Step 2 CK · Pediatrics

Adolescent Medicine

Name: Adolescent Medicine
Creator: Veli Bakalov, MD

Confidential care, HEEADSSS, and the shots at 11-12

Pediatrics·Growth, Development & Well-Child Care·4 min read·9 high-yield points·Reviewed by Veli Bakalov, MD @HemeOncBuddy

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Minors can consent confidentially to STI, contraception, pregnancy, substance-use, and mental-health care; emancipated minors consent to all care.
Break adolescent confidentiality only for danger to self or others (suicidality, homicidality) or suspected abuse.
HEEADSSS (Home, Education/Employment, Eating, Activities, Drugs, Sexuality, Suicide/depression, Safety) structures the psychosocial interview; see the adolescent alone for part of every visit.
Girls' first pubertal sign is thelarche (8–13) with menarche at Tanner 3–4; boys start with testicular enlargement (9–14); precocious is before 8 (girls) or 9 (boys), delayed is none by 13 (girls) or 14 (boys).
LARC (etonogestrel implant, IUD) is first-line adolescent contraception, plus condoms; no pelvic exam is needed first, and Pap testing starts at 21.
Screen sexually active females under 25 yearly for chlamydia and gonorrhea by NAAT and everyone 15–65 at least once for HIV.
Anorexia: low BMI, bradycardia, lanugo, osteoporosis, and refeeding hypophosphatemia; bulimia: normal BMI, Russell sign, parotid swelling, dental erosion, hypokalemic metabolic alkalosis.
CRAFFT screens adolescent substance use; SSRIs (fluoxetine, escitalopram) carry a black-box suicidality warning in youth, so monitor closely.
At 11–12 give Tdap, HPV (2 doses if started before 15, otherwise 3), and MenACWY (booster at 16); unintentional injury is the top cause of adolescent death.

Confidentiality, consent, and the adolescent interview

Minors consent to sensitive care. In most states a minor can independently consent to care for sexually transmitted infections, contraception, pregnancy, substance use, and mental health, and that care stays confidential—so a teen requesting STI testing or contraception without parental involvement receives it. Emancipated minors (for example, married, in the military, or living independently and self-supporting) consent to all of their own care.

Confidentiality breaks when there is danger to self or others—suicidality or homicidality—or suspected abuse. Explain these limits at the start of the visit.

HEEADSSS. Interview the adolescent alone for part of every visit to elicit honest, confidential answers, moving from less to more sensitive topics:

Home, Education/Employment, Eating, Activities
Drugs, Sexuality, Suicide/depression, Safety

Pubertal development

Tanner staging (sexual maturity rating, SMR 1–5) tracks breast, genital, and pubic hair development. In girls the order is breast, then hair, then growth, then period: thelarche, pubarche, the growth spurt (peak height velocity), and menarche at Tanner 3–4, roughly 2–2.5 years after thelarche. Boys start with testicular enlargement and reach peak height velocity later, at Tanner 3–4.

Puberty timing by sex

Feature	Girls	Boys
First sign	Breast budding (thelarche)	Testicular enlargement (≥4 mL)
Normal onset	About 8–13 years	About 9–14 years
Precocious	Before 8	Before 9
Delayed	No breast development by 13	No testicular enlargement by 14

Precocious puberty. Secondary sexual development before 8 in girls or 9 in boys, usually with an advanced bone age. Central (GnRH-dependent) disease is most often idiopathic in girls, whereas boys more often harbor a CNS lesion and need brain MRI. Peripheral (GnRH-independent) causes include McCune-Albright syndrome, congenital adrenal hyperplasia, and tumors. Work up with a bone age and GnRH stimulation testing: LH rises in central disease and stays suppressed in peripheral disease. Central disease is treated with a GnRH agonist.

Delayed puberty. Constitutional delay is the most common cause; also consider Turner (45,X), Klinefelter (47,XXY), and Kallmann syndrome (GnRH deficiency with anosmia). Start with a bone age and a hormone panel: high FSH and LH indicate gonadal failure (Turner, Klinefelter) and prompt a karyotype, while low levels fit constitutional delay or hypogonadotropic causes such as Kallmann syndrome.

Sexual health: contraception and STI screening

LARC is first-line. Long-acting reversible contraception—the etonogestrel implant and IUDs—is recommended first for adolescents: over 99% effective, safe (IUDs are appropriate even for nulliparous teens), and nothing to remember daily. Add condoms for STI protection, counsel on emergency contraception, and keep the care confidential. A pelvic exam is not required before prescribing contraception, and cervical cancer screening does not begin until age 21.

Chlamydia and gonorrhea: screen sexually active females under 25 every year with a nucleic acid amplification test (NAAT) on urine or a vaginal swab.
HIV: screen everyone at least once between 15 and 65, more often with ongoing risk.
Men who have sex with men: screen more frequently (at least yearly) for HIV, syphilis, gonorrhea, and chlamydia.
Treatment: treat gonorrhea and chlamydia together when either is suspected, and use expedited partner therapy so partners are treated too.

Eating disorders, substance use, and depression

Anorexia vs bulimia nervosa

Feature	Anorexia nervosa	Bulimia nervosa
Core behavior	Restriction with distorted body image	Binge eating with purging (vomiting, laxatives)
Weight	Low BMI	Usually normal or higher BMI
Exam	Bradycardia, hypotension, hypothermia, lanugo, amenorrhea	Knuckle calluses (Russell sign), parotid swelling, dental erosion
Labs and risks	Osteoporosis; refeeding hypophosphatemia	Hypokalemia with metabolic alkalosis
Treatment	Nutritional rehabilitation; family-based therapy	CBT plus fluoxetine

Refeeding syndrome in anorexia drops phosphate, potassium, and magnesium, risking arrhythmia and heart failure—advance calories slowly and monitor electrolytes. Admit (SAHM 2022) for heart rate below 50/min while awake, blood pressure below 90/45 mm Hg or marked orthostasis, temperature below 35.6 °C, weight below 75% of median BMI, electrolyte derangement, or arrhythmia. Avoid bupropion in eating disorders because it lowers the seizure threshold.

Substance use. CRAFFT (Car, Relax, Alone, Forget, Family/Friends, Trouble) is the validated adolescent screen; CAGE and AUDIT are adult tools. Alcohol, nicotine/vaping, and cannabis are the most commonly used substances. Respond with motivational interviewing rather than confrontation.

Depression and suicide. Screen adolescents for depression (e.g., PHQ-9A) and ask directly about suicidal thoughts—asking does not plant the idea, and suicide is a leading cause of adolescent death. Fluoxetine and escitalopram are approved for adolescent depression, but SSRIs carry a black-box warning for increased suicidality in youth, so monitor closely after starting or changing the dose.

Immunizations and injury prevention

Adolescent vaccines

Vaccine	Timing	Key point
Tdap	11–12 years	Single adolescent booster
HPV	11–12 years (may start at 9)	2 doses 6–12 months apart if started before 15; 3 doses if started at 15 or later or if immunocompromised
MenACWY	11–12 years, booster at 16	Covers serogroups A, C, W, and Y
MenB	16–18 years	Shared clinical decision
Influenza	Every year	Plus catch-up of any missed childhood vaccines

Injury prevention. Unintentional injury (motor vehicle crashes and, increasingly, drug overdose) is the leading category of adolescent death, followed by homicide and suicide; firearms are now the leading single mechanism of death in US children and adolescents, ahead of motor vehicle crashes. Counsel at every health-maintenance visit on seatbelts, helmets, safe driving (no texting or impaired driving), and firearm safety, including locked, unloaded storage.