Fig. 1
Framework for training in adolescent health
Best-Practices
Training in adolescent health psychology should be grounded in empirical evidence and a solid theoretical foundation. Within the past several decades, knowledge about adolescent health psychology has grown substantially with both researchers and practitioners recognizing the pivotal nature of the adolescent developmental period in terms of immediate and long-term health and mental health outcomes (Michaud et al., 2004; Walker & Townsend, 1999). Accordingly, outcome-based education models evolved from this recognition. These models base specific learning objectives and curricular content on the particular needs delineated by researchers, professionals, and educators (Michaud et al., 2004).
Consistent with outcome-based models, policy and practice in training should integrate key content areas as indicated by the current empirical knowledge (i.e., epidemiological, group outcome, and case study designs), as well use empirically supported format and processes for training (Ford, 2008; Michaud et al., 2004). Key content areas include knowledge of adolescent-specific developmental characteristics, disorders, diseases, and psychosocial problems unique to this population (e.g., eating disorders, sexually transmitted disease, and teenage pregnancy), treatment needs (e.g., treatment compliance and adherence), and prevention and wellness issues (e.g., emotional regulation, physical activity, and nutrition; Ford, 2008; Michaud et al., 2004). According to researchers, educational strategies have proven effective for trainees and professions such as interactive lectures, role playing, and focus group and problem-based learning (Michaud et al., 2004).
Policy
Policy regarding training in adolescent health can be informed by national, organizational (e.g., American Pediatric Association, American Medical Association, and the American Psychological Association), and state/local agencies. Resources to construct such curricula include the Guide to Clinical Preventive Services which was developed by the US Preventive Services Task Force (1996); Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents (Green, 1994), created by the Maternal and Child Health Bureau; the American Academy of Pediatrics Health Supervision Guidelines (Stein, 1997); The Clinician’s Handbook of Preventive Services (US Department of Health and Human Services, 1994); Improving the Health of Adolescents & Young Adults: A Guide for States and Communities (National Adolescent Health Information Center, 2010); and the American Medical Association Guidelines for Adolescent Preventive Services (GAPS; Elster & Kuznets, 1994). Specifically, the GAPS provides recommendations pertinent to the delivery of health care services, including the promotion of health and well-being of adolescents, the necessity of screening tools relevant to specific conditions prevalent to adolescents, and the utilization of immunizations (Elster & Kuznets, 1994). Additionally, the National Adolescent Health Information Center (NAHIC, 2010) provides guidance, initiatives, and resources to communities and state agencies with the goal to enhance adolescent health and safety by addressing mortality, unintentional injury, violence, mental health and substance abuse, reproductive health, and chronic diseases. The development of standards or guidelines for the delivery of adolescent health services makes it possible to assess the gaps in the provision of such services and help guide appropriate corrective action.
Training Initiatives
Training is conceptualized broadly and is flexible in terms of delivery methods and format. The available training initiatives can be viewed in terms of levels that ultimately serve to prepare professionals for work with adolescents. Training in adolescent health involves traditional programmatic curriculum (level one) as well as specialized fellowships (level two) and a variety of continuing educational programs (level three).
Standards for Programmatic Curricula Training relevant to adolescent health psychology tends to occur at the graduate and specialist level. As such, training programs are specifically designed to prepare students for a particular profession and are often beholden to external training mandates. Specifically, programmatic curricula frequently adhere to the standards set by the program’s corresponding professional organization (e.g., APA, AMA) as well as state licensure and certification requirements. The formulation of these guidelines and requirements is an ongoing and fluid process. Using an outcome-based approach, evolving guidelines ideally reflect the needs of key stakeholders (Michaud et al., 2004). Such stakeholders include individuals from a variety of settings: hospital physicians and practitioners, university staff and students, patients, researchers and epidemiologists, and leaders of patient groups (Michaud et al., 2004). This process involves identifying needs, translating needs into desired outcomes, and formulating desired outcomes into training objectives.
Likely related to the breadth of issues that are considered necessary to many training programs, the coverage of adolescent health issues is often deficient in many programs across disciplines. Those who desire in-depth training at this level must seek out programs dedicated to training in adolescent issues. For example, the Society of Adolescent Health and Medicine provides an updated listing of training opportunities in adolescent health medicine across five disciplines (i.e., medicine, nutrition, psychology, nursing, social work). However, the number of specific training programs varies, with 30 programs in adolescent medicine, ten in nutrition and psychology, nine in nursing, and eight in social work.
