1 00:00:00,120 --> 00:00:02,820 Senior professor of pediatrics here 2 00:00:02,820 --> 00:00:04,980 at the Larner College of Medicine 3 00:00:04,980 --> 00:00:07,470 and the division head of adolescent medicine, 4 00:00:07,470 --> 00:00:08,910 and also VCHIP faculty 5 00:00:08,910 --> 00:00:11,700 working to improve the peds to adult transition 6 00:00:11,700 --> 00:00:12,933 in primary care. 7 00:00:14,460 --> 00:00:17,760 With that said, I am going to turn it over to Erica 8 00:00:17,760 --> 00:00:20,163 to lead us in a discussion today. 9 00:00:22,350 --> 00:00:24,540 Great, thanks, Alyssa. 10 00:00:24,540 --> 00:00:29,340 Nice to see some names and faces of people I know so well 11 00:00:29,340 --> 00:00:30,420 and happy to be here. 12 00:00:30,420 --> 00:00:32,580 So we're gonna talk just a little bit about 13 00:00:32,580 --> 00:00:33,930 adolescents and young adults, 14 00:00:33,930 --> 00:00:37,830 otherwise known as AYAs and their development 15 00:00:37,830 --> 00:00:41,553 and some communication strategies around working with them. 16 00:00:42,660 --> 00:00:45,420 I'd just like to start some of my talks 17 00:00:45,420 --> 00:00:46,680 with a brief update about 18 00:00:46,680 --> 00:00:48,630 what the heck adolescent medicine is. 19 00:00:48,630 --> 00:00:49,710 Some folks aren't aware 20 00:00:49,710 --> 00:00:52,090 that there are adolescent medicine specialists 21 00:00:52,980 --> 00:00:55,050 and folks can specialize in adolescent medicine 22 00:00:55,050 --> 00:00:58,440 from pediatrics or family medicine 23 00:00:58,440 --> 00:01:00,390 or actually even internal medicine. 24 00:01:00,390 --> 00:01:02,820 Here at the medical center, 25 00:01:02,820 --> 00:01:05,520 we have three primary adolescent medicine clinics, 26 00:01:05,520 --> 00:01:08,190 a Pediatric and Adolescent GYN/ 27 00:01:08,190 --> 00:01:09,420 Sexual Reproductive Health Clinic 28 00:01:09,420 --> 00:01:11,490 that serves people of all genders, 29 00:01:11,490 --> 00:01:12,930 the Transgender Youth Program 30 00:01:12,930 --> 00:01:14,310 and an Eating Disorder Assessment 31 00:01:14,310 --> 00:01:16,500 and Recommendations Clinic. 32 00:01:16,500 --> 00:01:19,170 Also provide a lot of teaching internally 33 00:01:19,170 --> 00:01:20,700 and around the state to folks 34 00:01:20,700 --> 00:01:23,280 and do some great grant work with VCHIP 35 00:01:23,280 --> 00:01:28,170 and directly with VDH on a variety of topics just as an FYI. 36 00:01:28,170 --> 00:01:29,670 Another just quick thing about me 37 00:01:29,670 --> 00:01:32,040 is that I have spent a lot of time actually working 38 00:01:32,040 --> 00:01:34,530 in high schools with young people, 39 00:01:34,530 --> 00:01:36,750 not just in the medical field. 40 00:01:36,750 --> 00:01:38,880 I was a high school teacher long ago 41 00:01:38,880 --> 00:01:41,310 right after I got out of school 42 00:01:41,310 --> 00:01:43,590 and I was the medical director for eight large 43 00:01:43,590 --> 00:01:45,360 multidisciplinary school-based health centers 44 00:01:45,360 --> 00:01:47,700 in New York City right out of my fellowship 45 00:01:47,700 --> 00:01:50,400 before I came up here to Vermont. 46 00:01:50,400 --> 00:01:53,370 So I've worked with adolescents in a variety of settings 47 00:01:53,370 --> 00:01:55,590 just in case you're wondering why the heck you should listen 48 00:01:55,590 --> 00:01:58,263 to anything I have to say on the topic. 49 00:01:59,520 --> 00:02:02,220 So today we're just gonna talk a little bit about 50 00:02:02,220 --> 00:02:03,420 adolescent brain development. 51 00:02:03,420 --> 00:02:05,130 I'm sure a lot of you are familiar 52 00:02:05,130 --> 00:02:07,140 with a lot of what we're going to discuss today. 53 00:02:07,140 --> 00:02:10,260 So this might be just a little bit of a revisiting, 54 00:02:10,260 --> 00:02:14,200 a little bit of a reminder, an opportunity to think twice 55 00:02:15,270 --> 00:02:17,490 about your approach to adolescents 56 00:02:17,490 --> 00:02:18,993 and what works best for them. 57 00:02:19,980 --> 00:02:24,573 And so first of all, who are adolescents, right? 58 00:02:25,440 --> 00:02:27,810 Adolescents are defined in different ways 59 00:02:27,810 --> 00:02:28,800 by different folks. 60 00:02:28,800 --> 00:02:30,000 Here in Vermont, 61 00:02:30,000 --> 00:02:32,880 we know we have a wide variety of young people 62 00:02:32,880 --> 00:02:35,430 from all different backgrounds and cultures 63 00:02:35,430 --> 00:02:37,440 with all different lived experiences 64 00:02:37,440 --> 00:02:40,113 and we are all caring for them together. 65 00:02:41,160 --> 00:02:45,840 It's important to remember that adolescents in general 66 00:02:45,840 --> 00:02:49,470 are pretty healthy and resilient 67 00:02:49,470 --> 00:02:52,710 even though we have had a lot of focus more recently 68 00:02:52,710 --> 00:02:56,040 on adolescents actually not being so healthy, 69 00:02:56,040 --> 00:03:00,150 especially from a mental health point of view. 70 00:03:00,150 --> 00:03:03,060 Folks are pretty worried about that these days. 71 00:03:03,060 --> 00:03:04,620 They're very resilient. 72 00:03:04,620 --> 00:03:08,100 They are independent, yet still quite vulnerable 73 00:03:08,100 --> 00:03:11,280 as they're moving further into independence. 74 00:03:11,280 --> 00:03:14,970 It's really easy to sometimes forget 75 00:03:14,970 --> 00:03:18,060 that especially older adolescents aren't just little adults 76 00:03:18,060 --> 00:03:21,450 and can function in an adult-like way. 77 00:03:21,450 --> 00:03:23,220 They might not be all the way there yet 78 00:03:23,220 --> 00:03:25,980 and they're not also just really big children. 79 00:03:25,980 --> 00:03:28,443 They're their own genre. 80 00:03:29,610 --> 00:03:33,390 And again, defining adolescents specifically 81 00:03:33,390 --> 00:03:34,950 is complicated, right? 82 00:03:34,950 --> 00:03:37,350 Do we talk just about how old people are? 83 00:03:37,350 --> 00:03:40,110 Do we talk about how developed their brains are? 84 00:03:40,110 --> 00:03:42,960 Do we talk about their behaviors? 85 00:03:42,960 --> 00:03:46,050 All these things play a part. 86 00:03:46,050 --> 00:03:47,370 It is important to remember 87 00:03:47,370 --> 00:03:50,250 that age does not always equal cognitive 88 00:03:50,250 --> 00:03:53,370 and emotional maturity for a young person. 89 00:03:53,370 --> 00:03:56,640 In my experience, I have at times met 13 year olds 90 00:03:56,640 --> 00:04:01,640 who are incredibly savvy and together 91 00:04:01,980 --> 00:04:05,190 and have a capacity to process emotions 92 00:04:05,190 --> 00:04:08,130 and thoughts on a higher level than some of the 18 year olds 93 00:04:08,130 --> 00:04:09,933 that I've met and cared for. 94 00:04:11,310 --> 00:04:13,590 Brain development continues into the mid twenties. 95 00:04:13,590 --> 00:04:15,840 That's something that's really pretty well known now, 96 00:04:15,840 --> 00:04:18,450 although it was new news to a lot of folks 97 00:04:18,450 --> 00:04:20,013 10 to 20 years ago. 98 00:04:21,300 --> 00:04:24,210 And we know that adolescents live in a wide variety 99 00:04:24,210 --> 00:04:25,680 of different contexts, 100 00:04:25,680 --> 00:04:28,110 which has an effect on their development. 101 00:04:28,110 --> 00:04:30,540 So a picture down here at the bottom 102 00:04:30,540 --> 00:04:33,720 just shows the range from a five-year-old brain 103 00:04:33,720 --> 00:04:35,710 up to a 20-year-old brain 104 00:04:36,570 --> 00:04:38,340 and the rates of development 105 00:04:38,340 --> 00:04:40,170 in the different locations, right? 106 00:04:40,170 --> 00:04:43,650 So the red yellow portions in the younger folks 107 00:04:43,650 --> 00:04:46,170 are reflective of parts of the brain 108 00:04:46,170 --> 00:04:49,260 that are less fully mature 109 00:04:49,260 --> 00:04:52,590 and in particular the sites 110 00:04:52,590 --> 00:04:54,780 of the dorsal lateral prefrontal cortex 111 00:04:54,780 --> 00:04:57,870 where executive functions are developing, 112 00:04:57,870 --> 00:05:00,060 are those that are some of the parts of the brain 113 00:05:00,060 --> 00:05:03,540 that are developing a bit later in life. 114 00:05:03,540 --> 00:05:06,340 Important though not to use 115 00:05:07,770 --> 00:05:09,660 adolescent brain development 116 00:05:09,660 --> 00:05:11,820 and the fact that the brain might not be fully mature 117 00:05:11,820 --> 00:05:14,460 into twenties against a young person, right? 118 00:05:14,460 --> 00:05:16,470 And use that as an excuse for them 119 00:05:16,470 --> 00:05:18,210 not to be able to have some independence 120 00:05:18,210 --> 00:05:20,223 and make some of their own decisions, 121 00:05:21,150 --> 00:05:26,040 and certainly some folks have tried to do that to balance. 