Senior professor of pediatrics here
at the Larner College of Medicine
and the division head of adolescent medicine,
and also VCHIP faculty
working to improve the peds to adult transition
in primary care.
With that said, I am going to turn it over to Erica
to lead us in a discussion today.
Great, thanks, Alyssa.
Nice to see some names and faces of people I know so well
and happy to be here.
So we're gonna talk just a little bit about
adolescents and young adults,
otherwise known as AYAs and their development
and some communication strategies around working with them.
I'd just like to start some of my talks
with a brief update about
what the heck adolescent medicine is.
Some folks aren't aware
that there are adolescent medicine specialists
and folks can specialize in adolescent medicine
from pediatrics or family medicine
or actually even internal medicine.
Here at the medical center,
we have three primary adolescent medicine clinics,
a Pediatric and Adolescent GYN/
Sexual Reproductive Health Clinic
that serves people of all genders,
the Transgender Youth Program
and an Eating Disorder Assessment
and Recommendations Clinic.
Also provide a lot of teaching internally
and around the state to folks
and do some great grant work with VCHIP
and directly with VDH on a variety of topics just as an FYI.
Another just quick thing about me
is that I have spent a lot of time actually working
in high schools with young people,
not just in the medical field.
I was a high school teacher long ago
right after I got out of school
and I was the medical director for eight large
multidisciplinary school-based health centers
in New York City right out of my fellowship
before I came up here to Vermont.
So I've worked with adolescents in a variety of settings
just in case you're wondering why the heck you should listen
to anything I have to say on the topic.
So today we're just gonna talk a little bit about
adolescent brain development.
I'm sure a lot of you are familiar
with a lot of what we're going to discuss today.
So this might be just a little bit of a revisiting,
a little bit of a reminder, an opportunity to think twice
about your approach to adolescents
and what works best for them.
And so first of all, who are adolescents, right?
Adolescents are defined in different ways
by different folks.
Here in Vermont,
we know we have a wide variety of young people
from all different backgrounds and cultures
with all different lived experiences
and we are all caring for them together.
It's important to remember that adolescents in general
are pretty healthy and resilient
even though we have had a lot of focus more recently
on adolescents actually not being so healthy,
especially from a mental health point of view.
Folks are pretty worried about that these days.
They're very resilient.
They are independent, yet still quite vulnerable
as they're moving further into independence.
It's really easy to sometimes forget
that especially older adolescents aren't just little adults
and can function in an adult-like way.
They might not be all the way there yet
and they're not also just really big children.
They're their own genre.
And again, defining adolescents specifically
is complicated, right?
Do we talk just about how old people are?
Do we talk about how developed their brains are?
Do we talk about their behaviors?
All these things play a part.
It is important to remember
that age does not always equal cognitive
and emotional maturity for a young person.
In my experience, I have at times met 13 year olds
who are incredibly savvy and together
and have a capacity to process emotions
and thoughts on a higher level than some of the 18 year olds
that I've met and cared for.
Brain development continues into the mid twenties.
That's something that's really pretty well known now,
although it was new news to a lot of folks
10 to 20 years ago.
And we know that adolescents live in a wide variety
of different contexts,
which has an effect on their development.
So a picture down here at the bottom
just shows the range from a five-year-old brain
up to a 20-year-old brain
and the rates of development
in the different locations, right?
So the red yellow portions in the younger folks
are reflective of parts of the brain
that are less fully mature
and in particular the sites
of the dorsal lateral prefrontal cortex
where executive functions are developing,
are those that are some of the parts of the brain
that are developing a bit later in life.
Important though not to use
adolescent brain development
and the fact that the brain might not be fully mature
into twenties against a young person, right?
And use that as an excuse for them
not to be able to have some independence
and make some of their own decisions,
and certainly some folks have tried to do that to balance.
So adolescents is very much about searching for identity
and trying to figure out who somebody is
as an individual within the context
that they're growing up in.
So folks are trying to figure out who they are.