Educational Training Programs, Fellowships/Residency Programs, and Continuing Education. For those who do not receive training in adolescent health psychology as part of their graduate of specialist training curricula, or those who desire further specialization, there are additional opportunities at the next level of training. Currently, there are a variety of programs designed to provide multidisciplinary training. For example, to provide interdisciplinary training in adolescent health, The Leadership Education in Adolescent Health (LEAH) program was created to integrate the training of future physicians, psychologists, nurses, social workers, and nutritionists. Seven programs currently receive federal funding from the Maternal and Child Health Bureau, which include Baylor College of Medicine, Harvard Medical School (Children’s Hospital Boston), Indiana University, Johns Hopkins School of Medicine, University of California at San Francisco, University of Minnesota, and the University at Rochester School of Medicine. These programs are designed with the purpose of preparing future leaders in adolescent health care and are the only multidisciplinary training programs specifically targeted toward adolescent health supported by federal funding. Since its inception in 1977, LEAH programs have trained more than 600 long-term professionals across all disciplines. Graduates of these programs are prepared as health professionals for leadership roles in clinical care, research, training, advocacy, and administrators. In addition to multidisciplinary training, within medicine, the Accreditation Council for Graduate Medical Education (ACGME) oversees accreditation of post medical training programs. To date, there are 26 accredited programs that provide fellowship training in adolescent medicine. Moreover, specialized postdoctoral fellowships exist in psychology.
Another layer of training initiatives is continuing education. Continuing education in adolescent health is critical to ensure appropriate professional development for health service providers already in the field. The Society of Adolescent Health and Medicine offers up-to-date information on presentations, workshops, and conferences related to adolescent health and medicine. The European Training Effective Adolescent Care and Health (EuTEACH) also offers opportunities for educating practicing health care professionals.
Curricular Development in Adolescent Health Training
Syllabi from graduate level courses in adolescent health, adolescent development, psychology of adolescence, and adolescent risk taking and health, as well as pertinent textbooks, and journal articles were obtained to review essential content areas relevant to adolescent health. Key areas of focus included graduate course work objectives and topics, frameworks used for training programs, curricular development, and training methodologies. Government agencies and professional organizations were also reviewed to provide national data on adolescent health care services and guidelines and recommendations for best practice.
In addition to syllabi reviewed, the Society for Adolescent Health and Medicine, EuTEACH, the material provided through the RESOURCE project, and the adolescent health curriculum outlined by Dr. Lawrence S. Neinstein at The University of Southern California were utilized to identify the key content areas. The EuTEACH has created a framework used in curricular development designed for adolescent health using a multidisciplinary model. Starting in 1999, a group of 16 physicians across various specialties met to develop a consensual curriculum that intended to cover essential learning objectives for training adolescent health and medicine. Since that time, the group has reconvened biannually to discuss the goals of the curriculum, instructional trategies, specific content areas and modules, evaluation, and refinement. The EuTEACH curriculum targets trainees in health care professions and aims to enhance training in adolescent health (Michaud et al., 2004). The main function of the program is to offer training curriculum to all health professionals involved in teaching adolescent medicine and health. The program provides (a) descriptions of the main teaching objects, (b) training methods, (c) practical examples, (d) evaluation procedures, and (e) references (Michaud et al., 2004). Prospective trainers can select from curriculum that is both broad and narrow in scope depending on the needs of the target audience. Further, each training module focuses on knowledge, studies, and skills providing the instructor with the following strategies and methodologies: teaching objectives, corresponding teaching methods, concrete examples (i.e., case-stories), issues to be debated in small groups, and themes for role playing (Michaud et al., 2004). Each objective is accompanied by suggested readings and suggestions for assessment.
Overview of Key Content Areas
A consistent finding across the literature and syllabi reviewed was the importance of understanding adolescent health utilizing developmental-contextual and biopsychosocial frameworks. Ideally adolescent health needs should be understood in terms of the biological, psychological, and social changes that take place during this vulnerable time (Holmbeck, 2002; Williams et al., 2002), as well as understood within relevant systems, familial and community contexts. The interrelatedness of family support, school connections, peer influences, work opportunities, community resources, and media influences all collectively impact adolescents’ abilities to adapt successfully to these changes.