122 00:05:26,040 --> 00:05:30,750 So adolescents is very much about searching for identity 123 00:05:30,750 --> 00:05:33,480 and trying to figure out who somebody is 124 00:05:33,480 --> 00:05:35,760 as an individual within the context 125 00:05:35,760 --> 00:05:37,140 that they're growing up in. 126 00:05:37,140 --> 00:05:40,023 So folks are trying to figure out who they are. 127 00:05:40,860 --> 00:05:42,990 We have a lot of folks, 128 00:05:42,990 --> 00:05:44,520 even though we have all sorts of folks 129 00:05:44,520 --> 00:05:46,890 sort of across the spectrum 130 00:05:46,890 --> 00:05:50,640 who might not fit stereotypical notions 131 00:05:50,640 --> 00:05:52,050 or be quote unquote normal, 132 00:05:52,050 --> 00:05:53,700 still trying to figure out if they are normal 133 00:05:53,700 --> 00:05:55,800 because it can be a big part of fitting in. 134 00:05:55,800 --> 00:05:57,120 Although certainly there are folks out there there 135 00:05:57,120 --> 00:05:59,370 that pride themselves on not being normal, 136 00:05:59,370 --> 00:06:01,503 but what is normal, right? 137 00:06:02,730 --> 00:06:05,160 There is a fair amount of egocentricity, 138 00:06:05,160 --> 00:06:06,570 like how do others see me, 139 00:06:06,570 --> 00:06:09,180 feeling like you're on the stage all the time, 140 00:06:09,180 --> 00:06:10,560 comparison to others. 141 00:06:10,560 --> 00:06:13,170 I will say I feel like some of these things do not go away 142 00:06:13,170 --> 00:06:14,523 even as people mature. 143 00:06:15,510 --> 00:06:17,280 There's sorting out sort of what they're good at 144 00:06:17,280 --> 00:06:20,430 and what they wanna do, where they fit in, 145 00:06:20,430 --> 00:06:23,760 what they believe in, what's right, what's wrong, 146 00:06:23,760 --> 00:06:26,580 sort of searching for that moral compass 147 00:06:26,580 --> 00:06:28,530 and where are they headed in the future 148 00:06:29,400 --> 00:06:30,990 and the context of adolescent development 149 00:06:30,990 --> 00:06:32,490 is really quite essential. 150 00:06:32,490 --> 00:06:34,050 There's the individual, 151 00:06:34,050 --> 00:06:36,390 there's the family they're growing up in, 152 00:06:36,390 --> 00:06:40,170 whether it's a biological family, a chosen family, 153 00:06:40,170 --> 00:06:42,060 anyone that might be involved more intimately 154 00:06:42,060 --> 00:06:43,080 in young person's life. 155 00:06:43,080 --> 00:06:45,000 There's their peer group, 156 00:06:45,000 --> 00:06:47,580 those that they're associating with in their own age range. 157 00:06:47,580 --> 00:06:50,190 There's a school setting for younger folks 158 00:06:50,190 --> 00:06:51,930 who are hopefully attending school. 159 00:06:51,930 --> 00:06:54,690 We are aware some folks aren't able to attend school 160 00:06:54,690 --> 00:06:56,310 for a variety of reasons, 161 00:06:56,310 --> 00:06:59,160 and then the society and community they live in 162 00:06:59,160 --> 00:07:01,380 plays a large role also, right? 163 00:07:01,380 --> 00:07:02,670 So are they working? 164 00:07:02,670 --> 00:07:05,490 Are they involved in organizations, 165 00:07:05,490 --> 00:07:07,980 religious organizations, youth groups? 166 00:07:07,980 --> 00:07:10,890 What is the background for them in particular 167 00:07:10,890 --> 00:07:14,700 in terms of politics, racism, socioeconomic status? 168 00:07:14,700 --> 00:07:16,680 Luckily, I think here at the medical center 169 00:07:16,680 --> 00:07:18,870 we're getting better and better 170 00:07:18,870 --> 00:07:21,120 at checking on social determinants of health for folks 171 00:07:21,120 --> 00:07:23,370 when we're caring for them, which is really a key part 172 00:07:23,370 --> 00:07:26,163 of understanding their lived experience. 173 00:07:27,000 --> 00:07:31,680 So emerging independence is a big deal 174 00:07:31,680 --> 00:07:34,380 as young people are moving into later adolescence, 175 00:07:34,380 --> 00:07:38,070 which is a lot of what the Peds 176 00:07:38,070 --> 00:07:41,250 to Adult Transition Program focuses on, right? 177 00:07:41,250 --> 00:07:45,960 Helping those older adolescents shift to adult care. 178 00:07:45,960 --> 00:07:49,320 And we can't forget the strong popular cultural influence 179 00:07:49,320 --> 00:07:53,310 on folks, which has only increased with the tech boom 180 00:07:53,310 --> 00:07:56,040 and the connectivity on so many levels 181 00:07:56,040 --> 00:07:58,503 via the internet at this time. 182 00:07:59,370 --> 00:08:02,460 So why do we wanna focus on adolescent health? 183 00:08:02,460 --> 00:08:04,950 Well, first of all, from a strengths framework, 184 00:08:04,950 --> 00:08:07,020 we really wanna celebrate young people 185 00:08:07,020 --> 00:08:08,310 and their strengths and resilience 186 00:08:08,310 --> 00:08:11,550 while helping them with the problems that they're facing. 187 00:08:11,550 --> 00:08:15,000 A lot of our visits can be about reducing risk, 188 00:08:15,000 --> 00:08:17,610 whether it's immediate or in the future. 189 00:08:17,610 --> 00:08:19,890 But taking the time when you're meeting with someone 190 00:08:19,890 --> 00:08:23,700 to celebrate all their strengths is really important. 191 00:08:23,700 --> 00:08:26,890 We want to help young people to begin to understand 192 00:08:27,900 --> 00:08:29,790 that they have the right 193 00:08:29,790 --> 00:08:32,160 to fulfill their right to healthcare, 194 00:08:32,160 --> 00:08:35,700 especially sexual reproductive healthcare as they mature 195 00:08:35,700 --> 00:08:40,080 and if we can help them to be healthy in their adolescents, 196 00:08:40,080 --> 00:08:41,970 it hopefully increases the chance 197 00:08:41,970 --> 00:08:43,803 for a healthy adulthood also. 198 00:08:44,760 --> 00:08:46,860 A lot of people when I say I do adolescent medicine 199 00:08:46,860 --> 00:08:49,320 are like, oh my God, like how do you do that? 200 00:08:49,320 --> 00:08:51,330 That must be so hard. 201 00:08:51,330 --> 00:08:54,210 And I think a lot of folks think about adolescents 202 00:08:54,210 --> 00:08:57,540 as being problematic and challenging. 203 00:08:57,540 --> 00:09:00,360 But I really like this quote from one of our former heads 204 00:09:00,360 --> 00:09:02,310 of the Society for Adolescent Health and Medicine, 205 00:09:02,310 --> 00:09:04,170 who was actually a psychologist. 206 00:09:04,170 --> 00:09:07,050 That organization is a great multidisciplinary group 207 00:09:07,050 --> 00:09:11,070 that includes nurses, social workers, et cetera. 208 00:09:11,070 --> 00:09:13,170 He said, "Young people are not problems to be solved, 209 00:09:13,170 --> 00:09:14,970 but resources to be developed. 210 00:09:14,970 --> 00:09:19,970 And we as hopefully, relatable and trustworthy adults 211 00:09:20,730 --> 00:09:22,740 who understand their developmental context 212 00:09:22,740 --> 00:09:27,740 can be one of those folks that can help them to develop." 213 00:09:28,350 --> 00:09:30,630 So just a bit more on the brain development. 214 00:09:30,630 --> 00:09:33,630 I showed you that picture earlier, 215 00:09:33,630 --> 00:09:36,000 but to emphasize at birth, 216 00:09:36,000 --> 00:09:41,000 folks are equipped with most of the neurons in their brain 217 00:09:41,520 --> 00:09:45,420 and by age six, the size of the brain has actually grown 218 00:09:45,420 --> 00:09:49,800 to about 90 to 95% of its final adult size. 219 00:09:49,800 --> 00:09:52,530 In some MRI studies that they've done, 220 00:09:52,530 --> 00:09:57,530 what they see primarily in adolescents is this second wave 221 00:09:57,600 --> 00:10:00,300 of neuronal proliferation and pruning, right? 222 00:10:00,300 --> 00:10:03,540 So all the connections are being made 223 00:10:03,540 --> 00:10:05,730 and some connections are being cut 224 00:10:05,730 --> 00:10:06,960 and a lot of that 225 00:10:06,960 --> 00:10:11,850 is based on young person's actual experience in the world. 226 00:10:11,850 --> 00:10:13,233 It's pretty fascinating. 227 00:10:14,220 --> 00:10:16,350 And until the mid twenties, 228 00:10:16,350 --> 00:10:18,060 the gray and white matter 229 00:10:18,060 --> 00:10:22,980 do continue to undergo extensive structural changes, right? 230 00:10:22,980 --> 00:10:25,320 And those changes don't actually affect the number 231 00:10:25,320 --> 00:10:29,040 of nerve cells, but actually connections between everything. 232 00:10:29,040 --> 00:10:31,710 So you can understand how brain development 233 00:10:31,710 --> 00:10:35,583 might be significantly affected by traumatic experiences, 234 00:10:36,720 --> 00:10:38,883 substance abuse, et cetera. 235 00:10:40,380 --> 00:10:44,430 So first the limbic system is developing in adolescents, 236 00:10:44,430 --> 00:10:46,290 this is the emotional 237 00:10:46,290 --> 00:10:50,520 and stress sort of auto response center, right? 238 00:10:50,520 --> 00:10:52,890 And people are famous for talking about 239 00:10:52,890 --> 00:10:56,730 young people being hormonal and dramatic 240 00:10:56,730 --> 00:10:58,320 and all of that stuff 241 00:10:58,320 --> 00:11:00,600 that kind of fits with this development. 242 00:11:00,600 --> 00:11:02,460 The last section of the brains to develop 243 00:11:02,460 --> 00:11:03,780 is the prefrontal cortex. 244 00:11:03,780 --> 00:11:06,720 Those executive functions that then come in 245 00:11:06,720 --> 00:11:11,100 a little bit later that help with planning, organization, 246 00:11:11,100 --> 00:11:14,310 suppressing impulses, weighing consequences of things 247 00:11:14,310 --> 00:11:17,160 that are going on in their lives. 248 00:11:17,160 --> 00:11:20,400 So, and what are the implications of this brain development? 249 00:11:20,400 --> 00:11:24,480 Well, there's possibly some limited reasoning in planning. 