We have a lot of folks,
even though we have all sorts of folks
sort of across the spectrum
who might not fit stereotypical notions
or be quote unquote normal,
still trying to figure out if they are normal
because it can be a big part of fitting in.
Although certainly there are folks out there there
that pride themselves on not being normal,
but what is normal, right?
There is a fair amount of egocentricity,
like how do others see me,
feeling like you're on the stage all the time,
comparison to others.
I will say I feel like some of these things do not go away
even as people mature.
There's sorting out sort of what they're good at
and what they wanna do, where they fit in,
what they believe in, what's right, what's wrong,
sort of searching for that moral compass
and where are they headed in the future
and the context of adolescent development
is really quite essential.
There's the individual,
there's the family they're growing up in,
whether it's a biological family, a chosen family,
anyone that might be involved more intimately
in young person's life.
There's their peer group,
those that they're associating with in their own age range.
There's a school setting for younger folks
who are hopefully attending school.
We are aware some folks aren't able to attend school
for a variety of reasons,
and then the society and community they live in
plays a large role also, right?
So are they working?
Are they involved in organizations,
religious organizations, youth groups?
What is the background for them in particular
in terms of politics, racism, socioeconomic status?
Luckily, I think here at the medical center
we're getting better and better
at checking on social determinants of health for folks
when we're caring for them, which is really a key part
of understanding their lived experience.
So emerging independence is a big deal
as young people are moving into later adolescence,
which is a lot of what the Peds
to Adult Transition Program focuses on, right?
Helping those older adolescents shift to adult care.
And we can't forget the strong popular cultural influence
on folks, which has only increased with the tech boom
and the connectivity on so many levels
via the internet at this time.
So why do we wanna focus on adolescent health?
Well, first of all, from a strengths framework,
we really wanna celebrate young people
and their strengths and resilience
while helping them with the problems that they're facing.
A lot of our visits can be about reducing risk,
whether it's immediate or in the future.
But taking the time when you're meeting with someone
to celebrate all their strengths is really important.
We want to help young people to begin to understand
that they have the right
to fulfill their right to healthcare,
especially sexual reproductive healthcare as they mature
and if we can help them to be healthy in their adolescents,
it hopefully increases the chance
for a healthy adulthood also.
A lot of people when I say I do adolescent medicine
are like, oh my God, like how do you do that?
That must be so hard.
And I think a lot of folks think about adolescents
as being problematic and challenging.
But I really like this quote from one of our former heads
of the Society for Adolescent Health and Medicine,
who was actually a psychologist.
That organization is a great multidisciplinary group
that includes nurses, social workers, et cetera.
He said, "Young people are not problems to be solved,
but resources to be developed.
And we as hopefully, relatable and trustworthy adults
who understand their developmental context
can be one of those folks that can help them to develop."
So just a bit more on the brain development.
I showed you that picture earlier,
but to emphasize at birth,
folks are equipped with most of the neurons in their brain
and by age six, the size of the brain has actually grown
to about 90 to 95% of its final adult size.
In some MRI studies that they've done,
what they see primarily in adolescents is this second wave
of neuronal proliferation and pruning, right?
So all the connections are being made
and some connections are being cut
and a lot of that
is based on young person's actual experience in the world.
It's pretty fascinating.
And until the mid twenties,
the gray and white matter
do continue to undergo extensive structural changes, right?
And those changes don't actually affect the number
of nerve cells, but actually connections between everything.
So you can understand how brain development
might be significantly affected by traumatic experiences,
substance abuse, et cetera.
So first the limbic system is developing in adolescents,
this is the emotional
and stress sort of auto response center, right?
And people are famous for talking about
young people being hormonal and dramatic
and all of that stuff
that kind of fits with this development.
The last section of the brains to develop
is the prefrontal cortex.
Those executive functions that then come in
a little bit later that help with planning, organization,
suppressing impulses, weighing consequences of things
that are going on in their lives.
So, and what are the implications of this brain development?
Well, there's possibly some limited reasoning in planning.
