Bright Future -Middle Adolescence
(15 through 17 Year Visits)

Health supervision

Surveillance of development

• Forms caring and supportive relationships with family members, other adults, and peers
• Engages in a positive way with the life of the community
• Engages in behaviors that optimize wellness and contribute to a healthy lifestyle
• Demonstrates physical, cognitive, emotional, social, and moral competencies (including self-regulation)
• Exhibits compassion and empathy
• Exhibits resiliency when confronted with life stressors
• Uses independent decision-making skills (including problem-solving skills)
• Displays a sense of self-confidence, hopefulness, and well-being

Observation of Parent-Adolescent interaction

Do parents encourage self-management and independent decision-making about health? How do adolescent and parent interact? Who asks and answers most of the questions? Does adolescent express an interest in managing own health?

Complete Physical Examination, including

Measure: Blood pressure and compare with norms

Measure and plot: Height, weight, and BMI

Assess/observe for: Acne, acanthosis nigricans, atypical nevi, piercings, signs of abuse or self-injury

Examine: Back, spine

Females: Assess/Observe for SMR

Males: Assess/Observe for gynecomastia; SMR; testicular hydrocele, hernias, varicocele, masses

Screening (www.aap.org/periodicityschedule) universal: Depression: Adolescent; Dyslipidemia (once between 17 Year and 21 Year Visits); Hearing (once between 15 Year and 17 Year Visits); HIV (once between 15 Year and 18 Year Visits); Tobacco, Alcohol, or Drug Use; Vision (15 Year Visit) selective: Anemia; Dyslipidemia (if not universally screened at this visit); HIV (if not universally screened at this visit); Oral Health (through 16 Year Visit); STIs; Tuberculosis; Vision (16, 17 Year Visits)

Immunization

• CDC: www.cdc.gov/vaccines
• AAP: http://redbook.solutions.aap.org

Anticipatory Guidance

The first priority is to address the concerns of the adolescent and parents. In addition, the Bright Futures Adolescence Expert Panel has given priority to the following additional topics for discussion in the 3 Middle Adolescence Visits:

Social determinants of health: Risks (interpersonal violence, living situation and food security, family substance use), strengths and protective factors (connectedness with family and peers, connected- ness with community, school performance, coping with stress and decision-making)

• Learn to manage conflict nonviolently; walk away if necessary. Avoid risky situations.
  Call for help if things get dangerous.
• When dating or in sexual situations, no means NO. No is OK.
• Teach your adolescent nonviolent conflict- resolution Discuss Internet safety.
• Community agencies can help you with concerns about your living situation.
  Tell me about your living situation.
• Programs like SNAP are available to help you if you have concerns about your food situation.
  Within the past 12 months, were you ever worried whether your food would run out before you got money to buy more? Within the past 12 months, did the food you bought not last and you did not have money to get more?
• Don’t use tobacco/e-cigarettes; talk with me if you are worried about family member drug/alcohol use.
• Spend time with your family; work with them to solve problems.
• Making and keeping friends is an important life skill.
• Spend time with/praise/be affectionate with your adolescent; agree on limits, consequences; know where he and friends are; provide opportunities for independent decision-making.
• Help adolescent follow interests to new activities; increase awareness of community issues/needs.
• Take responsibility for schoolwork; follow family rules; ask for help when needed.
• Find ways to deal with stress; talk with parents/ trusted adult.
• Involve adolescent in family decision-making; encourage him to think through problems and practice independent decision-making.

Physical growth and development: Oral health, body image, healthy eating, physical activity and sleep

• Brush teeth twice a day; floss once.
• Continue dentist visits; give fluoride if dentist recommends.
• Figure out the healthy eating/physical activity combination that will keep your body strong and healthy.
• Eat when you’re hungry; stop when you’re satisfied.
• Eat breakfast; eat vegetables/fruits/whole grains/lean protein; have 24 oz or more low-fat/nonfat dairy/other dairy daily.
• Limit foods and drinks high in sugar/saturated fats/refined grains and low in nutrients.
• Drink water.
• Be physically active 60 minutes a day.
• Use safety equipment during sports.
• Get enough sleep.
• Support healthy self-image by praising activities/ achievements, not appearance.
• Support healthy weight and help your adolescent choose healthy eating (provide healthy foods, eat together as a family, be a role model).

Emotional well-being: Mood regulation and mental health, sexuality

• Recognize that hard times come and go; talk with parents/trusted adult.
  Have you been feeling bored, sad, or irritable all the time? Do you ever feel so upset that you wished you were not alive or that you wanted to die?
• Talk with me about concerns for your adolescent’s emotional well-being/mental
• Get accurate information about physical development as well as sexuality and sexual feelings toward opposite or same sex; talk with me/parents/trusted adults.
  Have you talked with your parents about dating and relationships and about sex? Are you sexually attracted to anyone now? Boys? Girls? Both? Not sure? Do you have any questions or concerns about your gender identity, meaning your identity as a male or female?
• Communicate often; share expectations clearly.
• If you have questions about adolescent sexual development, sexual orientation, or gender identity, ask me.

Risk reduction: Pregnancy and STIs; tobacco, e-cigarettes, alcohol, prescription or street drugs; acoustic trauma

• Don’t smoke/vape, drink alcohol, or use drugs; avoid situations with drugs/alcohol; don’t share your own or others’ prescription medications; support friends who don’t use; talk with me if concerned about family member’s use.
  What are your thoughts about smoking/vaping, drinking, using drugs? If offered: How did you handle it? If not offered: How would you handle it?
• Talk with adolescent about tobacco/alcohol/ drugs; know youth’s friends and activities; clearly discuss rules/expectations; praise her for not using; be a role model; lock liquor cabinet; store prescription medicines in locked location.
• Abstaining from sexual intercourse, including oral sex, is the safest way to prevent pregnancy and STIs; plan how to avoid sex, risky situations.
• If sexually active, protect against STIs and pregnancy by correctly/consistently using long-acting reversible contraception, such as IUD/contraceptive implant, or birth control pills. Use with a condom.
  Are you now in a romantic relationship? Have any of your relationships been sexual relationships? Have you ever been touched in a way that made you feel uncomfortable? Have you ever been pressured to do something sexual? If sexually active: Were your partners male or female, or have you had both male and female partners? Were your partners younger, older, or your age? Have you had oral sex? Vaginal sex? Anal sex? Did you use other birth control instead of, or along with, a condom? Are you aware of emergency contraception?
• Help your adolescent make a plan for resisting pressure; help her as she accepts responsibility for her decisions and relationships.
  How do you plan to help your adolescent deal with sexual pressures? Do you know where your adolescent is and what she does after school and on weekends? What have you discussed about alcohol, drugs?
• Wear hearing protection when exposed to loud noise (concerts, lawn mowing). Keep earbud volume moderate.

Safety: Seat belt and helmet use, driving; sun protection; firearm safety

• Wear seat belt; don’t talk/text/use mobile device when driving.
• Wear helmet, protective gear, life jacket.
• Wear seat belt; don’t talk/text/use mobile device when driving.
• Use sunscreen; wear hat; avoid prolonged sun exposure between 11:00 am and 3:00 pm; avoid tanning parlors.
• Remove firearms from home; if firearm necessary, store unloaded and locked, with ammunition locked separately.
  Do you ever carry a firearm or other weapon?