250 00:11:24,480 --> 00:11:29,480 There is also the high likelihood of experimenting, 251 00:11:30,000 --> 00:11:33,210 testing limits, pushing the envelope. 252 00:11:33,210 --> 00:11:34,800 I have this recurrent experience 253 00:11:34,800 --> 00:11:37,500 with my 12-year-old when we're driving in the car 254 00:11:37,500 --> 00:11:38,760 once in a while from the back seat. 255 00:11:38,760 --> 00:11:41,340 He'll say, "Sometimes I just wanna open the car door 256 00:11:41,340 --> 00:11:43,080 while we're driving." 257 00:11:43,080 --> 00:11:45,090 'Cause he just has that strong urge. 258 00:11:45,090 --> 00:11:47,760 It's hard to suppress, he wants to open it. 259 00:11:47,760 --> 00:11:49,800 I have to say he's never done it at high speed. 260 00:11:49,800 --> 00:11:51,870 He's done it when we were going five miles per hour 261 00:11:51,870 --> 00:11:54,450 in our neighborhood and it can be pretty alarming. 262 00:11:54,450 --> 00:11:56,700 I'm just glad he actually articulates it to me 263 00:11:56,700 --> 00:11:57,533 that that's happening. 264 00:11:57,533 --> 00:12:00,600 But it's interesting that he's articulating something 265 00:12:00,600 --> 00:12:03,510 that I know fits with sort of how his brain is working 266 00:12:03,510 --> 00:12:06,900 or not fully working sometimes at this time. 267 00:12:06,900 --> 00:12:09,630 I mean, he's otherwise a very bright young man 268 00:12:09,630 --> 00:12:11,283 who tends to make good choices. 269 00:12:12,840 --> 00:12:15,360 Habits formed during adolescence may be hard to break again 270 00:12:15,360 --> 00:12:17,430 because of all that pruning and those connections 271 00:12:17,430 --> 00:12:20,703 that are being made and reinforced by experiences. 272 00:12:21,870 --> 00:12:23,640 And then unfortunately sometimes 273 00:12:23,640 --> 00:12:26,910 some of that exploration and limit testing 274 00:12:26,910 --> 00:12:29,703 can have long-term consequences for young people. 275 00:12:30,990 --> 00:12:33,300 So there are different timetables 276 00:12:33,300 --> 00:12:34,980 for that frontal lobe development. 277 00:12:34,980 --> 00:12:38,373 It's not just all based on the age someone is. 278 00:12:39,330 --> 00:12:41,700 So that's important to keep in mind 279 00:12:41,700 --> 00:12:45,150 and that ability to connect present activity, 280 00:12:45,150 --> 00:12:48,090 for example, like unprotected sex with future outcomes, 281 00:12:48,090 --> 00:12:50,430 like getting a sexually transmitted infection 282 00:12:50,430 --> 00:12:51,960 can be highly variable 283 00:12:51,960 --> 00:12:55,440 for different folks at different times. 284 00:12:55,440 --> 00:12:58,890 There are some psychological tasks of adolescents 285 00:12:58,890 --> 00:13:01,200 in terms of cognitive maturation. 286 00:13:01,200 --> 00:13:04,110 They are moving from a place of concrete thinking 287 00:13:04,110 --> 00:13:08,400 to abstract thinking, from present to future orientation 288 00:13:08,400 --> 00:13:12,300 and from thinking about causality as being single 289 00:13:12,300 --> 00:13:14,640 versus multifactorial. 290 00:13:14,640 --> 00:13:19,110 They are working towards independence from parents, 291 00:13:19,110 --> 00:13:23,100 actually actively starts around middle adolescents 292 00:13:23,100 --> 00:13:24,690 into late adolescents. 293 00:13:24,690 --> 00:13:28,170 And again, trying to establish their identity, 294 00:13:28,170 --> 00:13:31,560 development and acceptance of body image is a key aspect, 295 00:13:31,560 --> 00:13:35,880 especially as bodies are going through pubertal changes, 296 00:13:35,880 --> 00:13:38,520 and that's may be one thing 297 00:13:38,520 --> 00:13:42,330 for designated females and designated males. 298 00:13:42,330 --> 00:13:44,220 And then quite a whole nother thing 299 00:13:44,220 --> 00:13:46,500 for gender diverse young folks 300 00:13:46,500 --> 00:13:48,273 for whom that might be harder. 301 00:13:49,890 --> 00:13:52,590 So, just a brief review of the stages 302 00:13:52,590 --> 00:13:55,110 of adolescent development. 303 00:13:55,110 --> 00:13:57,780 Typically, these are divided into early, 304 00:13:57,780 --> 00:13:59,610 middle and late adolescents 305 00:13:59,610 --> 00:14:03,750 and are different for cis females and cis males. 306 00:14:03,750 --> 00:14:06,120 Everything starts to happen a little earlier 307 00:14:06,120 --> 00:14:07,590 for cis females. 308 00:14:07,590 --> 00:14:08,940 For gender diverse youth, 309 00:14:08,940 --> 00:14:13,533 we don't really have research to date that's as specific, 310 00:14:14,430 --> 00:14:17,100 but we do know a variety of factors 311 00:14:17,100 --> 00:14:18,990 are influencing development 312 00:14:18,990 --> 00:14:21,150 whether it's designated sex, 313 00:14:21,150 --> 00:14:23,250 the environment a young person's growing up in. 314 00:14:23,250 --> 00:14:24,690 For a gender diverse young person, 315 00:14:24,690 --> 00:14:26,580 perhaps how much they're struggling 316 00:14:26,580 --> 00:14:28,350 with their identity or their body, 317 00:14:28,350 --> 00:14:30,483 the changes in their body in particular. 318 00:14:32,010 --> 00:14:35,280 As we're talking about a transitions project here, 319 00:14:35,280 --> 00:14:37,320 when folks are a little bit older, 320 00:14:37,320 --> 00:14:39,000 we're gonna focus a little bit more 321 00:14:39,000 --> 00:14:42,093 on sort of middle adolescents and late adolescence. 322 00:14:42,930 --> 00:14:45,810 So in that middle adolescence stage, 323 00:14:45,810 --> 00:14:48,210 we do have that transition in cognition. 324 00:14:48,210 --> 00:14:51,990 So a movement from concrete to abstract thinking, 325 00:14:51,990 --> 00:14:53,910 but still a little bit of both. 326 00:14:53,910 --> 00:14:56,613 So they might be going a little bit back and forth. 327 00:14:57,480 --> 00:14:59,190 And physical development 328 00:14:59,190 --> 00:15:04,020 is often fairly far along at this point, 329 00:15:04,020 --> 00:15:06,180 although not necessarily totally complete. 330 00:15:06,180 --> 00:15:08,040 And again, there might be those folks 331 00:15:08,040 --> 00:15:11,190 who might be quite unhappy with how their body has developed 332 00:15:11,190 --> 00:15:13,680 and they're really trying to become comfortable 333 00:15:13,680 --> 00:15:15,490 with what their body looks like 334 00:15:17,010 --> 00:15:20,400 given the changes that have occurred since childhood. 335 00:15:20,400 --> 00:15:21,570 Here's just a quote from, 336 00:15:21,570 --> 00:15:25,230 can anyone tell me this movie, anyone, anyone? 337 00:15:25,230 --> 00:15:26,430 Breakfast Club. 338 00:15:26,430 --> 00:15:27,450 [Erica] Yep, yep. 339 00:15:27,450 --> 00:15:30,090 A theme song from this movie was a theme song at my prom. 340 00:15:30,090 --> 00:15:31,890 Not to give away my age to everyone, 341 00:15:31,890 --> 00:15:34,200 but this is the young person 342 00:15:34,200 --> 00:15:37,530 that was playing one of the teenagers. 343 00:15:37,530 --> 00:15:38,910 He says at one point in the movie, 344 00:15:38,910 --> 00:15:39,743 when he looks in the mirror, 345 00:15:39,743 --> 00:15:41,907 "I see me and I don't like what I see." 346 00:15:44,280 --> 00:15:46,560 Right, so, but we often have a real disconnect 347 00:15:46,560 --> 00:15:48,690 between a teen's physical appearance 348 00:15:48,690 --> 00:15:51,330 and emotional maturity level at this point. 349 00:15:51,330 --> 00:15:53,280 Here's a picture of Calvin 350 00:15:53,280 --> 00:15:55,260 from Calvin and Hobbes in all his gear 351 00:15:55,260 --> 00:15:57,390 that he wore when he was just five, 352 00:15:57,390 --> 00:16:00,300 but clearly a bit larger and in teenage mode, 353 00:16:00,300 --> 00:16:03,520 but still with a lot of the accoutrements of being younger 354 00:16:05,190 --> 00:16:07,320 and just a reminder, 355 00:16:07,320 --> 00:16:10,890 a young person may look like an older person 356 00:16:10,890 --> 00:16:13,440 on the outside, but internally, 357 00:16:13,440 --> 00:16:18,440 they might still have a sort of affiliation or development 358 00:16:19,260 --> 00:16:21,610 that's more consistent with the younger person. 359 00:16:23,190 --> 00:16:25,710 So independence and peer relationships 360 00:16:25,710 --> 00:16:28,620 really start to emerge more in middle adolescence. 361 00:16:28,620 --> 00:16:31,650 This is when major parent-child conflict 362 00:16:31,650 --> 00:16:33,180 potentially starts to arise. 363 00:16:33,180 --> 00:16:35,010 That limit testing we talked about 364 00:16:35,010 --> 00:16:37,440 and that struggle for emancipation. 365 00:16:37,440 --> 00:16:39,840 Oh, can't I go do this by myself? 366 00:16:39,840 --> 00:16:42,060 Why do you have to drop me off and pick me up? 367 00:16:42,060 --> 00:16:45,540 Why do I have to tell you where I am all the time? 368 00:16:45,540 --> 00:16:46,680 Just a cartoon here, 369 00:16:46,680 --> 00:16:49,117 a young person and their parent saying, 370 00:16:49,117 --> 00:16:50,340 "We both see each other 371 00:16:50,340 --> 00:16:53,127 but we really are not understanding each other." 372 00:16:54,600 --> 00:16:58,680 Peers at this time can start to provide a lot more support 373 00:16:58,680 --> 00:16:59,700 versus parents. 