There is also the high likelihood of experimenting,
testing limits, pushing the envelope.
I have this recurrent experience
with my 12-year-old when we're driving in the car
once in a while from the back seat.
He'll say, "Sometimes I just wanna open the car door
while we're driving."
'Cause he just has that strong urge.
It's hard to suppress, he wants to open it.
I have to say he's never done it at high speed.
He's done it when we were going five miles per hour
in our neighborhood and it can be pretty alarming.
I'm just glad he actually articulates it to me
that that's happening.
But it's interesting that he's articulating something
that I know fits with sort of how his brain is working
or not fully working sometimes at this time.
I mean, he's otherwise a very bright young man
who tends to make good choices.
Habits formed during adolescence may be hard to break again
because of all that pruning and those connections
that are being made and reinforced by experiences.
And then unfortunately sometimes
some of that exploration and limit testing
can have long-term consequences for young people.
So there are different timetables
for that frontal lobe development.
It's not just all based on the age someone is.
So that's important to keep in mind
and that ability to connect present activity,
for example, like unprotected sex with future outcomes,
like getting a sexually transmitted infection
can be highly variable
for different folks at different times.
There are some psychological tasks of adolescents
in terms of cognitive maturation.
They are moving from a place of concrete thinking
to abstract thinking, from present to future orientation
and from thinking about causality as being single
versus multifactorial.
They are working towards independence from parents,
actually actively starts around middle adolescents
into late adolescents.
And again, trying to establish their identity,
development and acceptance of body image is a key aspect,
especially as bodies are going through pubertal changes,
and that's may be one thing
for designated females and designated males.
And then quite a whole nother thing
for gender diverse young folks
for whom that might be harder.
So, just a brief review of the stages
of adolescent development.
Typically, these are divided into early,
middle and late adolescents
and are different for cis females and cis males.
Everything starts to happen a little earlier
for cis females.
For gender diverse youth,
we don't really have research to date that's as specific,
but we do know a variety of factors
are influencing development
whether it's designated sex,
the environment a young person's growing up in.
For a gender diverse young person,
perhaps how much they're struggling
with their identity or their body,
the changes in their body in particular.
As we're talking about a transitions project here,
when folks are a little bit older,
we're gonna focus a little bit more
on sort of middle adolescents and late adolescence.
So in that middle adolescence stage,
we do have that transition in cognition.
So a movement from concrete to abstract thinking,
but still a little bit of both.
So they might be going a little bit back and forth.
And physical development
is often fairly far along at this point,
although not necessarily totally complete.
And again, there might be those folks
who might be quite unhappy with how their body has developed
and they're really trying to become comfortable
with what their body looks like
given the changes that have occurred since childhood.
Here's just a quote from,
can anyone tell me this movie, anyone, anyone?
Breakfast Club.
[Erica] Yep, yep.
A theme song from this movie was a theme song at my prom.
Not to give away my age to everyone,
but this is the young person
that was playing one of the teenagers.
He says at one point in the movie,
when he looks in the mirror,
"I see me and I don't like what I see."
Right, so, but we often have a real disconnect
between a teen's physical appearance
and emotional maturity level at this point.
Here's a picture of Calvin
from Calvin and Hobbes in all his gear
that he wore when he was just five,
but clearly a bit larger and in teenage mode,
but still with a lot of the accoutrements of being younger
and just a reminder,
a young person may look like an older person
on the outside, but internally,
they might still have a sort of affiliation or development
that's more consistent with the younger person.
So independence and peer relationships
really start to emerge more in middle adolescence.
This is when major parent-child conflict
potentially starts to arise.
That limit testing we talked about
and that struggle for emancipation.
Oh, can't I go do this by myself?
Why do you have to drop me off and pick me up?
Why do I have to tell you where I am all the time?
Just a cartoon here,
a young person and their parent saying,
"We both see each other
but we really are not understanding each other."
Peers at this time can start to provide a lot more support
versus parents.
