Adolescent Screening: The Adolescent Medical History in the Age of Big Data

Vincent Morelli

• Publisher: Elsevier
• Year: 2019
• Print ISBN: 9780323661300
• eBook ISBN: 9780323661317
• Topic: Medicine
• Subtopic: Family Medicine & General Practice

In this comprehensive look at adolescent screening and holistic health in the technology age, Dr. Vincent Morelli reviews the history of the adolescent health screen, what is being used now, and what needs to be considered in the future. An ideal resource for primary care physicians, pediatricians, and others in health care who work with adolescents, it consolidates today's available information on this timely topic into a single convenient resource.- Covers the history of the adolescent medical history and the need for an update of the biopsychosocial model, which has not significantly changed since 1977.- Discusses nutrition screening, sleep screening, exercise screening, adverse childhood experiences (ACEs) screening, educational screening, behavioral and emotional screening, and more.- Presents the knowledge and experience of leading experts who have assembled the most up-to-date recommendations for adolescent health screening.- Explores today's knowledge of health screening and discusses future directions to ensure healthy habits in adolescents, including education and self-efficacy.

Chapter 1

Adolescent Health Screening

Toward A More Holistic Approach

Vincent Morelli, MD, and Chenai Nettey, MD

Abstract

Adolescence is a time when home, school, and other environmental influences can impact not only adolescent health but also their future adult health. Currently, adolescent health screening has focused loosely on the biopsychosocial (BPS) model of health screening. Unfortunately, the biopsychosocial diagnostic process is not without barriers and shortcomings in adolescent health screening. We propose that it is currently possible for primary care providers to have more robust tools and methods to help with disease prevention and health promotion. Besides outlining the importance of the HEEADSSS approach to the adolescent patient, our work hopes to both simplify and amplify the efficacy of current tools used in adolescent screening. In the age of big data, we now have enlarged data pools allowing us to increase the accuracy and decrease the biases in our screening. Our hope is that this book will help primary care providers to better implement the BPS model toward a more robust approach to adolescent healthcare.

Keywords

Adolescent; Biopsychosocial; Development; Engel; Health; HEEADSSS assessment; Screening

Introduction

Adolescence is a critical time of transition and identity formation ¹ that lays the foundation for healthy adulthood. This period of physical, cognitive, social, and emotional change can be stressful for both adolescents and those around them. It can be a trying time of learning to navigate new emotions, changes in school or home life, increased responsibility, and a new sense of autonomy. It can also mark the beginning of a youth's search for meaning and spiritual evolution (see the chapter on spirituality). Importantly, the values, behaviors, and habits developed in adolescence can significantly impact adult health, life satisfaction, and overall long-term quality of life. ²

Also important, when discussing adolescence, is that adolescence can generally be divided into three development phases: early adolescence (ages 10–13 years old), middle adolescence (ages 14–17), and late adolescence (ages 17–21). ³ As we will see later, any biopsychosocial assessment of the adolescent should consider these developmental stages, probing appropriate areas of health and development and eliciting age-relevant health information.

This book's focus is on adolescent health screening, our intent being to identify adolescent health risks early and, if possible, to address them before the untoward effects are manifest.

In the remainder of this chapter, we will first review the general principles of screening, then look at our current method of health screening in adolescents (the biopsychosocial model), and finally draw some conclusions and steer the reader into the chapters that follow.

Principles of Screening

There are two main reasons for screening: early detection and prevention. ⁴ “Detection screening” should have acceptable sensitivity, specificity, and predictive value and should be judged in terms of measurable outcome (i.e., does screening for cancer accurately detect cancer and will this detection actually improve survival rates). “Prevention screening” is held to similar standards, with the intent to intervene to prevent some future harmful health outcome (i.e., screening for alcohol use to prevent liver disease).

As set out by the World Health Organization (WHO) ⁵ screening is optimal when

1. • patients are given clear information regarding the risks and benefits of screening;
2. • the health issues screened for are significant—meaning issues with high incidence or high morbidity;
3. • the tools themselves are well validated; and
4. • the illuminated health issues benefit more from early intervention than delayed treatment.

Naturally, the benefits of screening should outweigh any potential for harm brought on by screening, and the costs should be considered acceptable. Finally, screening is only useful when it can be disseminated outside of the academic setting and takes hold in the larger population.

In the chapters that follow we will sometimes talk of screening for detection and sometimes of screening for prevention. Our emphasis, however, will be on prevention, hoping to highlight leading indicators of affliction so that the primary care provider may intervene, educate, and prevent.

It is important to note that the gold standard for verifying and validating screening—the prospective randomized trial—is often lacking in the adolescent literature. The current state of adolescent screening often relies instead on observational or epidemiologic studies or on small studies with methodological shortcomings—flaws that can lead to potential biases such as selection bias, statistical lead-time bias, and over diagnosis bias. Although all of this can become statistically complicated, the authors of this issue have attempted to simplify the data and make the information accessible to primary care providers.

