Adolescents go through a dynamic and complex maturation process. The changes in their bodies, the emergence of new cognitive abilities and their new role in society are determinants of the questioning of the values ​​of the adults around them. For this reason, they are willing to try out new experiences, testing attitudes and situations that may threaten their current and future health, such as accidents, unplanned pregnancies, sexually transmitted diseases, drug use and eating disorders.

Although adolescent care programs have been implemented for almost three decades, significant changes have been observed in the morbidity and mortality profile of this population group, with an increase in problems that could be avoided by health promotion and disease prevention measures.

Given this scenario, the viable and coherent alternative is to change the emphasis of health services aimed at this clientele. Health professionals should include preventive measures as a fundamental component of their care practice, instead of strictly biological and curative care. The aim of these clients’ consultations in health services should be not only to prevent problems, but also to diagnose, monitor, treat and rehabilitate their health problems.

RECEPTION IN HEALTH SERVICES

Regardless of the reason why the adolescent/young person seeks health services, each visit offers the professional the opportunity to detect, reflect on and help resolve issues other than the main reason for the consultation. The interview is an exercise in interpersonal communication that encompasses verbal and non-verbal communication. In addition to words, attention should be paid to the client’s emotions, gestures, tone of voice and facial expression.

The reception in services should be cordial and understanding, so that adolescents feel valued and at ease. A hostile reception, which imposes a series of demands, may drive them away, losing the opportunity to adhere to the service. Due to the characteristics of this stage of development, they often have difficulty respecting the times and dates of appointments, which means that the service must create more flexible organizational mechanisms.

ADEQUACY OF PHYSICAL SPACE

In general, adolescents prefer a waiting room exclusively for their use during appointment times. This space must be, above all, welcoming, pleasant and comfortable for clients and their companions. This presupposes spacious, well-ventilated and clean spaces, suitable for the development of group activities that can have multiple objectives, such as presentation of the service, integration with the team, health education and access to educational materials (books, magazines, videos, computer programs).

The office door should remain closed during the visit to prevent interruptions, and the room should have enough space to accommodate furniture that allows the adolescent and his/her family to be interviewed. The examination room should be separate from the interview space, ensuring privacy during the physical examination.

PREVENTIVE ACTIONS AS COMPONENTS OF THE CONSULTATION

According to the American Medical Association (1997), routine visits by adolescents and young people and their families to health services are opportunities to:

1) reinforce health promotion messages;

2) identify adolescents and young people who are subject to risk behaviors or who are in the early stages of physical and/or emotional disorders;

3) promote adequate immunization;

4) develop relationships that favor open dialogue about health issues.

All adolescents and young people should receive information about their physical growth and psychosocial and sexual development. The importance of becoming active participants in decisions related to their health care should be emphasized.

When approaching traffic accident prevention, young people should be advised not to drive under the influence of alcohol or psychoactive substances, and to always wear a seatbelt.

The benefits of regular physical activity should be emphasized, including its role in promoting physical and mental health and socialization, emphasizing the need for adequate physical conditioning before exercising or practicing sports.

Adolescents should receive information about oral health care, adequate nutritional habits, including the benefits of a healthy diet and maintaining an ideal weight.

Consultations are privileged moments for counseling on responsible and safe sexual practices. The use of condoms should be emphasized as an essential practice in preventing sexually transmitted diseases and HIV infection. This is also an opportunity to clarify doubts, to talk about the importance of affection and pleasure in romantic relationships and to warn about situations of risk for abuse and/or sexual exploitation.

According to blood pressure control protocols, all adolescents and young people should have their blood pressure measured annually. Those with a family history of hypercholesterolemia should be investigated with serum total cholesterol levels, as well as adolescents who present multiple risk factors for cardiovascular disease (smokers, hypertensive, obese, diabetic or those who consume a diet rich in saturated fats and cholesterol).

The use of cigarettes, alcohol/drugs and anabolic steroids should be investigated during consultations so that preventive measures can be taken and, if necessary, referrals can be made. Other important issues are difficulties at school and at work. This approach should be developed creatively and should not be inquisitive.

Common sense will determine the best way to relate the numerous issues listed here, and it should be clear that there is no obligation to cover all the topics in a single session.

The use of educational materials is a great help in developing preventive actions. It is important to emphasize, however, the importance of adapting them to local realities in order to achieve the proposed objectives.

INTERVIEW/CHARACTERISTICS OF THE HEALTH PROFESSIONAL

The interview should not follow rigid and preconceived formats, since this involves a heterogeneous group of individuals with their own characteristics. Specifically in relation to this population group, in addition to the differences of each individual, it is important to highlight those related to the age range of younger or older adolescents, gender, family environment, adolescents who live with their families or not, education level, among many others.

There is no specific profile of health professionals to care for adolescents/young people. Some characteristics, however, should be highlighted as very important:

• be available to assist the patient and their family without being authoritarian;
• be attentive to the teenager and be able to ask questions that help the conversation, seeking to understand their perspective;
• not be prejudiced, avoiding making judgments, especially when it comes to approaching certain topics such as sexuality and drug use;
• continually seek technical updates in the specific area of ​​professional activity.