Previously, there also can be a conformity with peer values
for many folks, right?
All those trends that folks are coming home with
in terms of what everyone's wearing at school
or what they own
and wanting to have what everyone else has
sometimes still plays a really large role in lives.
Folks also are paying quite a bit of attention to,
again, how they're looking, how they're feeling
if they're fitting in.
So tips for middle adolescents.
Friendly relationships really can create trust.
We always wanna try to build rapport with young people
when they are still in the school age years
and in visits with parents,
you're building rapport often with the family.
But as you're spending more time talking to young people
and then hopefully having some time alone to chat with folks
as they reach their early teen years,
you're hopefully developing a direct rapport with them
and for adult providers,
if this is done well in pediatric care,
then they're gonna be more well prepared
when they're moving into adult care.
One thing I find with young people
is that those open-ended questions we're trained to ask
so much in medical school and residency,
sometimes don't always work for young people.
They might not quite be able
to answer an open-ended question,
or if they do answer, it might be like pretty expansive
and not what you need to focus on.
So sometimes it is important to move
to more focused questionings
or just helping them clarify what you really wanna know
and using messaging and tools
that teens can really relate to,
whether it's handouts or pictures,
outlines can really help also.
A focus in visits on independence,
but the importance of supportive adult connections,
like finding out from someone
what adult do you feel like you can talk to?
Is that a parent or guardian
or is that someone else you know,
someone else in your family, someone at school.
And then again, health promotion and harm reduction
are key points of what we focus on.
In settings where peer counseling is available,
so perhaps in school-based health center settings
or other community-based clinics,
peer counseling has been found
to be really effective in this age group.
As folks are moving into late adolescences,
that concrete thinking becomes more abstract,
usually memory improves, there's improved logical reasoning
and identity developed has started to coalesce more.
Not that it won't totally continue to shift
as someone moves into adulthood,
but folks at that point have moved a bit more
towards their own values,
more clarity perhaps about what they wanna do
with their life in the future.
Body image concerns are usually improving by this point,
but as I said before, plenty of these things
might persist into adulthood for plenty of people.
Independence and peer relationships
are usually pretty well established at this point
and while folks may have had separation from family,
there tends to sometimes be this reintegration
back into family sort of building relationships
based on who a young person has become as they've matured.
And reintegration, for example, of family values
into personal experience or behaviors
might be something that comes about.
Some folks are moving towards financial independence
at this point and there tends to be an increased capacity
for mature friendships and intimacy for a lot of folks.
So when folks are a bit older,
more abstract reasoning may allow
for sort of more traditional approaches in care.
And there is often a better understanding
about the relationship between behaviors and consequences.
And something that can be helpful for folks I find
is if they do have someone that they want to accompany them
to visit, even if it's a friend
or someone outside the family,
not that they would be there necessarily
for all of a visit if there are a lot of privacy
or private issues being discussed,
can be helpful for folks just to feel like,
they have someone by their side and helping them
to understand and clarify things.
So I would be remiss in not touching base
on the real importance of a strengths-based approach
in caring for young people
and the strengths-based approach has been focused on
by a few key folks in the world
of pediatrics and adolescent medicine over the years.
One of those folks is the wonderful Paula Duncan
who worked here in Vermont for such a long time.
Dr. Kenneth Ginsburg down at CHOP
has done a lot of work on this
and the emphasis is on the importance
of being able to build a really comfortable, trusting
and non-judgmental relationship with a young person.
And really I think for anyone who's doing adult care,
you're working on doing this with adults too,
so that you can have an effective relationship
with them, right?
And not just launching into, again,
all the things that are going wrong
and all the complaints and problems,
but taking a little time to assess
what folks' strengths are, what their resiliency is,
and building on those
as you're facing some of the challenges, right?
And working with them
on starting to build their own solutions to problems,
giving them constructive feedback
but also positive feedback while you're talking to them
and one of the strengths-based approaches in particular
that Dr. Duncan focused on
was something called the Circle of Courage,
which comes out of the context
of the Native American Circle of Courage.