In nearly all graduate course syllabi, the key content area covered reflected variables and topics related to interpersonal, developmental, demographic, and intrapersonal variables. Particular content areas covered in courses included common mental health issues prevalent in adolescent populations, risky behaviors demonstrated during adolescence (e.g., substance use, sexual behaviors, injury, and violence), ecological systems (e.g., family, school, community), interpersonal variables, and intrapersonal variables (e.g., identity development, gender, ethnicity) as well as current prevention and treatment programs. Additional content areas were reflective of unique issues related to adolescent health such as confidentiality, privacy, and treatment adherence. Research on adolescent development through the integration of a wide variety of disciplines and contexts was also an emphasis in various syllabi. Specifically, theoretical perspectives and content were incorporated from interdisciplinary fields including biology, education, sociology, and anthropology. Another goal of training courses included current assessment and treatment issues relevant to understanding adolescent psychopathology such as examining symptom characteristics, screening tools, assessment methods, treatment protocols, and research issues. Based on the information gathered, the table below was organized and depicts key content areas and suggested training topics in adolescent health (Table 1).
Table 1
Key content areas and suggested topics for training in adolescent health
1.Adolescent development and ecological context | |
Understanding adolescent development Growth and puberty Cognitive development Sexual identity and gender Nutritional needs Reproductive health Common medical conditions Variance in chronic conditions Variance in developmental disabilities | Ecological factors Family influences and dynamic Socioeconomic status Cultural and ethnic issues Social context |
2.Resiliency, specific disorders, exploratory and risky behaviors | |
Risk and outcomes for specific disorders and problems Overweight and obesity Sexually transmitted diseases Mental illness (anxiety, depression, suicide) Eating disorders Substance use and abuse Accidental injuries Self-harm Abuse in relationships | Adolescent risk behavior Resiliency in adolescents Risky and exploratory behaviors Sexual behavior Mental health Smoking Illegal drug use Diet exercise |
3.Adolescent characteristics, health education, and advocacy | |
Adolescent characteristics, knowledge, and skills Health literacy Locus of control Health optimism Self-efficacy Socio-environmental context | Health education and promotion Adolescent health literacy Positive youth development Personal advocacy |
4.Prevention, treatment, clinical skills, and multidisciplinary environments | |
Prevention Screening Assessment Treatment | Clinical skills Setting Communication skills Process skills Multidisciplinary work |
5.Confidentiality, privacy, treatment adherence, and access | |
Confidentiality Consent Privacy rights | Treatment adherence Health decision-making Access/health care disparity |
Key Concepts for Training Programs
The following five sections review key concepts to be covered in training programs relevant to the specific needs of the adolescent developmental period.
1.
Adolescent development and ecological context. Adolescent development is an essential component to understanding and managing health-related issues during this period. Pertinent factors are related to biological, cognitive, psychological, and social influences. Specific issues include puberty, sexual identity, cognitive development, individuation, identity development, gender roles, unique nutritional needs, and medical conditions.
Training should also encompass ecological factors such as family influences and dynamics (Michaud et al., 2004). Numerous factors impact teenager’s adaptation, which can be organized and categorized within the following four realms: interpersonal, developmental, demographic, and intrapersonal. Interpersonal variables include family, peers, school, and work. Developmental transformation variables include biological, cognitive, and social changes. Developmental outcome factors include achievement, autonomy, identity, intimacy, psychosocial adjustment, and sexuality. Intrapersonal factors include family structure, ethnicity, race, gender, neighborhood, community, economic opportunities, and socioeconomic status.
2.
Resiliency, specific disorders, and exploratory and risky behaviors. The European Training in Effective Care and Health provides definitions detailing the concepts of exploratory and risky behavior, resilience, and protective factors related to adolescence from a bio-psychosocial context. Exploratory behaviors are considered highly related to this period of development, and are essentially integrated in teenagers’ learning experiences. Risk behaviors are defined as variables that increase one’s likelihood of experiencing negative outcomes. Some common exploratory and risky behaviors associated with adolescence include sexual behaviors, drug and alcohol experimentation, excessive dieting or exercise, inadequate physical activity, violence, and dangerous driving practices (US Department of Health & Human Services, 2008). Protective factors are related to the variables (individual competencies or external support) that shield a teen from negative outcomes. Resiliency is then the culmination of protective factors that allow an individual to successfully cope and manage stressors.
This knowledge directly impacts adolescent heath training programs. It is vital for programs to adequately prepare future practitioners to assess, treat, and provide education to teens who engage in risky behaviors. Equally important, training programs should prepare future educators and researchers to develop and implement effective prevention and intervention programs designed to provide psycho-education and treatment.
