Adolescent Development and Health 473skateboards, and all-terrain vehicles, as well as “rearms,
drowning, poisoning, sports, and home “res. The fre-
quency and extent of accidental injury is exacerbated by alco-
hol and other substance use and failure to use seat belts or
helmets, and ameliorated by nighttime curfews and manda-
tory seatbelt laws (see Neinstein, 1996c; Patel et al., 2000).
The New Morbidity
The physical results of injury-risking behavior, illegal sub-
stance use, unprotected sex, “ghting, homicide, and suicide
have been termed •the new morbidityŽ (Haggerty, 1986).
In the second half of the twentieth century, these behav-
iorally based threats to health eclipsed the previous causes
of pediatric mortality and morbidity as medical advances
eradicated many childhood diseases. Unfortunately, im-
provements in health care have not led to better health status
among American teenagers; adolescents are the only age
group in the United States whose mortality rate has actually
increased over the past 30 years (Gans, 1990). Increased
recognition of the new morbidity prompted major changes in
pediatrics.
A national survey of pediatricians conducted by the
American Academy of Pediatrics clearly indicated that they
felt inadequately trained to assess and address behavioral is-
sues. The report of this Task Force in 1978 spurred signi“cant
changes in pediatric education and the development of a new
specialty, behavioral pediatrics (American Academy of Pedi-
atrics, 1978). As part of this same national change, adolescent
medicine began a transformation from a traditional, biologi-
cally focused practice of medical care for adolescents to a
multidisciplinary approach to promoting adolescent health
(Phillips, Moscicki, Kaufman, & Moore, 1998). Funding
from private foundations and the Department of Health, Edu-
cation, and Welfare provided the “nancial support to recruit
additional pediatric faculty members from the “eld of psy-
chology, as well as to provide faculty positions for nurses,
nutritionists, and social workers. The in”ux of these profes-
sionals, while not an enormous number, signi“cantly
changed training in adolescent medicine and, especially, con-
tributed disproportionately to knowledge and dissemination
of information about adolescent health (Cromer & Stager,
2000; Phillips et al., 1998).
The Adolescent as a Patient
The adolescent is in transition, having left the world of child-
hood but not yet having achieved adult status, either develop-
mentally or legally. This fact has numerous implications for
the structure of health care for teenagers. One of the earliest
issues addressed by adolescent medicine practitioners was
the advisability of establishing an inpatient ward speci“cally
designed for teenagers rather than housing adolescents on
children•s or adult wards (McAnarney, 1992). Similarly, pri-
mary care practitioners were advised to avoid decorating
their waiting rooms and of“ces with bunny pictures and to in-
clude reading material appropriate for teenagers, possibly
also setting different times for of“ce visits by children versus
adolescents. More thorny practice issues include how and
when to see the teenager alone and with his parent(s), con“-
dentiality and its limitations, and fees.
The issue of billing illustrates problems engendered by
the adolescent•s •in-betweenŽ status. If parents are paying the
bills, to what extent is it possible to maintain con“dentiality
regarding diagnosis or the content and purpose of care? Is the
provider•s primary responsibility to the teenager or to his par-
ents? For what conditions is the teenager considered to be an
emancipated minor, legally entitling him or her to seek care
without parental knowledge or consent? If the family is not
involved, how can the adolescent pay for professional fees
and medication? The issue of payment is particularly prob-
lematic for teenagers because they almost always require
more professional time than children, whose parents typi-
cally assume responsibility for reporting symptoms, under-
standing treatment recommendations, and managing care, or
adults, who have generally learned how to be patients. For
example, consider the “nancial implications of the average
Medicaid reimbursement rate for the following services: $37
for a 30-minute counseling visit, $47 for a preventive visit,
and $18 for a hepatitis B immunization (English, Kaplan, &
Morreale, 2000). Given these dif“culties, it is hardly surpris-
ing that adolescent services often struggle “nancially and that
funding is a signi“cant barrier to good adolescent health care
(Hein, 1993).The Health Care ProviderThe onset of adolescence signals the beginning of a new rela-
tionship between the patient and health care provider, with a
host of new issues that ideally should be assessed and ad-
dressed. The American Medical Association (AMA) published
guidelines in 1994 for health screening in adolescence (Guide-
lines for Adolescent Preventive Services, or GAPS). The
GAPS recommendations suggest annual preventive visits with
additional counseling for parents twice during adolescence
and comprehensive physical examinations at least three times
between the ages of 11 and 21. For the general population,
screening is recommended to include height, weight, blood
pressure, and problem drinking and, for females, a Pap test,
chlamydia screen, and Rubella serology. Routine intervention