And a lot of research was done on this in the 90s
and it sort of spread throughout
the pediatric adolescent world
and developed into what we would now call
the Positive Youth Development model that a lot of us use
with the strengths based approach.
And basically it turned out when folks took a closer look
at sort of Native American child rearing values
and the positive effects of that,
that a lot of the studies within psychology and medicine
about development and the benefits
of positive strength-based care really all worked together
and agreed with each other, right?
And it's interesting that the strength-based approach
was so strong within this context
of the Native American cultures,
whereas in a lot of the Western cultures
around the same period of time,
childbearing was really quite strict
and aligned with some harsh punishment at times.
And the Circle of Courage really addresses the fact
that while folks are attached,
they're moving towards independence
while they're struggling to learn,
they're moving towards achievements,
they're moving towards autonomy
and altruism is also a really key aspect of that.
So I won't go into more detail on that,
but here are some additional slides on that topic.
So in our well visits here at General Pediatrics at UVM,
we're always checking in with folks,
not directly but assessing in our conversations with them
about their levels of generosity, belonging,
independence, and mastery.
And then this is the framework from Dr. Ginsburg
and he's got a big book called Reaching Teens
put out by AAP if anyone wants to take a peek at that.
And everyone probably remembers learning about
the HEADSS, psychosocial evaluation in medical school.
That has evolved a little bit more
into what we call SSHADESS
which has put an S at the front
recommending folks address strengths right up front,
assess strengths as part of their check-ins with people.
And including asking family members and parents
about strengths of young people too
upfront before you're checking in on all the other aspects
of their psychosocial existence.
All of which of course, affects their health and wellbeing.
In addition to sexuality,
we wanna check in in general about relationships,
peer relationships, and maybe more intimate
or romantic relationships
and of course gender identity
also is important to check in on these days too.
So can I get a time check
just 'cause I don't have my clock up right now.
We're at 12:44, Erica.
Okay, so I'm not gonna go into detail
on our wellness screening questions
that we use for our visits
in pediatrics and adolescent medicine,
but I just wanted to touch on them briefly.
I know a lot of the specialists
are doing some screening questions in their clinics,
like social determinants of health
or mood screening questionnaires.
We do know that a combination of screening questionnaires
that someone can fill out alone privately
with no one staring them down
in concert with asking direct questions often works best.
We tend to do full behavioral health screenings
at AWV visits along with screenings
for mood and substance use
and then of course, screenings for mood and substance use
might be used in other settings or other visits also
and then there are additional screenings
that folks might consider using.
So I think sometimes young people tell us
that they're taken aback by getting all these questions
that they don't feel like
a doctor really needs to know about.
So clarifying why you're asking
these really personal questions and setting the stage
for how we understand a lot
of young people's lived experience on a day-to-day basis,
where they're going, what they're doing,
it does affect their health and wellbeing is important.
And ideally if again,
folks have been asked these questions appropriately
as they've matured through their pediatric care,
it's going to make sense to them when they get to adult care
that folks are continuing to ask some of these questions.
So I think it could be a little bit hard
for some young people
when they move on to a brand new care provider
to be asked a lot of personal questions right up front.
And again, helping them understand
that the fabric of their lives
has an effect on their health and wellbeing.
For the pediatric providers,
I think sometimes asking personal questions can be tough
as someone gets older, especially if you've known them
their entire life
and they might completely and totally trust you
and feel like they have an adolescent provider relationship
with you and understand what you sort of can keep private
and speak with them about
without necessarily bringing parents or guardians in.
But they also might feel a little worried
that you're really aligned with their parents
and not necessarily with them
and so confidentiality isn't so much an issue
when someone's 18,
that's when someone's guaranteed confidentiality.
But again, in pediatric care,
as people move into older adolescents,
they do have the right
to confidential care in some specific realms,
specifically sexual reproductive healthcare
and some mental healthcare aspects
which hopefully have been introduced to them appropriately
and they've been comfortable talking
about some of those things
and will continue to be comfortable talking about
those things as they move on to adult care.
