Milestones in Adolescent Health: The First 75 Years

Commentary From the Committee on Adolescence and the Section on Adolescent Health

The mission of the Committee on Adolescence (COA) is to educate and provide guidance on key areas of adolescent and young adult health to pediatricians and other health care clinicians so that optimal health care services can be delivered. The Section on Adolescent Health is charged with providing education and resources to assist both general pediatricians and adolescent medicine specialists enhance their skills in caring for adolescent and young adult patients.

Through its publications, Pediatrics has consistently recognized the importance of adolescent and young adult health. COA and SOAH chose articles that highlight the evolution and unique aspects of adolescent health care, as well as to reflect major issues in the three different quarter centuries of Pediatrics.

Milestones in Adolescent Health: The First 75 Years

Elizabeth M. Alderman, MD, FSAHM, FAAP¹, Margaret Stager, MD, FAAP²

Affiliations: ¹Chief, Division of Adolescent Medicine, Professor of Pediatrics, Professor of Obstetrics & Gynecology and Women’s Health, Children’s Hospital at Montefiore, Albert Einstein College of Medicine, Chairperson, Committee on Adolescence; ²Director of Adolescent and Young Adult Health at MetroHealth Medical Center, Cleveland, Ohio, Professor of Pediatrics, Case Western Reserve University School of Medicine, Chairperson, Section on Adolescent Health

Highlighted Articles From Pediatrics

• Gallagher JR, Heald FP. Adolescence: Summary of round table discussion. Pediatrics. 1956;18(6):1019-1025
• Deisher RW, Schroeder AJ, Allen VR, et al. Drug abuse in adolescence: The use of harmful drugs—a pediatric concern. Pediatrics. 1969;44(1):131-141
• Remafedi G, Resnick M, Blum R, Harris L. Demography of sexual orientation in adolescents. Pediatrics. 1992;89(4):714-721
• Blake DR, Duggan A, Quinn T, Zenilman J, Joffe A. Evaluation of vaginal infections in adolescent women: Can it be done without a speculum? Pediatrics. 1998;102(4):939-944
• Mayne SL, Hannan C, Davis M, et al. COVID-19 and adolescent depression and suicide risk screening outcomes. Pediatrics. 2021;148(3):e2021051507

First Quarter Century (1948 to 1973)

• Gallagher JR, Heald FP. Adolescence: Summary of round table discussion. Pediatrics. 1956;18(6):1019-1025
• Deisher RW, Schroeder AJ, Allen VR, et al. Drug abuse in adolescence: The use of harmful drugs—a pediatric concern. Pediatrics. 1969;44(1):131-141

Origins of Adolescent Medicine as a Subspecialty

The 1955 roundtable discussion¹ was an early publication that described the origins of adolescent medicine as a subspecialty of general pediatrics. Dr. Gallagher of Boston Children’s Hospital described his philosophy of adolescent medicine as a distinctly different approach to the care of adolescents in the outpatient setting. The newly established “Adolescent Unit” was a general medical outpatient clinic for the care of people 12-21 years of age and provided a novel clinical model for adolescent health care. Gallagher explained that young people deserve a clinic of their own whereby “they can tell their own story to their own doctor.” Furthermore, he described how the clinic would train other physicians to learn about this unique age group and their common ailments and concerns. In his narrative, one can appreciate the origins of adolescent medicine as a pediatric subspecialty that relates to “special care to this somewhat neglected age group.”

Several decades later, adolescence as a distinct developmental stage became well established within medical, societal, and cultural norms. Clinicians recognized that unique stages of growth and development occurred during adolescence that included experimentation with sexuality and recreational drug use. In 1969, at the height of the counter-culture movement in the United States, rates of illicit drug use among adolescents had increased to historically high levels. The American Academy of Pediatrics (AAP) described the integral role of the pediatrician in the assessment and management of youth engaged in recreational drug use.² The authors explained the various tenets of care, which included understanding reasons for use, patterns of use, and “providing factual information in a non-authoritarian manner.” In addition, the concept of confidentiality emerged for the first time, and pediatricians were encouraged to talk one-on-one with their adolescent patients in a private setting (without the presence of their parents) regarding their patterns of drug experimentation and use. This new approach to adolescent care—one that did not directly involve parents—empowered the doctor-patient relationship and set new standards for adolescent confidentiality in the health care setting.

Second and Third Quarter Centuries (1973 to 2023)

• Remafedi G, Resnick M, Blum R, Harris L. Demography of sexual orientation in adolescents. Pediatrics. 1992;89(4):714-721
• Blake DR, Duggan A, Quinn T, Zenilman J, Joffe A. Evaluation of vaginal infections in adolescent women: Can it be done without a speculum? Pediatrics. 1998;102(4):939-944
• Sieving RE, McRee A, Mehus C, et al. Sexual and reproductive health discussions during preventive visits. Pediatrics. 2021;148(2):e2020049411
• Mayne SL, Hannan C, Davis M, et al. COVID-19 and adolescent depression and suicide risk screening outcomes. Pediatrics. 2021;148(3):e2021051507