Mental health issues: Mental health issues are common in the adolescent population. Annual rates of mental health diagnoses are between 10 and 20 % (Kataoka, Zhang, & Wells, 2002), with depression, anxiety, attention-deficit/hyperactivity, and substance use the most commonly diagnosed (Knopf, Park, & Mulye, 2008). A recent study examining the lifetime prevalence data across a broad range of mental disorders in a nationally representative sample of 10,123 US adolescents (ages 13–18) revealed that approximately 1 out of 4 or 5 youth suffers from a mental illness (Merikangas et al., 2010). The survey demonstrated that approximately 32 % met the lifetime criteria for anxiety disorder, followed by behavioral disorders (19 %), mood disorders (14 %), and substance-related disorders (11 %). Due to the high prevalence rates of mental health problems in adolescence, health care providers must be able to recognize symptoms associated with disorders, understand the contextual and systemic factors contributing to the issue, and be able to provide the most effective treatment plan to address the problem.
Further, there are health disparities regarding access to mental health treatment and lower quality of care based on socioeconomic, minority, or gender status. For instance, when compared to Caucasian clients, minority clients are less likely to obtain mental health services, receive poorer services, and are underrepresented in research (US Department of Health and Human Services 2001). Given that mental illness is significantly correlated with low socioeconomic status, being female, single, and being non-Hispanic black (Kessler et al., 2006), training programs must recognize these disparities and inadequacies of health care toward certain groups to ensure equality of treatment and unbiased mental health care.
Suicide: In a survey conducted in 2005, nearly 17 % of teenagers in the United States seriously considered attempting suicide; and approximately 8 % attempted suicide (Eaton et al., 2006). Thus, suicide risk assessment is an important goal for training, as suicidal ideation and attempts are more likely during this developmental time period.
Depression: Depression is a common psychiatric illness diagnosed in adolescence (APA, 2000), with prevalence rates at 8 % for a Major Depressive Episode (Erk, 2008; Substance Abuse and Mental Health Services Administration, SAMHSA, 2009).
Sleep disturbances: Sleep disturbances is an additional area that affects a large percentage of teenagers. According to Ohayon, Roberts, Zulley, Smirne, and Priest (2000) it is estimated that 25 % of adolescents report symptoms associated with sleep disturbances.
Disruptive behavior disorders: In 2005, approximately 9 % adolescents aged 12–17 had a lifetime diagnosis of attention-deficit/hyperactivity disorder (Pastor & Reuben, 2008). Estimates of oppositional defiant disorder prevalence rates have ranged from 1 to 6 %; the prevalence of conduct disorder in preadolescents and older teens (ages 9 to 17) varies from 1 to 4 % (Shaffer et al., 1996).
Eating disorders: Eating disorders are categorized into four diagnostic classifications including anorexia nervosa, bulimia nervosa, binge eating disorder, and eating disorder not otherwise specified (APA, 2000). Hoek and van Hoeken (2003) reviewed the prevalence rates of diagnosed eating disorders in females and found average prevalence rate for anorexia nervosa is 0.3 % (aged 11–36). The prevalence rates for bulimia nervosa were 1.0 % for women (aged 12–44) and 0.1 % for men of all ages. Adolescent females are more likely to exhibit eating disorder symptoms than males. To ensure that health care providers are able to identify, assess, and treat eating disorders, training programs should emphasize the range of adolescent body shape, social influences on body image, psychosocial factors contributing to symptoms, and treatment strategies targeted toward patients with specific types of eating disorders.
Disordered eating and obesity: An extraordinarily large number of young women exhibit subthreshold symptomology associated with disordered eating (i.e., excessive exercise, dieting pills, laxative use). Furthermore, 31 % of adolescents aged 12–19 were considered at risk of being overweight and overweight in 1999–2002 (Hedley et al., 2004). Specifically, obesity has become an increasing health concern faced by youth and can result in serious health consequences for adolescents, increasing the risk of high cholesterol, hypertension, diabetes, and the metabolic syndrome (Dietz, 1998).
Drugs and alcohol: The rate of illicit drug use among those ages 12–17 and 18–25 has increased from 9.3 to 10.0 and from19.6 to 21.2, respectively (SAMHSA, 2010). According to the 2009 survey, illicit drug use varied by educational attainment, employment status, and race/ethnicity. The engagement in these behaviors poses serious health risks both during adolescence and into adulthood. Specifically, use in adolescence greatly increases the risk for developing a clinical substance use disorder in adulthood.