I'm happy to provide like a little more detail
on confidentiality at a later date
or through some documents I have for folks
if some of the folks that are in pediatrics
are interested in that.
So some adolescent friendly office strategies
to think about,
and this is information that we've gleaned
from studies that have been done nationally
on what adolescents want from services
and also from adolescents we've worked with here in Vermont.
Making sure that folks are accessible,
that there's some flexibility
to scheduling and availability of appointments,
making sure an environment feels adolescent friendly
in terms of the way the space is set up
and ideally if folks can have
as many multidisciplinary services onsite as possible
to serve needs, that's great.
But we know that can be a challenge.
We're lucky that we have some resources in the state
for folks to have community health teams
and other folks available, but that's not always the case.
What some of the young folks in Vermont specifically said
when they went to visit a lot of different family medicine
and pediatric clinics
and evaluated sort of waiting room spaces and stuff,
some things they said they really would like to see
are posters of people who look like them.
Free wifi, of course, we all want that at this point.
Information about confidentiality in those sites
serving folks under 18, ally stickers,
information on teen issues.
They like the idea of folks posting information about
community events related to young people in school.
They love accessible technology,
information, websites and the like.
They like doing questionnaires on tablets or on paper
before face-to-face
and they really like it when people respect them,
engage with them, smile at them and talk to them,
even if maybe they have a parent by their side.
These are just examples
of some great materials out there in the world
that folks could possibly access to use in clinics.
And then in terms of systems, this is interesting.
I find in our busy, busy day-to-day lives
where there's a lot of patient volume for providers,
for people at the front desk, for phone calls,
for triage nurses, especially in a setting
where adults are served in addition to young people.
Those young people often can be treated a little bit
as those mini adults we talked about,
and then if people aren't meeting those expectations
we have of them to behave more maturely
or be more cognitively with it, it can be frustrating to us
and that can show and that can be hard for them.
So I think if folks can remember to take the time
to just try to get a sense of someone's cognitive
and emotional functioning when they're engaging, right?
Like are they making eye contact?
Are they asking questions themselves?
Are they responding appropriately?
Are they understanding you?
I mean, and of course I think everyone knows about
health literacy and using interpreters and all that stuff.
All really important.
In terms of communication for young people with offices.
Thinking about what people have available
for folks to use is key.
Sorry, I'm gonna take a drink.
So everyone loves the texting,
we love the texting as adults too.
We adults do still use email.
Young people don't use it so much anymore.
We adults still use phones but less often than we used to.
A lot of young people really aren't so comfortable
using phones, like they don't answer phones,
they don't necessarily check messages.
So in setting up systems, finding out from folks
like what works best for you,
I realize we don't have like text messaging set up
within our medical center beyond using MyChart,
but that's the closest we can get.
So if we can at least really engage with young people
and try to get them to sign up for MyChart
and communicate that way and communicate appropriately
'cause that can be challenging
because sometimes folks will just use MyChart
for everything when things are more maybe more acute
and need phone calls.
So checking in about that, helping young people,
especially as they're moving into adult care,
understand in more detail,
like the different types of visits
people are going to be having.
So they might not fully understand the difference
between like short acute visits, well visits, nurse visits,
or different types of visits for different topics.
So helping explain to them
how the system actually works
might help them to be more responsive to care.
And then clarifying scheduling appointments in advance,
what late policies are, cancellation policies are,
if they cancel at the last minute,
they might not be able to get in
for a longer period of time
and that could be frustrating.
And actually in our work with pediatric
to adult primary care transition
with the offices downstairs, adult care at UHC.
They actually have this really nice welcome packet
they provide to folks
that provide a lot of this information and we give it out
when we're having the last peds visit with them
and they're getting ready to transition for that
and review it with them
and then when they first see adult providers downstairs,
they go over it also to just sort of reinforce everything.
