printable version5 questions: Ammerman on adolescents
Seth Ammerman
The Lucile Packard Children's Hospital's Teen Health Van is a mobile clinic that provides free, comprehensive primary health care services to homeless and uninsured adolescents from San Francisco to San Jose. The van, which is in its ninth year of operation, is supported through the Packard Foundation for Children's Health by grants and gifts from foundations, corporations, and individuals. Medical Center Report writer Krista Conger talked with Seth Ammerman, MD, associate clinical professor in the Department of Pediatrics in the Division of Adolescent Medicine and a member of the LPCH staff, about his work on the van.
1. Who visits the Teen Health Van?
Ammerman: We provide a medical home for adolescents who often have no other access to care. We perform more than 900 examinations each year, and our return visit rate is more than 60 percent, which is remarkably high for these youth. We see twice as many girls as boys. Many of our patients with serious illnesses such as diabetes or seizure disorders are not getting appropriate treatment or are not taking their medications. In some cases we see kids who've never had any immunizations past childhood. They also often have behavioral and mental health problems such as anxiety, depression and even sometimes psychosis. We frequently see teens with substance abuse problems or who are engaging in risky sexual behaviors. Often one patient has multiple problems, which makes treatment more complicated.
2. Do you think you're actually getting through to these kids?
Ammerman: Yes. For example, three years ago we began treating a 16-year-old girl who had dropped out of school and been living on the streets. She came in at the suggestion of a friend because she was having some trouble breathing due to untreated asthma, and she was at first very reluctant to talk about other things that were going on with her. We spent a good hour with her, talking and getting to know her, and discovered that she was having problems with headaches, was addicted to alcohol and tobacco and was engaging in some risky sexual behaviors. She was also somewhat malnourished.
She became a regular patient of ours, and over the years we were able to help her with many of her problems. We got control of her asthma and headaches and helped her cut out her risky alcohol abuse and decrease significantly her smoking. We gave her nutritional counseling that improved her diet, and our social worker helped her when we discovered she was suffering from depression. We also hooked her up with a program that helped her return to and graduate from high school. She now has a full-time job and recently won an employee-of-the-month award.
Now even though she doesn't need our services anymore, she still stops by to say hello, and at one point she referred to us as her 'Van family.' Kids like her, who we are able to help, make it all worthwhile. Most do turn their lives around. Some don't do well, though, which is just heartbreaking.
3. Preventive counseling worked for this girl, but does it work for most? After all, they're teens.
Ammerman: Counseling can be an effective way to motivate teens to change risky behaviors, as long as it's done in a non-judgmental way over time. One visit is not likely to have a big impact, but ongoing follow-up for particular issues can make a significant difference. It's important to build a trusting relationship, which often starts with a referral from friends. If a teen hears from a peer that we're cool, and there to help, they're more likely to listen. It's also important to be respectful. Teens have a really good sense of how you feel about them, even if you don't say anything. One reason why the Teen Van is so successful is that everyone, including the driver, is very teen-centered. Sometimes a teen's behavior isn't that pleasant; they can curse and be rude. We call them on it, while trying to let them know that we're not judging them as a person.
4. This sounds like it might be aggravating. Why would someone choose to work with teens all day?
Ammerman: I've always liked working with kids, and I'm fascinated by the intersection between normal adolescent development and chronic disease. It's a mix of medical, psychosocial and developmental issues occurring all in one patient, and you must deal with each of these issues to be successful. Adolescence is such a big time of change, that in my mind this is in one sense the last opportunity to really have an impact on kids before they reach adulthood.
5. What can other physicians do to ensure that teens are getting the counseling they need?
Ammerman: We use an acronym (it's getting longer all the time) called "HEADSSS" to remind us of the wide range of psychosocial and behavioral issues to discuss with teens. "H" for example, stands for home, as in "How's it going at home? How's your relationship with your parents? With your siblings? Any problems at home or worries about your home situation?" For a homeless youth, we might ask "Where are you living? Who are you living with? Do you need help getting a more stable living situation? Are there adults in your life that you can talk to or depend on?"
"E" stands for education and school issues, "A" for activities, "D" for depression and mood, "S" for sexual activity, "S" for substance abuse and "S" for safety.
This is a lot of ground to cover. Some practitioners are just too busy, some don't have the experience to address all these issues and some aren't sure about what community resources exist, if any, if a teen does need extra help. Community physicians should consider referring teen patients with particularly difficult problems to adolescent medicine specialists, who are trained to deal with a broad range of medical and psychosocial and behavioral issues.
For more information about the Teen Van program, please visit the Web site, www.adolescenthealthvan.lpch.org or email seth.ammerman@stanford.edu.