Pregnancy and sexually transmitted disease: A qualitative study conducted by McManus and colleagues (2003) across four cities identified reproductive health issues as the second most pervasive category impacting adolescents. In addition to sexually transmitted diseases, teenage pregnancies are an additional reproductive health issue. A national survey conducted in 2006 revealed that 750,000 females aged 20 and younger became pregnant (Kost, Henshaw, & Carlin, 2010). More specially, among teens ages 15–19, the pregnancy rate was nearly 72 pregnancies per 1,000 (Kost, Henshaw, & Carlin, 2010).
Furthermore, according to the Youth Risk Behavior Surveillance System (YRBSS), 47 % of teens reported having sexual intercourse, and 37 % of sexually active students had not used a condom during their last sexual intercourse (Grunbaum et al., 2004). These risky sexual behaviors in adolescence contribute to high rates of sexually transmitted diseases (STDs). For example, according to the Center for Disease Control and Prevention (2006), 5,259 individuals ages 13–24 were diagnosed with HIV/AIDS, which accounted for 14 % of new cases that year. It is crucial for health care providers to be cognizant of the issues related to adolescent sexuality in order to help decrease risk of STDs, and provide appropriate counseling services and treatment for pregnant adolescent females.
Mortality rates: According to the US Department of Health and Human Services (2008), there were reportedly 13,703 deaths among adolescents aged 15–19 years in 2005. The leading cause of mortality among this age aggregate is unintentional injury (i.e., motor vehicle accidents), which accounts for nearly half (49 %) of deaths.
Chronic illnesses: According to the Society for Adolescent Health and Medicine, common medical problems in adolescence include abdominal pain, chest pain, headaches, orthopedic problems (i.e., scoliosis), dermatological problems (e.g., acne), and asthma. Physical health conditions identified as the most prevalent in adolescents include obesity and asthma, which are believed to be influenced by poor nutrition, lack of exercise, and sleep disturbances (McManus et al., 2003). On the EuTEACH website, there are specific training modules with training goals and objectives relevant to chronic medical conditions in adolescents. Goals outlined include communicating to the adolescent that his or her experiences are understood, understanding the illness within the bio-psychosocial framework, demonstrating competencies in creating and implementing an appropriate treatment plan, and communicating effectively with all stakeholders.
3.
Adolescent characteristics, health education, and advocacy. As part of the unique and dynamic developmental changes, there are new challenges faced during adolescence that are related to increasing autonomy and individuation. Factors related to locus of control, health optimism, and self-efficacy differentiate this period from childhood. To address these characteristics and promote optimal heath, adolescents need to acquire new knowledge and skills, which can be accomplished through health literacy, promotion, and education.
4.
Prevention, treatment, clinical skills, and multidisciplinary environments. Clinical skills refer to practice-oriented variables including setting, communication skills, clinical skills, and multidisciplinary work. In regard to setting variables, both inpatient and outpatient facilities should be targeted toward adolescent populations. Adolescent-friendly settings should offer an adequate waiting area, pertinent literature, and unique confidentiality practices for teenagers (World Health Organization, 2002). Effective communication skills are also important to effectively work with adolescents. Successful communication with adolescents is developed via the provider’s trustworthiness, openness, honesty (Ehrman & Matson, 1998), and active listening (Coupey, 1997). The goal is to establish a partnership with the adolescent and parents to facilitate all stages of treatment. To establish this partnership, clinical skills need to be drawn upon to create a nonjudgmental atmosphere.
Training should include effective preventative techniques, tools for screening and assessment, and empirically supported treatment method for physical and mental health problems (Sieving & Shrier, 2009). Measurement modalities relevant to adolescents include self-report, observation, and biological measurement. Specifically, self-reported anthropometric measures pose problems as adolescents tend to inaccurately report their weight and height. The greatest discrepancies between actual and self-reported weight tend to be in adolescent females and youth who are overweight while older Caucasian youth tend to report their height as taller than measured height (Brener, McManus, Galuska, Lowry, & Wechsler, 2003). Underestimations of height are most often seen in overweight adolescents (Lee, Valeria, Kochman, & Lenders, 2006). Body mass index (BMI) calculated from self-reported weight and heights therefore maybe underestimated (Brener, McManus et al., 2003). Additionally, self-reported puberty stage in comparison to a clinician’s examination have found similar discrepancies, indicating adolescents to be poor reporters of their pubertal stage (Bonat, Pathomvanich, Keil, Field, & Yanovski, 2002; Lee et al., 2006). Overall, self-reported information tends to be bias and maybe a better reflection of adolescents’ misperceptions and/or distortions of information deemed as unacceptable (i.e., alcohol/drug use, sexual behavior).
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