374 00:16:59,700 --> 00:17:03,510 Previously, there also can be a conformity with peer values 375 00:17:03,510 --> 00:17:06,060 for many folks, right? 376 00:17:06,060 --> 00:17:08,790 All those trends that folks are coming home with 377 00:17:08,790 --> 00:17:10,860 in terms of what everyone's wearing at school 378 00:17:10,860 --> 00:17:12,240 or what they own 379 00:17:12,240 --> 00:17:15,780 and wanting to have what everyone else has 380 00:17:15,780 --> 00:17:18,363 sometimes still plays a really large role in lives. 381 00:17:19,380 --> 00:17:22,740 Folks also are paying quite a bit of attention to, 382 00:17:22,740 --> 00:17:24,840 again, how they're looking, how they're feeling 383 00:17:24,840 --> 00:17:26,910 if they're fitting in. 384 00:17:26,910 --> 00:17:29,580 So tips for middle adolescents. 385 00:17:29,580 --> 00:17:32,580 Friendly relationships really can create trust. 386 00:17:32,580 --> 00:17:36,210 We always wanna try to build rapport with young people 387 00:17:36,210 --> 00:17:39,510 when they are still in the school age years 388 00:17:39,510 --> 00:17:40,860 and in visits with parents, 389 00:17:40,860 --> 00:17:43,020 you're building rapport often with the family. 390 00:17:43,020 --> 00:17:45,240 But as you're spending more time talking to young people 391 00:17:45,240 --> 00:17:48,570 and then hopefully having some time alone to chat with folks 392 00:17:48,570 --> 00:17:50,970 as they reach their early teen years, 393 00:17:50,970 --> 00:17:54,330 you're hopefully developing a direct rapport with them 394 00:17:54,330 --> 00:17:55,950 and for adult providers, 395 00:17:55,950 --> 00:17:58,230 if this is done well in pediatric care, 396 00:17:58,230 --> 00:18:00,660 then they're gonna be more well prepared 397 00:18:00,660 --> 00:18:02,553 when they're moving into adult care. 398 00:18:03,420 --> 00:18:04,950 One thing I find with young people 399 00:18:04,950 --> 00:18:08,100 is that those open-ended questions we're trained to ask 400 00:18:08,100 --> 00:18:10,320 so much in medical school and residency, 401 00:18:10,320 --> 00:18:13,203 sometimes don't always work for young people. 402 00:18:14,130 --> 00:18:15,870 They might not quite be able 403 00:18:15,870 --> 00:18:18,150 to answer an open-ended question, 404 00:18:18,150 --> 00:18:21,180 or if they do answer, it might be like pretty expansive 405 00:18:21,180 --> 00:18:22,950 and not what you need to focus on. 406 00:18:22,950 --> 00:18:25,080 So sometimes it is important to move 407 00:18:25,080 --> 00:18:26,850 to more focused questionings 408 00:18:26,850 --> 00:18:29,680 or just helping them clarify what you really wanna know 409 00:18:30,660 --> 00:18:31,980 and using messaging and tools 410 00:18:31,980 --> 00:18:33,990 that teens can really relate to, 411 00:18:33,990 --> 00:18:36,690 whether it's handouts or pictures, 412 00:18:36,690 --> 00:18:39,480 outlines can really help also. 413 00:18:39,480 --> 00:18:43,050 A focus in visits on independence, 414 00:18:43,050 --> 00:18:45,570 but the importance of supportive adult connections, 415 00:18:45,570 --> 00:18:47,370 like finding out from someone 416 00:18:47,370 --> 00:18:49,410 what adult do you feel like you can talk to? 417 00:18:49,410 --> 00:18:50,670 Is that a parent or guardian 418 00:18:50,670 --> 00:18:52,560 or is that someone else you know, 419 00:18:52,560 --> 00:18:55,110 someone else in your family, someone at school. 420 00:18:55,110 --> 00:18:58,110 And then again, health promotion and harm reduction 421 00:18:58,110 --> 00:19:00,480 are key points of what we focus on. 422 00:19:00,480 --> 00:19:03,750 In settings where peer counseling is available, 423 00:19:03,750 --> 00:19:06,300 so perhaps in school-based health center settings 424 00:19:06,300 --> 00:19:08,760 or other community-based clinics, 425 00:19:08,760 --> 00:19:10,200 peer counseling has been found 426 00:19:10,200 --> 00:19:12,780 to be really effective in this age group. 427 00:19:12,780 --> 00:19:16,230 As folks are moving into late adolescences, 428 00:19:16,230 --> 00:19:19,440 that concrete thinking becomes more abstract, 429 00:19:19,440 --> 00:19:23,430 usually memory improves, there's improved logical reasoning 430 00:19:23,430 --> 00:19:26,220 and identity developed has started to coalesce more. 431 00:19:26,220 --> 00:19:28,530 Not that it won't totally continue to shift 432 00:19:28,530 --> 00:19:29,880 as someone moves into adulthood, 433 00:19:29,880 --> 00:19:32,760 but folks at that point have moved a bit more 434 00:19:32,760 --> 00:19:34,740 towards their own values, 435 00:19:34,740 --> 00:19:36,720 more clarity perhaps about what they wanna do 436 00:19:36,720 --> 00:19:38,460 with their life in the future. 437 00:19:38,460 --> 00:19:42,570 Body image concerns are usually improving by this point, 438 00:19:42,570 --> 00:19:45,570 but as I said before, plenty of these things 439 00:19:45,570 --> 00:19:49,083 might persist into adulthood for plenty of people. 440 00:19:50,370 --> 00:19:51,990 Independence and peer relationships 441 00:19:51,990 --> 00:19:55,110 are usually pretty well established at this point 442 00:19:55,110 --> 00:19:58,410 and while folks may have had separation from family, 443 00:19:58,410 --> 00:20:01,260 there tends to sometimes be this reintegration 444 00:20:01,260 --> 00:20:04,500 back into family sort of building relationships 445 00:20:04,500 --> 00:20:08,970 based on who a young person has become as they've matured. 446 00:20:08,970 --> 00:20:13,200 And reintegration, for example, of family values 447 00:20:13,200 --> 00:20:17,130 into personal experience or behaviors 448 00:20:17,130 --> 00:20:19,830 might be something that comes about. 449 00:20:19,830 --> 00:20:22,230 Some folks are moving towards financial independence 450 00:20:22,230 --> 00:20:25,320 at this point and there tends to be an increased capacity 451 00:20:25,320 --> 00:20:29,010 for mature friendships and intimacy for a lot of folks. 452 00:20:29,010 --> 00:20:31,500 So when folks are a bit older, 453 00:20:31,500 --> 00:20:33,720 more abstract reasoning may allow 454 00:20:33,720 --> 00:20:38,040 for sort of more traditional approaches in care. 455 00:20:38,040 --> 00:20:40,590 And there is often a better understanding 456 00:20:40,590 --> 00:20:44,403 about the relationship between behaviors and consequences. 457 00:20:45,510 --> 00:20:49,290 And something that can be helpful for folks I find 458 00:20:49,290 --> 00:20:53,040 is if they do have someone that they want to accompany them 459 00:20:53,040 --> 00:20:54,630 to visit, even if it's a friend 460 00:20:54,630 --> 00:20:56,610 or someone outside the family, 461 00:20:56,610 --> 00:20:57,990 not that they would be there necessarily 462 00:20:57,990 --> 00:21:00,780 for all of a visit if there are a lot of privacy 463 00:21:00,780 --> 00:21:03,420 or private issues being discussed, 464 00:21:03,420 --> 00:21:06,270 can be helpful for folks just to feel like, 465 00:21:06,270 --> 00:21:08,370 they have someone by their side and helping them 466 00:21:08,370 --> 00:21:10,830 to understand and clarify things. 467 00:21:10,830 --> 00:21:13,800 So I would be remiss in not touching base 468 00:21:13,800 --> 00:21:17,340 on the real importance of a strengths-based approach 469 00:21:17,340 --> 00:21:19,900 in caring for young people 470 00:21:20,820 --> 00:21:24,150 and the strengths-based approach has been focused on 471 00:21:24,150 --> 00:21:26,280 by a few key folks in the world 472 00:21:26,280 --> 00:21:30,000 of pediatrics and adolescent medicine over the years. 473 00:21:30,000 --> 00:21:32,730 One of those folks is the wonderful Paula Duncan 474 00:21:32,730 --> 00:21:35,880 who worked here in Vermont for such a long time. 475 00:21:35,880 --> 00:21:37,920 Dr. Kenneth Ginsburg down at CHOP 476 00:21:37,920 --> 00:21:39,840 has done a lot of work on this 477 00:21:39,840 --> 00:21:43,470 and the emphasis is on the importance 478 00:21:43,470 --> 00:21:47,700 of being able to build a really comfortable, trusting 479 00:21:47,700 --> 00:21:51,180 and non-judgmental relationship with a young person. 480 00:21:51,180 --> 00:21:53,670 And really I think for anyone who's doing adult care, 481 00:21:53,670 --> 00:21:56,730 you're working on doing this with adults too, 482 00:21:56,730 --> 00:22:00,600 so that you can have an effective relationship 483 00:22:00,600 --> 00:22:01,890 with them, right? 484 00:22:01,890 --> 00:22:04,500 And not just launching into, again, 485 00:22:04,500 --> 00:22:05,940 all the things that are going wrong 486 00:22:05,940 --> 00:22:07,290 and all the complaints and problems, 487 00:22:07,290 --> 00:22:09,930 but taking a little time to assess 488 00:22:09,930 --> 00:22:14,930 what folks' strengths are, what their resiliency is, 489 00:22:15,060 --> 00:22:16,350 and building on those 490 00:22:16,350 --> 00:22:18,870 as you're facing some of the challenges, right? 491 00:22:18,870 --> 00:22:20,220 And working with them 492 00:22:20,220 --> 00:22:23,940 on starting to build their own solutions to problems, 493 00:22:23,940 --> 00:22:25,560 giving them constructive feedback 494 00:22:25,560 --> 00:22:29,080 but also positive feedback while you're talking to them 495 00:22:30,240 --> 00:22:34,350 and one of the strengths-based approaches in particular 496 00:22:34,350 --> 00:22:36,270 that Dr. Duncan focused on 497 00:22:36,270 --> 00:22:38,430 was something called the Circle of Courage, 498 00:22:38,430 --> 00:22:40,320 which comes out of the context 499 00:22:40,320 --> 00:22:43,350 of the Native American Circle of Courage. 