*"It doesn't matter if the cat is black or white as long as it catches
mice."*

Deng Hsaio P'ing 1904-1997

This a page for sharing "what works" as seen in the published literature
as well as what is done at sites that care for American Indian/Alaskan
Native children. If you have any suggestions, comments or questions
please contact Steve Holve, MD, Chief Clinical Consultant in Pediatrics
at sholve@tcimic.ihs.gov

IHS Child Health Notes

June 2004

# Quote of the month

*"The young always have the same problem -- how to rebel and conform at
the same time. They have solved this by defying their parents and
copying one another.*"

Quentin Crisp

# Information of Interest

The IHS Primary Care Discussion forum recently hosted a listserv on
Adolescent Risk Behavior Screening hosted by Donna Perry, MD. The
summary is listed below along with links to the full discussion and
other websites with information on adolescent care. Twenty years ago for
American Indian/Alaska Native children the high- risk group in pediatric
care was infants with infectious diseases. Now the highest risk
pediatric age group is clearly teenagers.

ADOLESCENT RISK BEHAVIOR SCREENING

**SUMMARY OF LISTSERV DISCUSSION**

Donna R. Perry, MD, FAAP, FSAM

During the month of May 2004 the combined IHS Primary Care Discussion
Forum and the AAP Indian Health Special Interest Group listserv
discussed:

-   The presence or absence of culturally acceptable and useable
    screening tools to identify adolescent health risk behaviors

-   Some strategies to use in the office or clinic setting

-   A few issues unique to AI/AN communities

High- risk behaviors of teenagers are responsible for the leading causes
of mortality and morbidity during the adolescent years. They often are
the starting points for adult morbidity and mortality. YRBSS data from
the Navajo area and BIA schools compared to the US was an indicator that
the AI/AN youth are participating in similar and sometimes greater
reported risk taking behavior. If we want to prevent the short and long
term morbidity and mortality, we have to identify the risk behaviors and
have the resources and/or skills to intervene with best practices or
evidence based treatment.

Sounds great, very tough to do.

Trigger questionnaires, either paper or computer-based, can be helpful.
I suggested a few that are commonly used, including the GAPS from the
AMA, the CAGE or CRAFFT questions for alcohol and substance abuse, a
self esteem questionnaire, and the ACOG adolescent questions. Each has
some problems:

-   population and cultural appropriateness,

-   reading level

-   length

Tuba City shared the questionnaire they have used which is an adaptation
of the AMA's GAPS questionnaire.

Screening for resiliency at the same time as risk behaviors can help the
provider identify if and where there are strengths on which a teen can
rely. Providers rarely can 'fix' the issues which put the teen at risk,
and it is more rewarding to support positive elements of relationships
and environments if they are present.

What to do about the identified risk behaviors generated a lot of
discussion because:

-   most of our communities have limited behavioral health programs

-   drug treatment programs for youth

-   cultural support for ongoing counseling

-   school based services to address mental health concerns

-   neither the IHS or the 638 programs have enough mental health
    providers to provide the intervention

-   most primary care providers have limited skills in providing short
    term office interventions

Providing confidential care for teens, its limits, and its impact on
cultural family values concerned a number of our participants. The
discussion pointed out the need to understand how confidentiality is
viewed in each AI/AN community, how to provide care to teens with some
degree of privacy and the need for wisdom in applying guidelines for
teen care. Teens are reluctant to discuss personal or risk behaviors
when parents are present. However, family and extended family units for
many AI/AN communities define "privacy" differently than the
Euro-centric cultures around them. Unfortunately, these families may not
feel comfortable talking about these 'private' matters until the
behavior is out of control. Providing separate time for the parent and
the teen has been used with some success, but doesn't fit in most busy
clinics. Providers also have to judge when the behavior constitutes a
significant risk to life and therefore confidentiality must be breeched
for the patient's safety.

Confidentiality also has limits defined by state laws on what medical
information parents can access, and thereby thwart the efforts to
provide confidential care while attempting to keep parents involved in
their teens' life. Options for resolving the conflict included:

-   confidential files with information not put in the primary chart
    until teen is an "adult"

-   shredding the questionnaires to avoid breaching confidentiality

-   Use of a variety of abbreviations that would be harder for parents
    to decipher

-   Setting up the 'rules' of the teen care to include parent and teen
    acknowledgment of the provision of confidential care and use of
    secondary records.

