors to consent to abortion is a complex, controversial and rapidly-changing legal issue. This is, fortunately, not an issue that hospitalists typically handle. Two states and the District of Columbia explicitly allow all minors to consent to abortions, while the remainder of states require at least one parent’s consent, one parent’s prior notification, at least one parent’s prior consent and prior notification, or have no relevant policy or case law. The Guttmacher Institute maintains a table available online which specifically outlines the requirements for consent and notification in regard to abortion for each state.

Pregnancy

A majority of states explicitly give minors the ability to consent to prenatal care without the involvement of a parent/legal guardian. The remaining states have no state law or statute pertaining to this. Of note, sterilization is a separate and more complex issue.

Substance abuse treatment

Minors are explicitly allowed to consent to treatment for alcohol and/or drug abuse in 45 states. The remaining 6 states have no state law or policy. This is applicable to both inpatient and outpatient settings.

Emergency treatment

In all US states and territories, if medical care is deemed to be an emergency, this can be provided without parental consent. If the patient is not considered to be a mature minor or legally/medically emancipated (see above), parental notification after treatment is necessary.

What do the Health Insurance Portability and Accountability Act of 1996 regulations require in regards to adolescents?

The protected health information (PHI) of adolescents is covered under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and the December 2000 Privacy Rule. Overall, federal regulations defer to state law and statutes, but do address some specific guidelines under HIPAA. In general, parent(s)/legal guardian(s) act as “personal representatives” for adolescents, and thus have access to PHI. Minors emancipated by court order are, of course, treated equivalently to adults in regards to PHI.

Outside of this specific situation, whether a minor is able to act as an “individual” under HIPAA and maintain the privacy of PHI hinges on two conditions:

The minor is able to consent to the specific health care service without the consent of a parent or any other person
The parent/guardian agrees to confidentiality between a provider and the minor.

Simply put, if you have appropriately consented the minor to a medical service based on existing laws, statutes and your own personal beliefs, you are required to maintain the privacy of their PHI.

How do I approach interviewing an adolescent?

Consider introducing yourself first to the adolescent patient then having him/her introduce you to the people in the room. Subsequently, asking the adolescent his/her preferences in regards to privacy and confidentiality (even in the presence of a parent/legal guardian) is appropriate. These preferences should be discussed and agreed upon by patient and parents/legal guardians.

In cases where there is disagreement on the part of parents/legal guardians to the preferences of the adolescent, the physician generally advocates for the confidentiality and privacy of the adolescent, in accordance with state and federal laws/statutes.

Typically, obtaining the history of present illness (HPI) and past medical history (PMH) can be aided by the presence of a parent/legal guardian to fill in details that the adolescent does not remember or was not privy to. Upon embarking on a discussion of social history/risk assessment, it would be appropriate to encourage that this be done without the presence of parents/legal guardians, even if the stated preference of the adolescent is that the parents/legal guardians be present. This can be an uncomfortable process, but assurances to the routine nature of this process can help ease the situation.

While a full psychosocial review can require the time and focus of an outpatient setting, hospitalists should be comfortable performing a brief screening on all adolescents. Assessing risk factors pertaining to both the current presentation as well as long-term morbidity is necessary in all adolescent inpatients. Identification of behaviors and habits that place an adolescent at risk of future morbidity should lead to either inpatient consultations or outpatient referrals for timely follow-up and treatment.

A commonly used mnemonic for the psychosocial risk assessment in adolescent patients is “HEEADSSS.” This can be used as a rough guideline to your approach to the social history, but should be tailored to the patient’s clinical presentation and responses:

H ome: Who lives with the patient and in what type of setting? What is the psychosocial support system at home? Are there any recent changes to the home setting (such as a parent’s new significant other, new family members in the household)?

E ducation/ E mployment: What school do they go to? What grade are they in? What are their current grades like? Are they missing school because of medical illness, bullying or other reasons (such as drug use)? What sports/extracurricular activities are they involved in? Do they have a part-time job? How many hours per week does this involve? Does their job affect their school performance?