Screening via the Biomedical Model

In 1977, internist and psychoanalysis George Engel wrote an impassioned article on what he called the “crisis of medicine”. ⁶ He wrote that the current medicine management model of that time (the biomedical model) was “no longer adequate for the scientific tasks and social responsibilities of medicine or psychiatry.” He believed that the biomedical model, which focused solely on the “somatic parameters” of disease, was inadequate. Instead, he held that psychosocial issues were also significant contributors that should be considered in approaching illness. ⁶ According to his writing, the biomedical model “interferes with patient care” by ignoring other factors that could also be contributing to a person's disease or response to medical management. ⁶

During that period, psychiatry as a profession was battling to win acceptance, fighting to be included as part of conventional somatic medicine. Engel's stance was that by taking into account a patient's social and psychological factors, medical diagnosis and management would be more encompassing, resulting in legitimizing the field of psychiatry in modern medicine and leading to improved diagnosis and treatment of medical ailments. Thus, Engel proposed the biopsychosocial model (BPS model)—a model would look at disease from multiple angles: genetic, biochemical, psychological (e.g., mood, personality, and behavior), and social (e.g., cultural, familial, socioeconomic, and medical), acknowledging that there are other elements besides the “science of the body” affecting patient disease states.

Criticism of the BPS Model

Several psychiatrists have since responded to Engel's BPS model to either criticize or praise it. Nassir Ghaemi's “The rise and fall of the biopsychosocial model” stated that the “evidence-based practices,” used by pharmaceutical, insurance, and national health industries favored the biomedical model, and that opponents only embraced the BPS model as a way to combat the oppression of industry. ⁷ He believed that the BPS model was only designed as a way to legitimize the failing field of psychoanalysis (Engel's specialty) not, as Engel had stated, to incorporate biology and sociology into a more holistic approach. He supported this view by pointing out that even Engel's later research was devoid of mentioning biological or social issues in the face of psychological diagnoses. He also mentioned that for many, the BPS model was a means to justify one's “unscientific” management of a patient. In essence, he felt that the BPS model was being used to allow practitioners to manage their patients however they wanted to manage them. Instead of Engel's comprehensive, holistic approach, Ghaemi believed in allowing the practitioner to choose which aspect of the three (biological, psychological, or social) to focus on when treating the patient. ⁷

Benning furthered Ghaemi's criticism by writing that for many, the BPS model was an idea and not a method to be followed. He did not believe that the BPS model's theories gave a list of organized steps for practitioners to follow to give proper weight to biological, psychological, or social factors in a patient's disease process. He too felt that not all diseases were grounded in all three BPS categories It seemed to him that a sore throat would not require a full psychosocial evaluation.

In more of an academic argument, Benning pointed out that the BPS model received its roots in the general systems theory (GST), which broadly applied concepts and principles to more than one domain of knowledge. However, he states, “Engel himself fails to live up to some of the central tenets of GST” by neglecting the psychopathology of large social units (e.g., community, culture, subculture, and society-nation). ⁸

Despite such critics, proponents of the BPS model have praised and embraced the idea—especially in adolescent healthcare where changing factors—growth, and development, family environment, school environment, etc., can be more fully assessed and factored into ...

Table of contents

• Cover image
• Title page
• Table of Contents
• Copyright
• List of Contributors
• Chapter 1. Adolescent Health Screening: Toward A More Holistic Approach
• Chapter 2. Holistic Health Screening
• Chapter 3. Dietary Screening—Questioning Adolescent Dietary Trends and Providing Evidence-Based Dietary Recommendations
• Chapter 4. Obesity Screening in Adolescents
• Chapter 5. Sleep Disorders
• Chapter 6. Adolescent Exercise Screening
• Chapter 7. ACES: Screening for Adverse Childhood Experiences
• Chapter 8. Adolescent Educational Assessment: Risk Factors Associated With Academic Achievement and Indicators of Learning Challenges
• Chapter 9. Screening Adolescents for ADHD, Oppositional Defiant Disorder, and Conduct Disorder in Primary Care
• Chapter 10. Screening for Violent Tendencies in Adolescents
• Chapter 11. Depression and Suicide Screening
• Chapter 12. Screening for Body Image Concerns, Eating Disorders, and Sexual Abuse in Adolescents: Concurrent Assessment to Support Early Intervention and Preventative Treatment
• Chapter 13. Addressing Substance Use with the Adolescent in Primary Care: The SBIRT Model
• Chapter 14. Screening for Leading Indicators of Juvenile Delinquency
• Chapter 15. Screening for Resilience in Adolescents
• Chapter 16. Spiritual Screening in Adolescents
• Chapter 17. Screening for Strengths and Assets in Adolescents
• Chapter 18. Screening for Screen Time: Screen Time and Your Child's Health
• Chapter 19. Putting It All Together: A Role for Big Data in Health and Adolescent Health Screening
• Index