Pamela J. Burke

Pregnancy in Adolescence

Pregnancy in adolescence is a complex experience that affects youth, their offspring, and their families. In addition to personal costs, there is both an economic and societal impact from adolescent pregnancy. Although the adolescent birthrates have decreased since 1991 and social norms have fostered an increased tolerance for early childbearing, adolescent pregnancy continues to be a public health challenge. Research on brain development and protective factors informs program development as we design interventions that factor in the social determinants of health and endeavor to eliminate health disparities. Access to reliable contraceptive methods such as long-acting reversible contraception (intrauterine device and hormonal implant) is but one means for reducing unintended or mistimed pregnancy. More broadly, adolescents need to learn how to develop healthy relationships and prevent intimate partner violence. Safe passage through adolescence demands that we work collaboratively to build systems of care that foster positive youth development.

Adolescent substance use: brief interventions by emergency care providers.

Abstract: Use of tobacco, alcohol and other drugs plays a major role in adolescent morbidity and mortality. When under the influence of alcohol or other drugs, adolescents are at increased risk for injuries, unprotected sex, or interpersonal violence. Alcohol and other drugs are major factors in adolescent deaths, contributing to motor vehicle crashes, homicides, and suicides. Adolescents tend to have shorter substance use histories therefore they often experience emergency/acute care health treatment resulting from substance use related trauma and/or overdose. Substance use screening of adolescents who present to an Emergency Department (ED) is vitally important. The CRAFFT is a valid and reliable screening tool that was developed for use with adolescents. If an adolescent screens positive, then the next step is to determine their stage of use and readiness for change in preparation for doing a brief intervention. Helping patients to recognize the potential relation between their substance use and health related consequences, may motivate them to decrease their use for harm reduction. Motivational interviewing is an effective, evidence-based approach to helping people change their high risk behavior.

Real-time, contextual intervention using mobile technology to reduce marijuana use among youth: A pilot study

We evaluated the feasibility, acceptability, and potential efficacy of MOMENT, an intervention to reduce youth marijuana use that combines brief motivational enhancement therapy with mobile self-monitoring and responsive messaging. At baseline, primary care patients ages 15-24 who used marijuana frequently (at least 3 times per week) completed a recall assessment, then 1 week of mobile momentary and daily reports on use-related factors. For the intervention, youth participated in two motivational enhancement therapy sessions, during which they identified their top-3 social and emotional triggers for use and discussed healthy ways to manage them. They then completed two weeks of mobile reports. Upon reporting a top-3 trigger for use, desire to use, or recent use, they received a message supporting self-efficacy and prompting consideration of coping strategies. Generalized estimating equations examined changes in momentary-, daily-, and individual-level measures on 3-month recall and mobile assessments. Twenty-seven youth (M=19.2 years, 70% female) enrolled; there were 377-677 momentary and 50-106 daily reports per study phase. Participants reported reading the messages and finding them motivating, being comfortable with participation, and not experiencing the study as burdensome. Although proportion of momentary reports of being in a top-3 trigger context did not change (36%-43%), marijuana desire in a top-3 trigger context and marijuana use after top-3 trigger exposure decreased over the study (p<.0001 and p=.03, respectively). Daily- and individual-level measures showed similar, non-significant, improvements. The MOMENT intervention appears feasible, well-accepted, and potentially efficacious for youth who use marijuana frequently.

Firm foundations: strength-based approaches to adolescent chronic disease

Purpose of review Chronic disease management is an increasingly important aspect of caring for adolescents. Strength-based approaches hold tremendous promise in the face of current challenges. Recent clinical innovations and research findings that provide evidence of the efficacy of strength-based approaches and represent a fundamental evolution in the clinical approach to adolescent care are reviewed. Recent findings Resilience and positive youth development are important conceptual frameworks in adolescent health, which have recently been brought into the clinic setting in the form of the strength-based approach to care. In parallel, studies of motivational interviewing, a strength-based technique with known efficacy in behavioral change, have begun to demonstrate clinical efficacy in various adolescent chronic disease applications. The coupling of a strength-based approach with motivational interviewing holds promise for not only modifying end behaviors but also helping teens to develop strengths and assets to promote general well-being and healthy development. This distinction in goals might be described as the difference between being transiently problem-free and durably problem-resistant. Summary Strength-based approaches, including motivational interviewing, hold tremendous potential for equipping providers to address the rapidly increasing burden of chronic disease in adolescents.

Adolescent pregnancy diagnosis and outcomes: a six-year clinical sample.