And I like to provide people with resources
for health information handouts
that are really adolescent friendly
and I think the best ones to use
are from Boston Children's Adolescent Medicine Division
Health Education websites, which are listed here.
They are very binary.
There's not a lot of information specifically geared
to gender diverse youth,
but they have a little bit of that,
they're easy to print out and just hand to folks,
which I think can be very important also for young people,
for all patients really when they're leaving a visit,
anything you can have them take home to look at,
to reinforce what you've talked about can be great,
and just wanna acknowledge
that I've done different versions of this talk
for years with different people
and here at UVM, I worked with Barbara Frankowski
and when I was working at Columbia,
I worked a great deal with Dr. Al Cohall,
and I believe maybe we have time for a few questions
or chatting if folks are up for that.
I do have clinic starting at one,
but we all know patients aren't in the room right at one so.
All right, thank you so much Erica.
That was a great overview
and a lot of great information and tips.
So we do have some time for a few questions
so I wanna open it up
if anyone has any questions or comments, oh, Vicky?
Oops.
Got it, oh hi, hi there.
Dr. Gibson, I haven't met you yet.
I work with the patient family-
-Oh yes, yes. -[Vicky] Yeah, I know.
So nice to see your face.
[Vicky] I know your name, great.
[Erica] So great to hear you.
Yeah.
So great to be here.
So two things I'm thinking about, one, I'm thinking about
the whole brain development impulsivity
and the connection to suicide,
especially just in that talk that Dr. Bell gave
over the grand rounds.
But my question for you
is around chronic illness and brain development.
Yeah, I think it can be affected for sure.
We know already puberty can be affected
and I am not familiar with any long-term studies.
I think it would depend on, again, all the different layers
of what's going on with the young person
and what the actual physical challenges have been.
But definitely should be considered, right.
Should be taken into account.
-[Vicky] Yeah, thank you. -Yeah.
Are there other questions or comments?
Erica, I have a quick question.
[Erica] Sure.
What advice do you have for maybe providers?
What we're noticing is that visit times
are getting shorter and shorter
and as you know, schedules are really crunched.
Do you have any like tried and true questions
that might work well for just helping
to open the door quickly with young adults
and help open the conversation?
Well, it's interesting, when people come to see me,
my first question is,
do you know why you're here to see me, right?
If they've made the appointment,
which some of the older adolescents have,
then they know while they're there.
But if folks are coming with parents sometimes
they might not actually know
and then I always like to ask like,
what's most important for you to talk about?
'Cause there might be a long list of things
you wanna talk about,
especially if you're following someone pretty routinely
over long term
and once in a while other things might float to the top
that you might not even be aware of.
So I'm really big on trying to make the most of my time
on the most important issue
and not just trying to fit everything in
and saying why don't we have you come back
a little bit later to talk about this other piece?
And I rarely am the person who's like, see ya in a year.
I mean they have to be just thriving and doing so well
for me to say that even if someone's had a AWV visit
where everything seems to be going well,
I often will ask if they wanna just check in
maybe in six months.
And for other folks I might be,
especially if they have ongoing issues,
be more likely to see them at least quarterly.
Because when you have shorter time,
you just kind of have to maybe see them more often
if their needs are greater.
But I also am not shy about just saying
I need to see someone for a longer period of time
and if admins wanna come after me they can,
I know not everyone can do that.
But if you want maximize your billing, right?
'Cause we can do time-based billing now
that also includes review of medical information
leading up to the visit
as long as it's within a certain timeframe.
So you can include that in your time-based billing
and then get a longer visit potentially.
Great, thank you.
Right, couple more minutes.
Are there other questions or comments?
Dr. Mariani doesn't have any hot tips
with her vast experience with young people?
[Dr. Mariani] No, I was thinking of questions,
I was thinking of the opposite.
I was thinking of questions to pick your brain.
Yeah.
Well, I'm here,
my brain isn't always available to be picked.
I think everyone knows that.
[Dr. Mariani] I think that one of the things
as you were talking (indistinct) thinking about
was how meds interact with all of...