500 00:22:43,350 --> 00:22:47,370 And a lot of research was done on this in the 90s 501 00:22:47,370 --> 00:22:49,380 and it sort of spread throughout 502 00:22:49,380 --> 00:22:52,350 the pediatric adolescent world 503 00:22:52,350 --> 00:22:54,910 and developed into what we would now call 504 00:22:56,100 --> 00:22:58,950 the Positive Youth Development model that a lot of us use 505 00:22:58,950 --> 00:23:02,490 with the strengths based approach. 506 00:23:02,490 --> 00:23:07,350 And basically it turned out when folks took a closer look 507 00:23:07,350 --> 00:23:09,750 at sort of Native American child rearing values 508 00:23:09,750 --> 00:23:12,780 and the positive effects of that, 509 00:23:12,780 --> 00:23:15,690 that a lot of the studies within psychology and medicine 510 00:23:15,690 --> 00:23:18,120 about development and the benefits 511 00:23:18,120 --> 00:23:23,120 of positive strength-based care really all worked together 512 00:23:23,130 --> 00:23:25,680 and agreed with each other, right? 513 00:23:25,680 --> 00:23:27,960 And it's interesting that the strength-based approach 514 00:23:27,960 --> 00:23:30,720 was so strong within this context 515 00:23:30,720 --> 00:23:32,460 of the Native American cultures, 516 00:23:32,460 --> 00:23:34,020 whereas in a lot of the Western cultures 517 00:23:34,020 --> 00:23:36,180 around the same period of time, 518 00:23:36,180 --> 00:23:39,360 childbearing was really quite strict 519 00:23:39,360 --> 00:23:42,150 and aligned with some harsh punishment at times. 520 00:23:42,150 --> 00:23:45,810 And the Circle of Courage really addresses the fact 521 00:23:45,810 --> 00:23:48,060 that while folks are attached, 522 00:23:48,060 --> 00:23:49,470 they're moving towards independence 523 00:23:49,470 --> 00:23:51,420 while they're struggling to learn, 524 00:23:51,420 --> 00:23:52,920 they're moving towards achievements, 525 00:23:52,920 --> 00:23:54,360 they're moving towards autonomy 526 00:23:54,360 --> 00:23:59,220 and altruism is also a really key aspect of that. 527 00:23:59,220 --> 00:24:01,800 So I won't go into more detail on that, 528 00:24:01,800 --> 00:24:05,130 but here are some additional slides on that topic. 529 00:24:05,130 --> 00:24:09,330 So in our well visits here at General Pediatrics at UVM, 530 00:24:09,330 --> 00:24:11,253 we're always checking in with folks, 531 00:24:12,210 --> 00:24:15,810 not directly but assessing in our conversations with them 532 00:24:15,810 --> 00:24:18,660 about their levels of generosity, belonging, 533 00:24:18,660 --> 00:24:20,553 independence, and mastery. 534 00:24:21,600 --> 00:24:24,090 And then this is the framework from Dr. Ginsburg 535 00:24:24,090 --> 00:24:26,370 and he's got a big book called Reaching Teens 536 00:24:26,370 --> 00:24:30,510 put out by AAP if anyone wants to take a peek at that. 537 00:24:30,510 --> 00:24:32,970 And everyone probably remembers learning about 538 00:24:32,970 --> 00:24:36,030 the HEADSS, psychosocial evaluation in medical school. 539 00:24:36,030 --> 00:24:38,010 That has evolved a little bit more 540 00:24:38,010 --> 00:24:39,640 into what we call SSHADESS 541 00:24:40,950 --> 00:24:43,500 which has put an S at the front 542 00:24:43,500 --> 00:24:46,710 recommending folks address strengths right up front, 543 00:24:46,710 --> 00:24:50,640 assess strengths as part of their check-ins with people. 544 00:24:50,640 --> 00:24:53,160 And including asking family members and parents 545 00:24:53,160 --> 00:24:54,970 about strengths of young people too 546 00:24:56,190 --> 00:24:59,880 upfront before you're checking in on all the other aspects 547 00:24:59,880 --> 00:25:01,800 of their psychosocial existence. 548 00:25:01,800 --> 00:25:05,193 All of which of course, affects their health and wellbeing. 549 00:25:06,210 --> 00:25:07,500 In addition to sexuality, 550 00:25:07,500 --> 00:25:10,320 we wanna check in in general about relationships, 551 00:25:10,320 --> 00:25:12,570 peer relationships, and maybe more intimate 552 00:25:12,570 --> 00:25:14,310 or romantic relationships 553 00:25:14,310 --> 00:25:16,560 and of course gender identity 554 00:25:16,560 --> 00:25:21,303 also is important to check in on these days too. 555 00:25:22,140 --> 00:25:23,970 So can I get a time check 556 00:25:23,970 --> 00:25:27,300 just 'cause I don't have my clock up right now. 557 00:25:27,300 --> 00:25:29,206 We're at 12:44, Erica. 558 00:25:29,206 --> 00:25:32,160 Okay, so I'm not gonna go into detail 559 00:25:32,160 --> 00:25:34,650 on our wellness screening questions 560 00:25:34,650 --> 00:25:37,830 that we use for our visits 561 00:25:37,830 --> 00:25:39,930 in pediatrics and adolescent medicine, 562 00:25:39,930 --> 00:25:41,670 but I just wanted to touch on them briefly. 563 00:25:41,670 --> 00:25:43,080 I know a lot of the specialists 564 00:25:43,080 --> 00:25:46,140 are doing some screening questions in their clinics, 565 00:25:46,140 --> 00:25:48,480 like social determinants of health 566 00:25:48,480 --> 00:25:50,730 or mood screening questionnaires. 567 00:25:50,730 --> 00:25:54,900 We do know that a combination of screening questionnaires 568 00:25:54,900 --> 00:25:57,210 that someone can fill out alone privately 569 00:25:57,210 --> 00:25:58,660 with no one staring them down 570 00:26:00,060 --> 00:26:04,650 in concert with asking direct questions often works best. 571 00:26:04,650 --> 00:26:07,380 We tend to do full behavioral health screenings 572 00:26:07,380 --> 00:26:09,780 at AWV visits along with screenings 573 00:26:09,780 --> 00:26:11,070 for mood and substance use 574 00:26:11,070 --> 00:26:15,300 and then of course, screenings for mood and substance use 575 00:26:15,300 --> 00:26:18,330 might be used in other settings or other visits also 576 00:26:18,330 --> 00:26:20,580 and then there are additional screenings 577 00:26:20,580 --> 00:26:22,620 that folks might consider using. 578 00:26:22,620 --> 00:26:26,790 So I think sometimes young people tell us 579 00:26:26,790 --> 00:26:30,330 that they're taken aback by getting all these questions 580 00:26:30,330 --> 00:26:31,410 that they don't feel like 581 00:26:31,410 --> 00:26:34,080 a doctor really needs to know about. 582 00:26:34,080 --> 00:26:36,660 So clarifying why you're asking 583 00:26:36,660 --> 00:26:39,870 these really personal questions and setting the stage 584 00:26:39,870 --> 00:26:41,970 for how we understand a lot 585 00:26:41,970 --> 00:26:46,970 of young people's lived experience on a day-to-day basis, 586 00:26:48,030 --> 00:26:50,460 where they're going, what they're doing, 587 00:26:50,460 --> 00:26:53,550 it does affect their health and wellbeing is important. 588 00:26:53,550 --> 00:26:55,590 And ideally if again, 589 00:26:55,590 --> 00:26:57,990 folks have been asked these questions appropriately 590 00:26:57,990 --> 00:27:01,680 as they've matured through their pediatric care, 591 00:27:01,680 --> 00:27:04,350 it's going to make sense to them when they get to adult care 592 00:27:04,350 --> 00:27:07,110 that folks are continuing to ask some of these questions. 593 00:27:07,110 --> 00:27:11,340 So I think it could be a little bit hard 594 00:27:11,340 --> 00:27:13,050 for some young people 595 00:27:13,050 --> 00:27:15,900 when they move on to a brand new care provider 596 00:27:15,900 --> 00:27:18,723 to be asked a lot of personal questions right up front. 597 00:27:19,980 --> 00:27:24,210 And again, helping them understand 598 00:27:24,210 --> 00:27:26,370 that the fabric of their lives 599 00:27:26,370 --> 00:27:28,570 has an effect on their health and wellbeing. 600 00:27:29,670 --> 00:27:31,560 For the pediatric providers, 601 00:27:31,560 --> 00:27:34,110 I think sometimes asking personal questions can be tough 602 00:27:34,110 --> 00:27:36,540 as someone gets older, especially if you've known them 603 00:27:36,540 --> 00:27:38,160 their entire life 604 00:27:38,160 --> 00:27:43,160 and they might completely and totally trust you 605 00:27:43,230 --> 00:27:48,030 and feel like they have an adolescent provider relationship 606 00:27:48,030 --> 00:27:50,790 with you and understand what you sort of can keep private 607 00:27:50,790 --> 00:27:52,800 and speak with them about 608 00:27:52,800 --> 00:27:55,500 without necessarily bringing parents or guardians in. 609 00:27:55,500 --> 00:27:57,210 But they also might feel a little worried 610 00:27:57,210 --> 00:27:59,670 that you're really aligned with their parents 611 00:27:59,670 --> 00:28:01,510 and not necessarily with them 612 00:28:02,820 --> 00:28:05,460 and so confidentiality isn't so much an issue 613 00:28:05,460 --> 00:28:06,570 when someone's 18, 614 00:28:06,570 --> 00:28:09,030 that's when someone's guaranteed confidentiality. 