STUDY OBJECTIVE To explore pregnancy diagnosis, outcome choice, and time to referral appointment for adolescents. DESIGN A descriptive study using retrospective chart review and clinical logs of all positive pregnancy tests between January 2000 and December 2005. SETTING Adolescent clinic in a hospital-based academic center. PARTICIPANTS 625 pregnant teens were identified. Thirteen teens (2%) were lost to follow-up. Exclusion criteria included teens with advanced pregnancy, 22 weeks gestation or older at initial pregnancy diagnosis (n=11). INTERVENTIONS All pregnant teens participated in a multidisciplinary tracking program. MAIN OUTCOME MEASURES Outcome choice and time interval to prenatal or termination appointment. RESULTS The 601 pregnant teens had a mean age of 18.2 years with a range of 13 to 23 years. Pregnancy outcomes indicate 48.2% (N=290) opted to continue their pregnancy and entered prenatal care, 45% (N=275) chose to terminate, and 6% (N=36) experienced a miscarriage. Adolescents who continued their pregnancy presented with a mean gestational age of 7.98 weeks versus 7.20 weeks for teens choosing to terminate (P < or = 0.001). They also had a significantly longer time interval to their referral site, averaging 24 days until a prenatal appointment, compared to 17 days for a termination (P < or = 0.05). CONCLUSION Over the six-year study period, the number of adolescent pregnancies diagnosed within this clinical site remained constant. Adolescents who chose to continue their pregnancy were more likely to present later for diagnosis and experienced a longer wait time to their referral appointment for prenatal care. Pregnant adolescents may delay entry into timely reproductive health services.

Teen pregnancy prevention on a LARC: an update on long-acting reversible contraception for the primary care provider.

Purpose of review This update will highlight recent research and recommendations on long-acting reversible contraception (LARC) in the teen population, in order to make primary care providers more comfortable counseling on these methods in the medical home. LARC methods, which include intrauterine devices (IUDs) and subdermal hormonal implants, are used by only a small minority of sexually active teens, despite their endorsement by professional organizations as effective and well tolerated birth control options in this population. Recent findings Recent studies show a lack of knowledge about LARC methods among young women, as well as persistent misconceptions among providers regarding who is eligible for LARC use. Existing trials of small numbers of adolescents generally show enthusiasm for its use among teens who are educated about LARC, high satisfaction rates among users of subdermal implants and IUDs, as well as varying pregnancy and continuation rates. Summary The existing research on LARC shows promise for these methods in the teen population. However, larger trials are needed to establish accurate data on satisfaction, continuation, and failure rates, as well as to explore other barriers to use. Medical home providers should stay informed of research on LARC in order to improve contraceptive counseling to young women.

“Counselor in Your Pocket”: Youth and Provider Perspectives on a Mobile Motivational Intervention for Marijuana Use

Previous interventions for marijuana use have been administered out of the real-life contexts in which use occurs. In 2010, we interviewed youth aged 15–24 years who use marijuana frequently (n = 8) and providers who treat them (n = 6) on the acceptability and utility of a mobile intervention involving momentary self-monitoring of use-related contexts and responsive motivational messaging following clinic-based brief motivational enhancement therapy. Thematic analysis was used to examine youth and provider perspectives on the mobile intervention. Results suggest that mobile technology is a promising tool for brief interventions to reduce youth marijuana use and warrants further development.

Early pregnancy in adolescents: diagnosis, assessment, options counseling, and referral.

Health care providers are faced with many challenges when working with adolescents. Vague symptoms, unreliable menstrual history, and adolescent reluctance to disclose sexual activity present challenges to early diagnosis. When pregnancy is suspected, clinicians need skills for accurate diagnosis, conducting comprehensive assessments, and providing options counseling. Complexities of providing confidential care while balancing the needs of the adolescent and family may deter some clinicians. A clinical case scenario illustrates important elements of care. Through sharing lessons learned from 10 years of working in a Pregnancy Follow-up Clinic, the authors hope to empower other clinicians as they care for adolescents during this critical time.

Acute abdomen in infants of adolescent mothers: diagnostic challenges.

Caring for children of adolescent parents presents unique challenges. Because adolescent parents may lack parenting skills and knowledge of medical terminology, symptoms of life-threatening illnesses may be misinterpreted. We present two cases of unexpected acute abdomen in young infants with adolescent mothers. The first case involves midgut volvulus, which was discovered during a routine newborn visit. The second case, involving pyloric stenosis, presented a clinical management challenge when the adolescent mother refused diagnostic studies.

Intensive behavioral treatment weight loss program in an adult primary care practice

Background and purpose:To evaluate a nurse practitioner (NP) led intensive behavioral treatment program for obesity implemented in an adult primary care practice. Methods:The outcome variables for this study included weight loss as well as patient and provider ratings about program satisfaction, feasibility, and acceptability. Data sources were the patient medical records, patient satisfaction surveys, provider satisfaction surveys, and a provider focus group. Thirty‐six eligible patients completed the program. Conclusions:The program was feasible and effective with statistically significant weight loss (mean weight loss 6.7 lbs after four visits and 10.7 lbs at 12 weeks) and clinically significant with 39% of patients losing 5% or more of body weight at 12 weeks, with a high degree of acceptance. Implications for practice:Obesity is a national epidemic with significant health and economic consequences. The Centers for Medicare and Medicaid Services recognizes intensive behavioral therapy for obesity treatment in primary care and the U.S. Preventive Services Task Force established evidenced‐based program criteria. However targeted interventions to treat obesity are largely lacking in primary care. NPs with a focus on patient‐centered and evidence‐based care are well positioned to lead intensive behavioral therapy initiatives for obesity treatment.