Pediatric Primary Care Case Studies (119 page)

Counseling and Development

Counseling adolescents requires that the clinician make adjustments based on the teen’s stage of psychosocial developmental (Burgis & Bacon, 2003; Clark, 2003) because not all teens are developmentally at the same level. Piaget demonstrated that early adolescents, ages 12–14 years, are concrete thinkers and lack the ability to comprehend the abstract thought of “what if.” When counseling youth at this age, the healthcare provider needs to use language that is characterized by simple concrete terms. Pictures, direct questions, and statements will help facilitate their understanding. Middle adolescents such as Leslie, ages 15–17 years, are starting to understand abstract concepts but often regress to concrete thinking in stressful situations. The clinician needs to adjust the approach to the middle adolescent accordingly, helping him or her to identify inconsistencies in reasoning and guide the teen’s thought processing through to logical consequences of choices and behaviors. Late adolescents, ages 18–21 years, generally have abstract thought more firmly established and are future oriented. However, this ability will vary, as with the general adult population.

Contraceptive and Safer Sex Counseling

Clinicians who provide contraceptive and safer sex counseling to adolescents should understand that the successful use of any method requires a complex process of knowledge, decision-making skills, and public behaviors. It is also important to use gender-neutral phrasing when discussing safer sex and contraception and not assume heterosexuality. To use contraceptives/protective barriers successfully, an individual must master the following (Gerlt, Blosser, & Dunn, 2009):

•   
Knowledge for contraception:
Most adolescents need to learn about a barrier method for contraception, such as male or female condoms, to prevent an STI as well as about a variety of hormonal methods for contraceptive purposes.

•   
Ability to plan for the future:
Adolescents need to admit to themselves that they will have sex in the future and that they have the ability and resources necessary to use a contraceptive method consistently and correctly. Further, they must be willing to use the chosen method of protection consistently, not just when it is convenient to do so.

•   
Willingness to acquire needed contraceptive/barrier methods publicly:
Adolescents wanting to be successful in using contraceptive/barrier methods successfully will need to be public with requests for contraceptive and/or protective devices; for example, to purchase condoms at a local pharmacy or to seek services at the local clinic, school-based health facility, or private practice. This is not an easy step for many teens and may need rehearsal.

•   
Communication skills:
Adolescents must be able to communicate with another person or persons such as their partner, healthcare provider, pharmacist, or salesperson about their individual contraceptive/ protective barrier needs. The ability to express their feelings about sexual activity, how it affects them, and the thinking behind their decisions to be sexually active is also a needed communication skill.

The next afternoon you receive a faxed lab report: Leslie’s NAAT is positive for chlamydia but negative for GC.

What is your plan now?

You need to consider how to contact Leslie to assure her confidentiality. Will you treat her partner too? If not, who will you refer him to? Do you need to report to the public health officials, or will your lab do that? Many healthcare systems have guidelines or protocols to help you answer these questions.

Per CDC guidelines (CDC, 2006a), treatment of an uncomplicated chlamydial infection includes:

•   Azithromycin 1 g orally in a single dose
OR
doxycycline 100 mg orally twice a day for 7 days.

•   Refer partners for treatment. It is recommended to treat the last partner and any partner exposed within the 60 days before the onset of symptoms.

•   Recommend that the client abstain from intercourse for 1 week after single dose treatment or until completion of a 7-day course. The client also needs to abstain until after her partner has completed treatment.

•   Rescreen 3 to 4 months after the positive test because a high prevalence of
C. trachomatis
infection is found in women with a chlamydial infection in the preceding several months. Reinfection is usually the cause of infection and elevates the risk for PID.

For general STI treatment measures, see
Box 29-3
.

After contacting Leslie, she wants to come into the clinic to take her one-time dose of azithromycin and talk further about this new issue. When you see her the next day, she is very upset about having an STI and does not know how to talk with her boyfriend about this. How did this happen? Did he give it to her or her him? Was he cheating on her? Will this make her unable to have babies?

How will you answer her questions?

You answer Leslie’s many questions and reassure her that with treatment her risk of long-term sequelae is minimal; however, with reinfection the risk would increase. You help her problem solve talking with her partner about the chlamydial infection and plan for his evaluation and treatment. Once again you review with Leslie the guidelines for practicing safer sex in the future and role play negotiating skills that she can use with her partner.