615 00:28:09,030 --> 00:28:11,550 But again, in pediatric care, 616 00:28:11,550 --> 00:28:14,493 as people move into older adolescents, 617 00:28:15,420 --> 00:28:17,820 they do have the right 618 00:28:17,820 --> 00:28:21,420 to confidential care in some specific realms, 619 00:28:21,420 --> 00:28:23,680 specifically sexual reproductive healthcare 620 00:28:24,540 --> 00:28:27,120 and some mental healthcare aspects 621 00:28:27,120 --> 00:28:29,910 which hopefully have been introduced to them appropriately 622 00:28:29,910 --> 00:28:31,290 and they've been comfortable talking 623 00:28:31,290 --> 00:28:32,490 about some of those things 624 00:28:32,490 --> 00:28:34,500 and will continue to be comfortable talking about 625 00:28:34,500 --> 00:28:37,680 those things as they move on to adult care. 626 00:28:37,680 --> 00:28:39,870 I'm happy to provide like a little more detail 627 00:28:39,870 --> 00:28:42,330 on confidentiality at a later date 628 00:28:42,330 --> 00:28:44,470 or through some documents I have for folks 629 00:28:45,379 --> 00:28:48,990 if some of the folks that are in pediatrics 630 00:28:48,990 --> 00:28:50,140 are interested in that. 631 00:28:51,420 --> 00:28:54,810 So some adolescent friendly office strategies 632 00:28:54,810 --> 00:28:56,187 to think about, 633 00:28:56,187 --> 00:28:58,830 and this is information that we've gleaned 634 00:28:58,830 --> 00:29:01,830 from studies that have been done nationally 635 00:29:01,830 --> 00:29:04,050 on what adolescents want from services 636 00:29:04,050 --> 00:29:07,500 and also from adolescents we've worked with here in Vermont. 637 00:29:07,500 --> 00:29:10,710 Making sure that folks are accessible, 638 00:29:10,710 --> 00:29:12,090 that there's some flexibility 639 00:29:12,090 --> 00:29:15,240 to scheduling and availability of appointments, 640 00:29:15,240 --> 00:29:18,760 making sure an environment feels adolescent friendly 641 00:29:19,770 --> 00:29:23,070 in terms of the way the space is set up 642 00:29:23,070 --> 00:29:25,440 and ideally if folks can have 643 00:29:25,440 --> 00:29:29,520 as many multidisciplinary services onsite as possible 644 00:29:29,520 --> 00:29:32,040 to serve needs, that's great. 645 00:29:32,040 --> 00:29:33,840 But we know that can be a challenge. 646 00:29:33,840 --> 00:29:35,910 We're lucky that we have some resources in the state 647 00:29:35,910 --> 00:29:37,530 for folks to have community health teams 648 00:29:37,530 --> 00:29:42,393 and other folks available, but that's not always the case. 649 00:29:43,620 --> 00:29:46,020 What some of the young folks in Vermont specifically said 650 00:29:46,020 --> 00:29:49,620 when they went to visit a lot of different family medicine 651 00:29:49,620 --> 00:29:51,300 and pediatric clinics 652 00:29:51,300 --> 00:29:54,810 and evaluated sort of waiting room spaces and stuff, 653 00:29:54,810 --> 00:29:57,600 some things they said they really would like to see 654 00:29:57,600 --> 00:30:00,210 are posters of people who look like them. 655 00:30:00,210 --> 00:30:02,943 Free wifi, of course, we all want that at this point. 656 00:30:04,050 --> 00:30:06,510 Information about confidentiality in those sites 657 00:30:06,510 --> 00:30:10,020 serving folks under 18, ally stickers, 658 00:30:10,020 --> 00:30:13,500 information on teen issues. 659 00:30:13,500 --> 00:30:17,400 They like the idea of folks posting information about 660 00:30:17,400 --> 00:30:21,180 community events related to young people in school. 661 00:30:21,180 --> 00:30:24,720 They love accessible technology, 662 00:30:24,720 --> 00:30:27,330 information, websites and the like. 663 00:30:27,330 --> 00:30:30,270 They like doing questionnaires on tablets or on paper 664 00:30:30,270 --> 00:30:31,630 before face-to-face 665 00:30:32,640 --> 00:30:35,940 and they really like it when people respect them, 666 00:30:35,940 --> 00:30:39,990 engage with them, smile at them and talk to them, 667 00:30:39,990 --> 00:30:42,690 even if maybe they have a parent by their side. 668 00:30:42,690 --> 00:30:44,130 These are just examples 669 00:30:44,130 --> 00:30:47,010 of some great materials out there in the world 670 00:30:47,010 --> 00:30:51,000 that folks could possibly access to use in clinics. 671 00:30:51,000 --> 00:30:54,690 And then in terms of systems, this is interesting. 672 00:30:54,690 --> 00:30:57,360 I find in our busy, busy day-to-day lives 673 00:30:57,360 --> 00:31:00,240 where there's a lot of patient volume for providers, 674 00:31:00,240 --> 00:31:02,400 for people at the front desk, for phone calls, 675 00:31:02,400 --> 00:31:06,150 for triage nurses, especially in a setting 676 00:31:06,150 --> 00:31:09,870 where adults are served in addition to young people. 677 00:31:09,870 --> 00:31:12,600 Those young people often can be treated a little bit 678 00:31:12,600 --> 00:31:14,793 as those mini adults we talked about, 679 00:31:15,780 --> 00:31:19,500 and then if people aren't meeting those expectations 680 00:31:19,500 --> 00:31:22,710 we have of them to behave more maturely 681 00:31:22,710 --> 00:31:27,570 or be more cognitively with it, it can be frustrating to us 682 00:31:27,570 --> 00:31:31,320 and that can show and that can be hard for them. 683 00:31:31,320 --> 00:31:33,840 So I think if folks can remember to take the time 684 00:31:33,840 --> 00:31:36,360 to just try to get a sense of someone's cognitive 685 00:31:36,360 --> 00:31:38,790 and emotional functioning when they're engaging, right? 686 00:31:38,790 --> 00:31:40,260 Like are they making eye contact? 687 00:31:40,260 --> 00:31:42,480 Are they asking questions themselves? 688 00:31:42,480 --> 00:31:43,830 Are they responding appropriately? 689 00:31:43,830 --> 00:31:45,180 Are they understanding you? 690 00:31:45,180 --> 00:31:48,330 I mean, and of course I think everyone knows about 691 00:31:48,330 --> 00:31:52,080 health literacy and using interpreters and all that stuff. 692 00:31:52,080 --> 00:31:53,433 All really important. 693 00:31:54,660 --> 00:31:57,573 In terms of communication for young people with offices. 694 00:31:58,560 --> 00:32:00,630 Thinking about what people have available 695 00:32:00,630 --> 00:32:05,250 for folks to use is key. 696 00:32:05,250 --> 00:32:06,750 Sorry, I'm gonna take a drink. 697 00:32:09,600 --> 00:32:11,700 So everyone loves the texting, 698 00:32:11,700 --> 00:32:13,980 we love the texting as adults too. 699 00:32:13,980 --> 00:32:16,290 We adults do still use email. 700 00:32:16,290 --> 00:32:17,820 Young people don't use it so much anymore. 701 00:32:17,820 --> 00:32:21,213 We adults still use phones but less often than we used to. 702 00:32:22,050 --> 00:32:24,390 A lot of young people really aren't so comfortable 703 00:32:24,390 --> 00:32:26,460 using phones, like they don't answer phones, 704 00:32:26,460 --> 00:32:28,360 they don't necessarily check messages. 705 00:32:29,730 --> 00:32:32,190 So in setting up systems, finding out from folks 706 00:32:32,190 --> 00:32:33,450 like what works best for you, 707 00:32:33,450 --> 00:32:36,690 I realize we don't have like text messaging set up 708 00:32:36,690 --> 00:32:39,420 within our medical center beyond using MyChart, 709 00:32:39,420 --> 00:32:40,860 but that's the closest we can get. 710 00:32:40,860 --> 00:32:42,660 So if we can at least really engage with young people 711 00:32:42,660 --> 00:32:44,820 and try to get them to sign up for MyChart 712 00:32:44,820 --> 00:32:47,400 and communicate that way and communicate appropriately 713 00:32:47,400 --> 00:32:48,450 'cause that can be challenging 714 00:32:48,450 --> 00:32:50,460 because sometimes folks will just use MyChart 715 00:32:50,460 --> 00:32:52,950 for everything when things are more maybe more acute 716 00:32:52,950 --> 00:32:55,110 and need phone calls. 717 00:32:55,110 --> 00:32:57,360 So checking in about that, helping young people, 718 00:32:57,360 --> 00:32:59,220 especially as they're moving into adult care, 719 00:32:59,220 --> 00:33:02,580 understand in more detail, 720 00:33:02,580 --> 00:33:04,200 like the different types of visits 721 00:33:04,200 --> 00:33:06,270 people are going to be having. 722 00:33:06,270 --> 00:33:10,290 So they might not fully understand the difference 723 00:33:10,290 --> 00:33:14,580 between like short acute visits, well visits, nurse visits, 724 00:33:14,580 --> 00:33:16,890 or different types of visits for different topics. 725 00:33:16,890 --> 00:33:18,570 So helping explain to them 726 00:33:18,570 --> 00:33:20,280 how the system actually works 727 00:33:20,280 --> 00:33:23,400 might help them to be more responsive to care. 728 00:33:23,400 --> 00:33:27,780 And then clarifying scheduling appointments in advance, 729 00:33:27,780 --> 00:33:31,113 what late policies are, cancellation policies are, 730 00:33:32,430 --> 00:33:34,350 if they cancel at the last minute, 731 00:33:34,350 --> 00:33:36,270 they might not be able to get in 732 00:33:36,270 --> 00:33:37,830 for a longer period of time 733 00:33:37,830 --> 00:33:40,200 and that could be frustrating. 