474 Adolescent Health
includes immunizations, chemoprophylaxis (multivitamin
with folic acid for females), and counseling regarding injury
prevention, substance use, sexual behavior, diet and exercise,
and dental health. Additional interventions are suggested for a
variety of high-risk populations.
Given the content of much of the GAPS, it is obvious
that the care provider must be able to establish a trusting
and credible relationship with the teenager if assessment and
counseling are to be at all effective. Adolescent providers
thus have to not only learn the nature of health risks and
potential risk-reduction strategies, but also acquire skills in
interviewing, establishing rapport, and recommending be-
havioral changes. Textbooks in adolescent medicine, there-
fore, include a long list of tips for interacting with teenagers
and speci“c techniques to enhance the accuracy of informa-
tion they receive about illicit or illegal behavior (for example,
see Neinstein, 1996a).
Physicians do have some inherent advantages in this
process. They have literally seen the teenager naked and can
begin to establish their credibility and usefulness by reassur-
ing teenagers that their physical development is progressing
normally (or explain normal variations) and probe for com-
mon concerns in this area. Skilled physicians can build on the
unique nature of their relationship with a teenager in a way
that most mental health providers cannot.
It is especially important that all clinicians who treat ado-
lescents develop knowledge and skills regarding behavior
and development because the majority of American teenagers
will receive only screening and counseling, if at all, from a
primary care provider rather than from a mental health pro-
fessional or an adolescent medicine specialist (Silber, 1983).
The ability to detect, address, and potentially refer behavioral
problems is thus a key component of primary care. Yet, there
are consistent reports that pediatricians fail to detect psy-
chopathology, identifying, at most half of their patients with
mental health needs (e.g., Costello et al., 1988). Unfortu-
nately, current training for primary care providers falls short
in adolescent health care and may fare even worse in the
future as managed care weakens the “nancial stability of ado-
lescent divisions in teaching hospitals.
Compliance with Medical Regimens
Adolescence can signal a new era of noncompliance, even
with health routines that have been well-established in child-
hood. While noncompliance is certainly a problem for all age
groups and for a variety of acute and chronic conditions, it
has been of particular concern in chronic diseases such as di-
abetes, asthma, and juvenile rheumatoid arthritis because of
the potential for signi“cant and irreversible consequences. As
a corollary, evidence regarding diabetes suggests that inten-
sive management yields even better short-term effects and re-
duces long-term complications beyond those considered to
be the norm with conventional diabetes management (see
Ruggiero & Javorsky, 1999).
Considerable evidence suggests that adolescence is asso-
ciated with poorer compliance than childhood (Manne,
1998). For example, compared with children, diabetics ages
16 to 19 years administer their injections less regularly, exer-
cise less frequently, eat too few carbohydrates and too many
fats, eat less frequently, and test their glucose levels less
often (Delameter et al., 1989; Johnson, Freund, Silverstein,
Hansen, & Malone, 1990). The average age when children
“rst show a pattern of serious and persistent noncompliance
with diabetes management is 14.8 years (Kovacs, Goldston,
Obrosky, & Iyengar, 1992). Noncompliance is such a com-
mon problem with adolescents that it has been suggested
that adolescence per se is a contraindication for receipt of
organ transplantation (see discussion in Stuber & Canning,
1998).
Age differences in compliance vary as a function of the
treatment regimen under study (e.g., very young children
experience more problems with oral medications; Phipps &
DeCuir-Whalley, 1990). Adolescent noncompliance appears
most likely when the regimen is related to independence (ei-
ther rebelling against parental nagging or re”ecting reduced
parental supervision), undesirable side effects (e.g., cosmetic
side effects of steroids), or the need for peer conformity.
Some of these challenges are most evident with diabetes be-
cause adherence requires eating foods different from what
their peers eat and at different times from their peers, refrain-
ing from drinking alcohol, and giving oneself injections
(which can be readily misinterpreted by both peers and adults
as signi“cant drug abuse). It is no wonder, then, that
some teenagers try to hide their disease status (Johnson,
Silverstein, Rosenbloom, Carter, & Cunningham, 1986).
Finally, pubertal changes per se may exacerbate problems
with metabolic control during adolescence (see Ruggiero &
Javorsky, 1999), further complicating good management.
Relatively little systematic intervention has speci“cally
targeted adolescent noncompliance with disease manage-
ment. Three studies of social skill training (with peers and/or
parents) reported mixed, albeit promising, results with dia-
betic adolescents, as did one study of family interventions, a
study of anxiety management training, and a single-case
study of biofeedback training (see Manne, 1998). Most other
chronic-disease interventions have focused on children or a
mixed group of adolescents and children. There have also
been many and varied interventions with adolescents that
have targeted noncompliance with regimens such as dental