-   Encouraging all patients to discuss risk behaviors with parents

We have some challenges. I would suggest we consider more adolescent
topics at our local, regional and national meetings. This would be a
place for dialog, increasing our skills, and planning more standardized
approaches given our restraints on resources. We need to share programs
that work in our communities. We can develop outcomes measures that will
help us plan for improving care in our communities. A recent supplement
to the journal Pediatrics discussed how to measure effectiveness of
adolescent health care. How can we apply that to our communities? For
those who have school based or school linked clinics, IHS headquarters
is developing a discussion and work group in which we can participate.
We can also commiserate in our struggle to provide increasingly
accessible teen health care.

**References**

A January 2004 supplement to the journal *Pediatric*s 113(1) is focused
on measuring the quality of children\'s health care as a key step in
quality improvement.

Extensive quality problems have been documented across all sectors of
health services for children and adolescents. For example, problems
persist in asthma care, well-child and adolescent care, childhood
immunization rates, and sexually transmitted disease screening for
adolescents. Many other problems in children\'s health care delivery are
not being adequately measured and monitored.

[[http://www.ahrq.gov/research/apr04/0404RA15.htm#head1]{.underline}](http://www.ahrq.gov/research/apr04/0404RA15.htm#head1)

Patient Education handouts on Reproductive Health

[[www.contraceptiononline.com]{.underline}](http://www.contraceptiononline.com/)

Updated consent and confidentiality and other adolescent health care
related policy

[[www.guttmacher.org]{.underline}](http://www.guttmacher.org/)

School based health care and good evaluation of care suggestions and
outcomes options

[[www.nasbhc.org]{.underline}](http://www.nasbhc.org/) .

Primary Care Discussion Forum, IHS

The original question on this topic and the complete discussion are
available here:

<http://www.ihs.gov/MedicalPrograms/MCH/M/PCdiscForum.asp#mod>

Other Primary Care Forum discussions are here:

<http://www.ihs.gov/MedicalPrograms/MCH/M/PCdiscForum.asp>

To subscribe to this listserv, go here

<http://www.ihs.gov/generalweb/helpcenter/helpdesk/index.cfm?module=listserv&option=subscribe&newquery=1>

**Recent literature on American Indian/Alaskan Native Health**

Smoking-attributable mortality among British Columbia\'s first nations
populations.\
Int J Circumpolar Health. 2004 Mar;63(1):81-92.
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15139243&itool=iconabstr>

-   First Nations adults have higher rates of smoking than the general
    Canadian population and higher smoking associated mortality. The
    number of infant deaths partially attributable to smoking via SIDS
    was substantial The authors estimate that up to 8% of First Nations
    infant deaths could be prevented if smoking were eliminated. What
    successful smoking cessation programs can we use for AI/AN
    adolescents?

American Indian substance use: the hazards for substance use initiation
and progression for adolescents aged 14 to 20 years.\
J Am Acad Child Adolesc Psychiatry. 2004 Mar;43(3):316-24.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15076265&itool=iconabstr

-   The age of risk for substance use starts at age 14 years and peaks
    at age 18 years. Adolescents who initiated substance abuse with
    inhalants or marijuana were more likely to progress to other illicit
    substances than adolescents who initiated substance use with alcohol
    only

# Meetings of Interest for Child Health

## [Adolescent Health Issues in Indian Health]{.underline}

School Based Health and Adolescent Issues: Donna Perry, Susie John, and
others

...plus Sexually Transmitted Diseases, Contraception, and more....

These are all available at the Biennial IHS Tribal and Urban (ITU)
Meeting on Women's Health and Maternity Care, August 4-6, 2004 in
Albuquerque, NM.

<http://www.ihs.gov/MedicalPrograms/MCH/M/CN01.cfm#August2004>

Or contact Neil Murphy, MD for info at [nmurphy@anmc.org]{.underline}