734 00:33:40,200 --> 00:33:43,110 And actually in our work with pediatric 735 00:33:43,110 --> 00:33:44,850 to adult primary care transition 736 00:33:44,850 --> 00:33:48,210 with the offices downstairs, adult care at UHC. 737 00:33:48,210 --> 00:33:50,400 They actually have this really nice welcome packet 738 00:33:50,400 --> 00:33:51,300 they provide to folks 739 00:33:51,300 --> 00:33:55,510 that provide a lot of this information and we give it out 740 00:33:57,862 --> 00:33:59,367 when we're having the last peds visit with them 741 00:33:59,367 --> 00:34:01,650 and they're getting ready to transition for that 742 00:34:01,650 --> 00:34:02,730 and review it with them 743 00:34:02,730 --> 00:34:04,860 and then when they first see adult providers downstairs, 744 00:34:04,860 --> 00:34:08,703 they go over it also to just sort of reinforce everything. 745 00:34:10,830 --> 00:34:14,700 And I like to provide people with resources 746 00:34:14,700 --> 00:34:16,710 for health information handouts 747 00:34:16,710 --> 00:34:18,300 that are really adolescent friendly 748 00:34:18,300 --> 00:34:20,940 and I think the best ones to use 749 00:34:20,940 --> 00:34:24,660 are from Boston Children's Adolescent Medicine Division 750 00:34:24,660 --> 00:34:28,050 Health Education websites, which are listed here. 751 00:34:28,050 --> 00:34:30,360 They are very binary. 752 00:34:30,360 --> 00:34:32,460 There's not a lot of information specifically geared 753 00:34:32,460 --> 00:34:33,750 to gender diverse youth, 754 00:34:33,750 --> 00:34:37,260 but they have a little bit of that, 755 00:34:37,260 --> 00:34:40,560 they're easy to print out and just hand to folks, 756 00:34:40,560 --> 00:34:44,250 which I think can be very important also for young people, 757 00:34:44,250 --> 00:34:46,350 for all patients really when they're leaving a visit, 758 00:34:46,350 --> 00:34:48,990 anything you can have them take home to look at, 759 00:34:48,990 --> 00:34:51,540 to reinforce what you've talked about can be great, 760 00:34:52,890 --> 00:34:54,120 and just wanna acknowledge 761 00:34:54,120 --> 00:34:56,190 that I've done different versions of this talk 762 00:34:56,190 --> 00:34:57,810 for years with different people 763 00:34:57,810 --> 00:35:02,010 and here at UVM, I worked with Barbara Frankowski 764 00:35:02,010 --> 00:35:03,480 and when I was working at Columbia, 765 00:35:03,480 --> 00:35:07,617 I worked a great deal with Dr. Al Cohall, 766 00:35:07,617 --> 00:35:10,680 and I believe maybe we have time for a few questions 767 00:35:10,680 --> 00:35:12,810 or chatting if folks are up for that. 768 00:35:12,810 --> 00:35:14,790 I do have clinic starting at one, 769 00:35:14,790 --> 00:35:18,123 but we all know patients aren't in the room right at one so. 770 00:35:20,250 --> 00:35:21,690 All right, thank you so much Erica. 771 00:35:21,690 --> 00:35:25,050 That was a great overview 772 00:35:25,050 --> 00:35:28,500 and a lot of great information and tips. 773 00:35:28,500 --> 00:35:31,260 So we do have some time for a few questions 774 00:35:31,260 --> 00:35:32,640 so I wanna open it up 775 00:35:32,640 --> 00:35:37,640 if anyone has any questions or comments, oh, Vicky? 776 00:35:38,130 --> 00:35:38,963 Oops. 777 00:35:40,470 --> 00:35:43,260 Got it, oh hi, hi there. 778 00:35:43,260 --> 00:35:44,580 Dr. Gibson, I haven't met you yet. 779 00:35:44,580 --> 00:35:45,600 I work with the patient family- 780 00:35:45,600 --> 00:35:47,036 -Oh yes, yes. -[Vicky] Yeah, I know. 781 00:35:47,036 --> 00:35:48,130 So nice to see your face. 782 00:35:48,130 --> 00:35:49,746 [Vicky] I know your name, great. 783 00:35:49,746 --> 00:35:50,961 [Erica] So great to hear you. 784 00:35:50,961 --> 00:35:51,794 Yeah. 785 00:35:52,760 --> 00:35:53,593 So great to be here. 786 00:35:53,593 --> 00:35:55,380 So two things I'm thinking about, one, I'm thinking about 787 00:35:55,380 --> 00:35:57,750 the whole brain development impulsivity 788 00:35:57,750 --> 00:35:59,850 and the connection to suicide, 789 00:35:59,850 --> 00:36:03,300 especially just in that talk that Dr. Bell gave 790 00:36:03,300 --> 00:36:04,770 over the grand rounds. 791 00:36:04,770 --> 00:36:05,850 But my question for you 792 00:36:05,850 --> 00:36:09,153 is around chronic illness and brain development. 793 00:36:10,050 --> 00:36:13,050 Yeah, I think it can be affected for sure. 794 00:36:13,050 --> 00:36:15,820 We know already puberty can be affected 795 00:36:16,830 --> 00:36:20,940 and I am not familiar with any long-term studies. 796 00:36:20,940 --> 00:36:25,410 I think it would depend on, again, all the different layers 797 00:36:25,410 --> 00:36:27,720 of what's going on with the young person 798 00:36:27,720 --> 00:36:31,083 and what the actual physical challenges have been. 799 00:36:31,980 --> 00:36:35,250 But definitely should be considered, right. 800 00:36:35,250 --> 00:36:37,020 Should be taken into account. 801 00:36:37,020 --> 00:36:38,723 -[Vicky] Yeah, thank you. -Yeah. 802 00:36:42,720 --> 00:36:44,943 Are there other questions or comments? 803 00:36:53,130 --> 00:36:54,480 Erica, I have a quick question. 804 00:36:54,480 --> 00:36:55,680 [Erica] Sure. 805 00:36:55,680 --> 00:36:59,400 What advice do you have for maybe providers? 806 00:36:59,400 --> 00:37:02,430 What we're noticing is that visit times 807 00:37:02,430 --> 00:37:04,020 are getting shorter and shorter 808 00:37:04,020 --> 00:37:06,900 and as you know, schedules are really crunched. 809 00:37:06,900 --> 00:37:10,260 Do you have any like tried and true questions 810 00:37:10,260 --> 00:37:13,950 that might work well for just helping 811 00:37:13,950 --> 00:37:16,860 to open the door quickly with young adults 812 00:37:16,860 --> 00:37:20,043 and help open the conversation? 813 00:37:21,300 --> 00:37:24,540 Well, it's interesting, when people come to see me, 814 00:37:24,540 --> 00:37:25,470 my first question is, 815 00:37:25,470 --> 00:37:28,050 do you know why you're here to see me, right? 816 00:37:28,050 --> 00:37:29,490 If they've made the appointment, 817 00:37:29,490 --> 00:37:30,720 which some of the older adolescents have, 818 00:37:30,720 --> 00:37:32,220 then they know while they're there. 819 00:37:32,220 --> 00:37:34,290 But if folks are coming with parents sometimes 820 00:37:34,290 --> 00:37:36,270 they might not actually know 821 00:37:36,270 --> 00:37:37,560 and then I always like to ask like, 822 00:37:37,560 --> 00:37:39,870 what's most important for you to talk about? 823 00:37:39,870 --> 00:37:41,580 'Cause there might be a long list of things 824 00:37:41,580 --> 00:37:42,570 you wanna talk about, 825 00:37:42,570 --> 00:37:45,480 especially if you're following someone pretty routinely 826 00:37:45,480 --> 00:37:48,840 over long term 827 00:37:48,840 --> 00:37:51,000 and once in a while other things might float to the top 828 00:37:51,000 --> 00:37:52,650 that you might not even be aware of. 829 00:37:52,650 --> 00:37:57,630 So I'm really big on trying to make the most of my time 830 00:37:57,630 --> 00:37:58,980 on the most important issue 831 00:37:58,980 --> 00:38:00,600 and not just trying to fit everything in 832 00:38:00,600 --> 00:38:02,580 and saying why don't we have you come back 833 00:38:02,580 --> 00:38:06,120 a little bit later to talk about this other piece? 834 00:38:06,120 --> 00:38:11,120 And I rarely am the person who's like, see ya in a year. 835 00:38:11,790 --> 00:38:16,560 I mean they have to be just thriving and doing so well 836 00:38:16,560 --> 00:38:20,610 for me to say that even if someone's had a AWV visit 837 00:38:20,610 --> 00:38:23,010 where everything seems to be going well, 838 00:38:23,010 --> 00:38:25,350 I often will ask if they wanna just check in 839 00:38:25,350 --> 00:38:26,763 maybe in six months. 840 00:38:27,780 --> 00:38:30,240 And for other folks I might be, 841 00:38:30,240 --> 00:38:32,700 especially if they have ongoing issues, 842 00:38:32,700 --> 00:38:35,433 be more likely to see them at least quarterly. 843 00:38:36,690 --> 00:38:37,830 Because when you have shorter time, 844 00:38:37,830 --> 00:38:39,900 you just kind of have to maybe see them more often 845 00:38:39,900 --> 00:38:41,730 if their needs are greater. 846 00:38:41,730 --> 00:38:45,120 But I also am not shy about just saying 847 00:38:45,120 --> 00:38:47,190 I need to see someone for a longer period of time 848 00:38:47,190 --> 00:38:50,970 and if admins wanna come after me they can, 849 00:38:50,970 --> 00:38:52,803 I know not everyone can do that. 850 00:38:54,720 --> 00:38:56,850 But if you want maximize your billing, right? 851 00:38:56,850 --> 00:38:58,650 'Cause we can do time-based billing now 852 00:38:58,650 --> 00:39:03,650 that also includes review of medical information 853 00:39:04,290 --> 00:39:05,640 leading up to the visit 854 00:39:05,640 --> 00:39:07,590 as long as it's within a certain timeframe. 855 00:39:07,590 --> 00:39:09,600 So you can include that in your time-based billing 856 00:39:09,600 --> 00:39:13,290 and then get a longer visit potentially. 857 00:39:13,290 --> 00:39:14,523 Great, thank you. 858 00:39:16,920 --> 00:39:19,410 Right, couple more minutes. 859 00:39:19,410 --> 00:39:21,963 Are there other questions or comments? 860 00:39:27,780 --> 00:39:30,360 Dr. Mariani doesn't have any hot tips 861 00:39:30,360 --> 00:39:32,913 with her vast experience with young people? 862 00:39:34,170 --> 00:39:35,640 [Dr. Mariani] No, I was thinking of questions, 863 00:39:35,640 --> 00:39:36,840 I was thinking of the opposite. 864 00:39:36,840 --> 00:39:41,100 I was thinking of questions to pick your brain. 