Throw the pharmacology of medications
into this developing brain,
and I couldn't really form a question around it,
but I don't know if you have any comments
about what you think about in general,
pharmacology on the developing brain.
Yeah, I mean, I come across-
[Dr. Mariani] I guess sometimes we don't really see...
I think it's a good question.
[Dr. Mariani] I just don't see that meds work
with adolescents.
Yeah, I mean I never pretend I know
all the details of how all medications work
and what all the side effects are.
So I am always on Micromedex sort of double checking things
and trying to clarify.
It's not often that I come across information and studies
that say there's a negative effect on brain development.
But for example,
if a medication has a side effect of irritability
and that affects someone's day-to-day life
and interactions with folks
and then that affects the pruning
of the brain, then for sure.
I get asked more frequently in my work
with transgender youth about how puberty blockers,
for example, affect brain development
and people are starting to do more studies on that,
actual brain studies like PET scans
and they haven't shown any negative effect to date
and we know from the other research
that psychosocially for those young people,
it's really benefited them
in terms of being able to live a happier, peaceful existence
that then would more positively affect
that automatic pruning that's going on, I think, right.
So but I think fair question, yeah.
Sarah, did you have a question?
[Dr. Mariani] And not so much some, oh sorry.
Sorry, go ahead Kathy, you weren't done.
[Dr. Mariani] Oh, I was just gonna say that anecdotally,
being an adult and adolescent provider,
I just find that adults
tend to get more of a dramatic response from like the SSRIs.
Like I just see like, it's probably so many issues
that it just seems much more straightforward
when you're prescribing for an adult, six weeks on SSRI,
you tend to get an effect if you're gonna get one
and it's still a lot of times with the adolescent,
it's just really hard to measure.
'Cause from day-to-day,
their mood could be so different on meds or off meds.
Yeah, there's so many different factors
like there's so many moving parts, so to speak,
still for them potentially.
Yeah, I think that's pretty complex actually.
But a fair point, a good point.
And I don't wanna run into your clinic time too much,
but I have been thinking a lot recently about sort of,
adultification of kids
and I feel like with some of our younger adolescents
and I think there are some significant disparities by race
and also like, sometimes by even body size
in female patients where I think people look at them
and just think that they're older
because they are further along in puberty
and then treat them as an old individual
and I just didn't know if you had any tips
for like avoiding that and trying to kind of make sure
that we're really meeting kids and families where they are
and where they're comfortable.
Yeah, or that young person who comes in
and tends to be maybe a little more high functioning
in some ways in terms of being organized
about taking their medications
and coming to appointments,
collaborating with their parents
on helping to keep themselves well
but are still really young socially in a lot of other ways.
I think you have to just pause and remind yourself like,
I always on my little like crib notes
before I'm going into clinic,
one of the things I'm always writing down is people's ages
because I wanna look at their age
and remember how old they are,
what grade they're probably in,
and probably what stage of development they're in
no matter what's gonna be in front of me
when I walk into the room.
Does that make sense, yeah.
And in terms of like sex,
a lot of the sexual reproductive health work I've done
in the past, I think, yeah, it's really challenging
for especially a lot of the cis females
that develop earlier for whatever reason
and then become sort of sexualized in our society
and that proves very difficult for them
and confusing when they are still less mature
and might be pushed towards earlier sexual activity
potentially because of that.
I saw a little bit more of that in my work
in the large urban setting in New York City.
All right, well, we are a little bit over time
so I will wrap us up and send us on our way.
Again, we posted the link to an evaluation.
We hope that you would take a moment just to fill it out,
again, your feedback helps guide future activities and work.
And with that, a very special thank you again to Erica
for joining us today and having this conversation,
and we look forward to...
We're taking a break in the month of December
and we will see everyone back in January
and our topic will be MyChart
and we have somebody from UVMMC IT joining us
with tips and tricks and ins and outs of MyChart, great.
Alright, great, thanks everyone.