E ating: What do they typically eat for each meal? Do they have any special dietary preferences? Are they dieting? Do they participate in regular exercise? Do they suffer from signs of body image problems?

A ctivities: What does s/he do for fun? How much time is spent watching television or using electronic devices?

D rugs: Do they use tobacco products, illicit drugs or alcohol (be aware that adolescents often abuse household solvents, over-the-counter medications, prescription drugs of family members, even plants indigenous to local flora)? Do their family members or friends/peers abuse tobacco products, illicit drugs or alcohol?

S ex: Are they currently in a romantic relationship? Do they engage in sexual activity of any sort (be aware that using the term “sexually active” during an interview is vague and that more specific terms should be used)? Do they engage in sexual activity with their own sex, the opposite sex, or both? Do they use contraceptive methods and “safer sex”?

S uicide: Are they feeling sad, “down,” or bored all the time? Are they having trouble sleeping? Have they considered harming themselves or others?

S afety: Do they wear helmets if riding bicycles/scooters/motorcycles? Do they wear seatbelts? Have they ever driven drunk or otherwise impaired, or been a passenger in a car driven by a drunk or impaired individual? Do they own or have access to weapons/firearms? Do they feel safe at school and at home? Have they been bullied or abused?

IV. Common Pitfalls.

Physician discomfort with adolescent care

You should be comfortable with caring for an adolescent. Despite your board certification, admitting privileges, and physician group policies, if you do not feel comfortable caring for an adolescent patient, you should refer to another provider.

Billing

If the adolescent has asked to maintain privacy for some or all aspects of their medical care in the hospital (e.g. receiving STI treatment while being admitted for another reason), and this is legally appropriate (see above), attempting to maintain confidential billing (if the payor allows) is ideal. This may require the help of a social worker or financial counselor.

Establishing rapport

Adolescents are often distrustful of adult professionals, including physicians. Allowing sufficient time and privacy for your interview and exam is critical in increasing the likelihood that your patient will provide a complete and honest history. Setting the appropriate tone of the interview is also important – adolescents generally do not want to be treated as small children, nor do they want a health care provider who is acting like an adolescent.

Family dynamics

It is common for physicians treating adolescents to encounter friction between the patient and parents/legal guardians during their hospitalization. Keep in mind that as a physician you are an advocate for the adolescent’s health, but not an arbiter of the dynamics of the parent-adolescent relationship. The exception to this is, of course, concerns over physical, sexual or verbal abuse, which may require consultation with a social worker or child abuse specialist, if available.

Ulterior motives

Adolescent patients sometimes are embarrassed to discuss health or social problems that are critically important and are often their true reason for seeking health care. Typically, these hidden problems involve concerns over STI, sexual health, pregnancy, drug/alcohol use, or abuse. Somatic complaints such as abdominal or chest pain often serve as the “cover” for seeking care. “Teasing out” the underlying problem can be difficult, but you should allow sufficient time for assessment of these difficult-to-discuss issues.

V. National Standards, Core Indicators and Quality Measures.

The American Academy of Pediatrics has published a number of policy statements pertinent to the care of the hospitalized adolescent. Policy statements most pertinent to inpatient care are included in the evidence section below.

Currently, there are no core indicators or quality measures that are specific to adolescent health and pertinent to inpatient hospitalization.

VI. What's the evidence?

Shain, BN. “Suicide and Suicide Attempts in Adolescents”. Pediatrics. vol. 120. 2007. pp. 669

AAP News. 1989.

Pediatrics. vol. 128. 2011. pp. 182-200.

“The Role of the Pediatrician in Prevention and Intervention”. Pediatrics. vol. 107. 2001. pp. 188-190.

Pediatrics. vol. 126. 2010. pp. 1240-1253.

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Hospital Medicine