CONSULTATION DYNAMICS

Ideally, there should be two moments during the consultation: the adolescent alone and the adolescent with family members/companions. Interviewing the adolescent alone offers the opportunity to encourage him/her to express his/her perception of what is happening to him/her, and gradually become responsible for his/her own health and the conduct of his/her life. In addition, this space allows the adolescent/young person to address some confidential aspects that are worrying him/her. The interview with the family is essential for understanding the dynamics and structure of the family and for clarifying important details.

The health professional should not be limited to obtaining information about the main reason that led the adolescent to the health service, but rather get to know the client as a whole. This includes assessing how the adolescent is feeling in relation to the physical and emotional changes he/she is going through, his/her relationship with his/her family and peers, how he/she uses his/her leisure time, his/her previous experiences in the health service, expectations regarding the current care and his/her plans for the future.

It is important to note that communication barriers may arise during the anamnesis. In addition to recognizing and trying to overcome them, the professional should seek to explore the reasons that determine this behavior. Another situation that should be observed is the possibility of the health professional feeling seduced by the patient and vice versa. The professional must be clear about his or her role and avoid other types of relationships that are not strictly technical. One alternative to overcome these difficulties is to present the situation to the team and discuss solutions or referrals. At this time, other options may arise in the management of the case, including the possibility of referring to another professional.

PHYSICAL EXAMINATION

The physical examination is the procedure that presents the highest degree of difficulty for the poorly qualified health professional. This is due to the fact that, in the training of doctors or nurses, there are no disciplines that develop this skill taking into account the discomfort caused to the professional by the need to manipulate the body of an individual in full physical and sexual development and vitality. Given these difficulties, many professionals choose not to perform a complete physical examination, resulting in missed opportunities in the diagnosis of health problems(5).

An alternative for professionals in training, or for those who do not feel comfortable performing a physical examination, is for another professional from the team to participate as an observer during this part of the consultation. If the adolescent appears embarrassed about the physical examination, or if there is any indication of seduction on either side, it is also recommended that a member of the team be present during the procedure.

Explaining in advance what the physical examination is and how it will be performed is important to reassure the adolescent and reduce their fears. In addition to anxiety about handling their body, adolescents are often anxious about the prospect of abnormal findings. Therefore, it is desirable for the professional to respond to this expectation, revealing what is normal during the evaluation.

The physical examination should be an opportunity for the professional to address educational topics with the client regarding their body, such as by instructing them on self-examination of their breasts and testicles. Guidance on hygiene habits is also an important aspect to be addressed at this time.

Whenever possible, a complete physical examination should be performed at the first appointment, including visual screening , dental caries screening, careful observation of the skin and mucous membranes, examination of the spine and genital tract, among others.

During the clinical appointment, some instruments are essential for recording the data obtained during the consultation. Given the peculiarities of a maturing body, the measurement of anthropometric measurements and their arrangement in graphs (National Center for Health Statistics – NCHS), in addition to pubertal staging (Tanner criteria), are essential. Data related to the anamnesis and physical examination should be recorded on appropriate forms adopted by the services.

ADOLESCENT COMPUTER SYSTEM

The Adolescent Computer System[1] (SIA) was created to systematize adolescent care with the support of the Pan American Health Organization (PAHO) and the Latin American Center for Perinatology and Human Development (CLAP). The main objective of this system is to improve the quality of comprehensive care for adolescents in health services. In addition, it aims to promote epidemiological knowledge among the user population.

The SIA consists of forms for recording data on history, physical examination and clinical evolution. This system has a computer program that facilitates local processing of information. In cases of care for pregnant adolescents, the perinatal clinical history should be used.

A complementary reproductive health form was recently included. Data can be recorded by different team members, according to information obtained during the client’s visit to the service. To achieve this, there needs to be good integration between professionals and confidentiality in the handling of medical records.

THE HEALTH TEAM

Comprehensive health care for adolescents and young people requires the participation of professionals from different disciplines, who must interact through an interdisciplinary approach. Team care focuses on the problem, avoiding fragmented views from only each specialty and/or discipline.

The main characteristic of interdisciplinary work is the provision of services to the same population through interconsultation or referral. This work, even with good interaction between team members, is carried out independently, sometimes in different locations.

In multidisciplinary team work, professionals from different disciplines interact to provide care to the client. This integration is achieved through joint discussions, in which decisions are shared and made from different perspectives, resulting in a more effective therapeutic proposal.

LEVELS OF CARE

According to the degree of complexity, health services are classified into three levels: primary, secondary and tertiary. This hierarchy is important for the functioning of a service network that uses a referral and counter-referral system. For greater effectiveness, the client must move between the levels of care without losing the continuity of their care, which is guaranteed through integration between the three levels. The health service network must be organized into levels of increasing complexity, with adequate coordination between them.

RETHINKING A NEW PARADIGM

The team can take advantage of the moment of consultation with adolescents and young people to exchange information and understand the new trends of the target population. It should be borne in mind that, as this is a contingent in constant change, it is necessary to be aware of what is in transition and the new customs.

Another issue that services often avoid adopting is the client’s participation in the care provided. With this age group, distancing may mean little understanding of the rules and conduct, decreasing adherence to the service and low cooperation in planned activities.