865 00:39:41,100 --> 00:39:41,933 Yeah. 866 00:39:42,900 --> 00:39:43,733 Well, I'm here, 867 00:39:43,733 --> 00:39:45,644 my brain isn't always available to be picked. 868 00:39:45,644 --> 00:39:47,977 I think everyone knows that. 869 00:39:53,880 --> 00:39:55,560 [Dr. Mariani] I think that one of the things 870 00:39:55,560 --> 00:39:57,480 as you were talking (indistinct) thinking about 871 00:39:57,480 --> 00:40:01,430 was how meds interact with all of... 872 00:40:03,120 --> 00:40:06,873 Throw the pharmacology of medications 873 00:40:06,873 --> 00:40:10,112 into this developing brain, 874 00:40:10,112 --> 00:40:13,530 and I couldn't really form a question around it, 875 00:40:13,530 --> 00:40:16,380 but I don't know if you have any comments 876 00:40:16,380 --> 00:40:19,260 about what you think about in general, 877 00:40:19,260 --> 00:40:22,170 pharmacology on the developing brain. 878 00:40:22,170 --> 00:40:23,580 Yeah, I mean, I come across- 879 00:40:23,580 --> 00:40:26,380 [Dr. Mariani] I guess sometimes we don't really see... 880 00:40:28,050 --> 00:40:29,250 I think it's a good question. 881 00:40:29,250 --> 00:40:30,570 [Dr. Mariani] I just don't see that meds work 882 00:40:30,570 --> 00:40:31,533 with adolescents. 883 00:40:32,490 --> 00:40:35,140 Yeah, I mean I never pretend I know 884 00:40:36,480 --> 00:40:38,457 all the details of how all medications work 885 00:40:38,457 --> 00:40:40,080 and what all the side effects are. 886 00:40:40,080 --> 00:40:44,580 So I am always on Micromedex sort of double checking things 887 00:40:44,580 --> 00:40:46,170 and trying to clarify. 888 00:40:46,170 --> 00:40:50,310 It's not often that I come across information and studies 889 00:40:50,310 --> 00:40:54,090 that say there's a negative effect on brain development. 890 00:40:54,090 --> 00:40:58,200 But for example, 891 00:40:58,200 --> 00:41:01,710 if a medication has a side effect of irritability 892 00:41:01,710 --> 00:41:03,510 and that affects someone's day-to-day life 893 00:41:03,510 --> 00:41:04,680 and interactions with folks 894 00:41:04,680 --> 00:41:06,540 and then that affects the pruning 895 00:41:06,540 --> 00:41:08,850 of the brain, then for sure. 896 00:41:08,850 --> 00:41:10,920 I get asked more frequently in my work 897 00:41:10,920 --> 00:41:13,650 with transgender youth about how puberty blockers, 898 00:41:13,650 --> 00:41:16,590 for example, affect brain development 899 00:41:16,590 --> 00:41:19,050 and people are starting to do more studies on that, 900 00:41:19,050 --> 00:41:21,130 actual brain studies like PET scans 901 00:41:21,990 --> 00:41:25,890 and they haven't shown any negative effect to date 902 00:41:25,890 --> 00:41:27,390 and we know from the other research 903 00:41:27,390 --> 00:41:30,270 that psychosocially for those young people, 904 00:41:30,270 --> 00:41:31,830 it's really benefited them 905 00:41:31,830 --> 00:41:36,830 in terms of being able to live a happier, peaceful existence 906 00:41:37,050 --> 00:41:38,940 that then would more positively affect 907 00:41:38,940 --> 00:41:42,840 that automatic pruning that's going on, I think, right. 908 00:41:42,840 --> 00:41:45,753 So but I think fair question, yeah. 909 00:41:48,000 --> 00:41:49,020 Sarah, did you have a question? 910 00:41:49,020 --> 00:41:51,693 [Dr. Mariani] And not so much some, oh sorry. 911 00:41:52,620 --> 00:41:54,720 Sorry, go ahead Kathy, you weren't done. 912 00:41:56,280 --> 00:42:00,480 [Dr. Mariani] Oh, I was just gonna say that anecdotally, 913 00:42:00,480 --> 00:42:03,330 being an adult and adolescent provider, 914 00:42:03,330 --> 00:42:07,380 I just find that adults 915 00:42:07,380 --> 00:42:11,250 tend to get more of a dramatic response from like the SSRIs. 916 00:42:11,250 --> 00:42:15,983 Like I just see like, it's probably so many issues 917 00:42:17,820 --> 00:42:20,340 that it just seems much more straightforward 918 00:42:20,340 --> 00:42:25,050 when you're prescribing for an adult, six weeks on SSRI, 919 00:42:25,050 --> 00:42:27,660 you tend to get an effect if you're gonna get one 920 00:42:27,660 --> 00:42:31,290 and it's still a lot of times with the adolescent, 921 00:42:31,290 --> 00:42:33,573 it's just really hard to measure. 922 00:42:34,650 --> 00:42:35,970 'Cause from day-to-day, 923 00:42:35,970 --> 00:42:39,030 their mood could be so different on meds or off meds. 924 00:42:39,030 --> 00:42:40,650 Yeah, there's so many different factors 925 00:42:40,650 --> 00:42:42,990 like there's so many moving parts, so to speak, 926 00:42:42,990 --> 00:42:45,480 still for them potentially. 927 00:42:45,480 --> 00:42:48,483 Yeah, I think that's pretty complex actually. 928 00:42:49,500 --> 00:42:51,050 But a fair point, a good point. 929 00:42:54,000 --> 00:42:56,220 And I don't wanna run into your clinic time too much, 930 00:42:56,220 --> 00:43:00,240 but I have been thinking a lot recently about sort of, 931 00:43:00,240 --> 00:43:02,730 adultification of kids 932 00:43:02,730 --> 00:43:05,520 and I feel like with some of our younger adolescents 933 00:43:05,520 --> 00:43:09,390 and I think there are some significant disparities by race 934 00:43:09,390 --> 00:43:12,810 and also like, sometimes by even body size 935 00:43:12,810 --> 00:43:15,537 in female patients where I think people look at them 936 00:43:15,537 --> 00:43:17,670 and just think that they're older 937 00:43:17,670 --> 00:43:20,100 because they are further along in puberty 938 00:43:20,100 --> 00:43:22,560 and then treat them as an old individual 939 00:43:22,560 --> 00:43:24,450 and I just didn't know if you had any tips 940 00:43:24,450 --> 00:43:27,900 for like avoiding that and trying to kind of make sure 941 00:43:27,900 --> 00:43:31,950 that we're really meeting kids and families where they are 942 00:43:31,950 --> 00:43:33,840 and where they're comfortable. 943 00:43:33,840 --> 00:43:35,670 Yeah, or that young person who comes in 944 00:43:35,670 --> 00:43:40,670 and tends to be maybe a little more high functioning 945 00:43:41,100 --> 00:43:43,290 in some ways in terms of being organized 946 00:43:43,290 --> 00:43:44,730 about taking their medications 947 00:43:44,730 --> 00:43:46,110 and coming to appointments, 948 00:43:46,110 --> 00:43:47,100 collaborating with their parents 949 00:43:47,100 --> 00:43:48,570 on helping to keep themselves well 950 00:43:48,570 --> 00:43:52,320 but are still really young socially in a lot of other ways. 951 00:43:52,320 --> 00:43:56,100 I think you have to just pause and remind yourself like, 952 00:43:56,100 --> 00:43:58,440 I always on my little like crib notes 953 00:43:58,440 --> 00:44:00,000 before I'm going into clinic, 954 00:44:00,000 --> 00:44:03,030 one of the things I'm always writing down is people's ages 955 00:44:03,030 --> 00:44:04,530 because I wanna look at their age 956 00:44:04,530 --> 00:44:06,000 and remember how old they are, 957 00:44:06,000 --> 00:44:07,950 what grade they're probably in, 958 00:44:07,950 --> 00:44:09,990 and probably what stage of development they're in 959 00:44:09,990 --> 00:44:12,480 no matter what's gonna be in front of me 960 00:44:12,480 --> 00:44:14,670 when I walk into the room. 961 00:44:14,670 --> 00:44:16,533 Does that make sense, yeah. 962 00:44:17,910 --> 00:44:19,470 And in terms of like sex, 963 00:44:19,470 --> 00:44:21,300 a lot of the sexual reproductive health work I've done 964 00:44:21,300 --> 00:44:24,270 in the past, I think, yeah, it's really challenging 965 00:44:24,270 --> 00:44:26,700 for especially a lot of the cis females 966 00:44:26,700 --> 00:44:31,680 that develop earlier for whatever reason 967 00:44:31,680 --> 00:44:36,680 and then become sort of sexualized in our society 968 00:44:36,780 --> 00:44:40,110 and that proves very difficult for them 969 00:44:40,110 --> 00:44:43,920 and confusing when they are still less mature 970 00:44:43,920 --> 00:44:46,890 and might be pushed towards earlier sexual activity 971 00:44:46,890 --> 00:44:48,180 potentially because of that. 972 00:44:48,180 --> 00:44:50,730 I saw a little bit more of that in my work 973 00:44:50,730 --> 00:44:53,073 in the large urban setting in New York City. 974 00:44:58,457 --> 00:45:00,090 All right, well, we are a little bit over time 975 00:45:00,090 --> 00:45:02,820 so I will wrap us up and send us on our way. 976 00:45:02,820 --> 00:45:05,640 Again, we posted the link to an evaluation. 977 00:45:05,640 --> 00:45:07,740 We hope that you would take a moment just to fill it out, 978 00:45:07,740 --> 00:45:12,420 again, your feedback helps guide future activities and work. 979 00:45:12,420 --> 00:45:16,200 And with that, a very special thank you again to Erica 980 00:45:16,200 --> 00:45:18,960 for joining us today and having this conversation, 981 00:45:18,960 --> 00:45:21,240 and we look forward to... 982 00:45:21,240 --> 00:45:22,860 We're taking a break in the month of December 983 00:45:22,860 --> 00:45:25,650 and we will see everyone back in January 984 00:45:25,650 --> 00:45:28,350 and our topic will be MyChart 985 00:45:28,350 --> 00:45:32,040 and we have somebody from UVMMC IT joining us 986 00:45:32,040 --> 00:45:37,040 with tips and tricks and ins and outs of MyChart, great. 987 00:45:37,080 --> 00:45:39,070 Alright, great, thanks everyone.