Box 29–3   General Treatment Measures for Sexually Transmitted Infections

•   Have patient abstain from sexual intercourse until patient and partner are cured (treatment complete and symptoms resolved). The consequences of untreated sexually transmitted infections (STIs) should be explained.

•   Test for other STIs, including hepatitis B, human immunodeficiency virus, bacterial vaginosis, and trichomonas.

•   Notify, examine, and treat all partners of patient for any identified or suspected STI.

•   Report STIs to the state health department. Reporting to appropriate authorities is important to identify those at risk, recognize new strains, and assess the extent of infection in the community and the effect of prevention efforts.

•   Provide regular sex health assessment including Papanicolaou (pap) testing, vaginal examination, and testing for STIs.

•   Give hepatitis B and HPV vaccines if not done already.

•   Discuss safer sex practices, including abstinence and use of condoms.

•   Educate and counsel about complications and transmission of STIs, as well as perinatal consequences.

Source:
From Gerlt, T. J., Kollar, L. M., & Starr, N. B. (2009). Gynecologic conditions. In C. E. Burns, A. M. Dunn, M. A. Brady, N. B. Starr, & C. Blosser (Eds.),
Pediatric primary care
(4th ed., p. 936). Philadelphia: WB Saunders.

When will you see Leslie again?

You plan to see her again in 3 to 4 months for a repeat NAAT, to see how she is doing with her OCPs, and to generally check in. Keeping frequent contact with the adolescent helps build rapport and your education and counseling can be reinforced.

Key Points from the Case

1. Understanding the developmental level of your patient is essential for excellent care.

2. Open, honest, and nonjudgmental communication is crucial when working with adolescents.

3. Understanding the risk factors for STIs and why adolescents are inherently at risk by nature is important to their care.

4. Knowing where to find information, guidelines, and evidence-based resources (e.g., CDC, AAP, your healthcare system, etc.) will simplify your work.

REFERENCES

American Academy of Family Physicians. (2006).
Adolescent health care, sexuality and contraception
. Retrieved September 20, 2008, from
http://www.aafp.org/online/en/home/policy/policies/a/adol3.html

American Academy of Pediatrics, Committee on Psychosocial Aspects of Child and Family Health and Committee on Adolescence. (2001). Sexuality education for children and adolescents.
Pediatrics, 108
, 498–501.

American College of Obstetricians and Gynecologists. (2005).
Committee on Adolescent Health Care Resource Guide: Adolescent sexuality and sex education
. Retrieved September 20, 2008, from
http://www.acog.org/departments/dept_notice.cfm?recno=7&bulletin=3271

Biro, F. M., & Rosenthal, S. L. (1995). Adolescent STDs: diagnosis, developmental issues, and prevention.
Journal of Pediatric Health Care, 9
, 256–262.

Bonny, A. E., & Biro, F. M. (1998). Recognizing and treating STDs in adolescent girls.
Contemporary Pediatrics, 15
, 119–143.

Brown, R. T., & Brown, J. D. (2006). Adolescent sexuality.
Primary Care, 33
, 373–390.

Burgis, J. T., & Bacon, J. L. (2003). Communicating with the adolescent gynecology patient.
Obstetrics and Gynecology Clinics of North America, 30
, 251–260.

Centers for Disease Control and Prevention. (2006a). Sexually transmitted diseases: treatment guidelines.
Morbidity and Mortality Weekly Report, 55
(RR-11), 1–94.

Centers for Disease Control and Prevention. (2006b).
Sexually transmitted diseases: treatment guidelines 2006, clinical prevention guidance
. Atlanta, GA: U.S. Department of Health and Human Services. Retrieved September 17, 2008, from
http://www.cdc.gov/std/treatment/2006/clinical.htm#clinical2

Centers for Disease Control and Prevention. (2007).
Trends in reportable sexually transmitted infections in the United States, 2007
. Atlanta, GA: U.S. Department of Health and Human Services. Retrieved April 15, 2009, from
http://www.cdc.gov/std/stats07/main.htm

Centers for Disease Control and Prevention. (2008). Trends in HIV- and STD-related risk behaviors among high school students—United States, 1991–2007.
Morbidity and Mortality Weekly Report, 57
(30), 817–822.