Insights on Adolescent Sexual and Reproductive Health

Two decades later, there remained a need to study patterns of sexual orientation, because large-scale studies of the adolescent age group were lacking.³ In 1992, a survey of over 34,000 Minnesota junior and senior high school students included questions about sexual fantasy, behavior, orientation, and attraction/behavioral intent and were included in a larger self-administered survey of adolescent health. The majority of students (88.2%) described themselves as mostly or totally heterosexual, 10.7% were “unsure” of their sexual orientation, and 1.1% described themselves as mostly or totally bisexual or homosexual. The reported prevalence of homosexual attractions exceeded the prevalence of homosexual fantasies, sexual behavior, or affiliation. The percentage of students who were “unsure” about orientation declined by 20% with age (comparing 12- and 18-year-olds). Unsure students were more likely to report bisexual and homosexual attractions and fantasies and less likely to report heterosexual experiences. Males were more likely to report homosexual experiences, and these experiences increased with age. Of those reporting homosexual experiences, 27.1% identified themselves as homosexual or bisexual. Heterosexual experiences were reported equally by those who identified as heterosexual or homosexual. In the older age groups, uncertainty about sexual orientation decreased with increases in identification as heterosexual or homosexual. This study, although limited to adolescents in one state, suggested that sexual orientation unfolds during adolescence and that sexual experiences did not necessarily identify sexual orientation during adolescence.

The expanding literature around adolescent sexuality included increased publications on screening and testing for sexually transmitted infections (STIs) among adolescents. Urine testing for STIs was an established, noninvasive screening test that did not require a speculum exam; however, testing for vaginitis caused by bacterial vaginosis, Trichomonas vaginalis and Candida sp required a speculum exam. A landmark 1998 publication by Blake et al⁴ found that speculum and non-speculum methods of diagnosing STIs demonstrated equal sensitivity. The authors promoted the expansion of less-invasive gynecologic care through their demonstration that vaginitis caused by bacterial vaginosis, T vaginalis and Candida sp could be diagnosed without a speculum exam. This important study contributed significantly to today’s standard practice of evaluating vaginitis without the use of a speculum and helped to remove a barrier to this evaluation often cited by patients and pediatric providers.

The inability to receive confidential care for sexual and reproductive health still remains a barrier to access for many adolescents. The AAP recommends confidential discussions with adolescents on sexual and reproductive health, and encourages adolescents to involve parents or trusted adults, if possible, as an integral part of the annual preventive care visit. In 2021, a study of 11-17 year olds who had a preventive visit in the past 2 years (and their parents) looked at the perceived importance, by these groups, of discussions around sexual and reproductive health during the preventive care visit.⁵ The domains included questions about puberty, gender identity, sexual orientation, sexual decision making, safe dating, STI/HIV, contraception, and where to obtain sexual and reproductive health care. They were also asked about whether these discussions occurred confidentially. The majority of adolescents and parents surveyed felt that confidential provider-adolescent discussions about these topics were important. However, less than one-third of adolescents reported engaging in discussions about sexual and reproductive health topics, other than puberty, at their most recent preventive visit. Although most parents and adolescents value provider-adolescent discussions on such topics, this study found that these conversations do not occur routinely during preventive visits, pointing to missed opportunities for screening, education, and guidance around sexual and reproductive health.

Adolescent Mental Health and the COVID-19 Pandemic

The historic COVID-19 pandemic brought new issues to the forefront especially in the realm of mental health for adolescents. Mental health concerns among adolescents increased during the COVID-19 pandemic, including the fact that suicide became the second leading cause of death (surpassing homicide) in this age group. A study published in 2021 described changes in screening, depressive symptoms, and suicide risk among adolescents and young adults during the first 7 months of the pandemic.⁶ Electronic health records (EHRs) of 12-21 year-olds attending a large pediatric primary care network compared the percentage of primary care visits during which adolescents were screened for depression and screened positive for depressive symptoms or suicide risk prior to the COVID-19 pandemic (June–December 2019) to the first year of the pandemic (June–December 2020). The results found that although screening declined slightly, the percentage of adolescents screening positive for depressive symptoms increased from 5.0% to 6.2%, with greater increases among female, non-Hispanic Black, and non-Hispanic white adolescents. Positive suicide risk screens increased from 6.1% to 7.1%, with a 34% relative increase in reporting of recent suicidal ideation among females. These results suggested that depression and suicide concerns increased during the first 7 months of the pandemic, especially among female adolescents, and underscored the importance of consistent screening for depression and suicide risk. Additional studies over the course of the pandemic have corroborated these findings.

References

1. Gallagher JR, Heald FP. Adolescence: Summary of round table discussion. Pediatrics. 1956;18(6):1019-1025
2. Deisher RW, Schroeder AJ, Allen VR, et al. Drug abuse in adolescence: The use of harmful drugs—a pediatric concern. Pediatrics. 1969;44(1):131-141
3. Remafedi G, Resnick M, Blum R, Harris L. Demography of sexual orientation in adolescents. Pediatrics. 1992;89(4):714-721
4. Blake DR, Duggan A, Quinn T, Zenilman J, Joffe A. Evaluation of vaginal infections in adolescent women: Can it be done without a speculum? Pediatrics. 1998;102(4):939-944
5. Sieving RE, McRee A, Mehus C, et al. Sexual and reproductive health discussions during preventive visits. Pediatrics. 2021;148(2):e2020049411
6. Mayne SL, Hannan C, Davis M, et al. COVID-19 and adolescent depression and suicide risk screening outcomes. Pediatrics. 2021;148(3):e2021051507