Two themes undergird the history of training in adolescent health: changes in the understanding of young people and their health care needs, and development of a holistic approach to care.
HEALTH CARE NEEDS OF ADOLESCENTS
Before World War II, adolescents had not been identified as needing any kind of special health care. But the fact that 25 percent of the 18- and 19-year-old World War II recruits failed the military physical exam made it apparent that the health of many young people was poor. Therefore, in the late 1940's, for the first time, medical experts began to focus on adolescent health needs. The continued high percentage of military recruit rejections led President John F. Kennedy to make the health of children and youth a priority. By the early 1960's, the highest levels of government were coming to view adolescent health as an area in need of special attention.
As the decade wore on, adolescent health issues assumed new prominence: Young people made their presence felt, partly through the sheer force of their numbers, but also through certain new behaviors, some of them sex-related and others drug-related. Moreover, the spirit of the 1960's and 1970's challenged traditions of all kinds, including medical traditions. Many youth demanded new ways of receiving services and refused care that they perceived as paternalistic or otherwise unsatisfactory. Sex- and drug-related concerns about adolescents took on a new dimension in the 1980's with the twin epidemics of AIDS and crack cocaine; an epidemic of violence quickly followed, and by the 1990's, an unacceptably high rate of young people were dying as a result of gunshot wounds. By the end of the 1990's, adolescent health on any number of dimensions was worse than it had been in the 1950's, and adolescents were the only age group whose mortality rate had increased in the past four decades.
THE HOLISTIC APPROACH TO CARE
Research on adolescence launched in the 1950's identified new concepts that were soon accepted. These included ideas about the importance of peer groups, the need for adolescents to achieve independence from their families, and new ideas on adolescent privacy. Such issues affected the provision of health care in several ways, but, in particular, they led to the recognition of the fact that successful health care for adolescents would need to address a myriad of psychosocial and environmental factors in the lives of young people, and would need to be delivered in a way that respected the differences between adolescents and either younger children or adults. Most adolescents who visited the first adolescent health clinic, opened in Boston in 1952 by , came there for emotional, or “mental hygiene,” reasons and to seek help with school-related issues. In recognition of the importance of psychosocial issues in adolescent care, the founders of the field emphasized the idea that effective adolescent health care required a holistic, interdisciplinary approach. This new understanding of adolescents’ needs incorporated biological, psychological, social, and environmental factors.
THE ROLE OF MCH TRAINING IN THE DEVELOPMENT OF ADOLESCENT HEALTH SERVICES
The MCH Training Program has consistently been at the forefront in supporting efforts to improve adolescent health services and training. For example, shortly after Children’s Hospital of Boston opened the nation’s first adolescent unit, the MCH program funded fellowship training for pediatricians to study adolescent health at five sites, including Boston. In 1960, the program supported the first national forum on adolescent health ever to be held, entitled the “Joint Adolescent Clinic Conference.” A subsequent program supported by the MCH Training Program supported a series of annual conferences referred to as Adolescent Seminars. These were organized by Dr. Felix Heald of Children’s Hospital in the District of Columbia, himself a graduate of the MCH Training Program in Boston. These meetings, which were attended by essentially all physicians dedicated to adolescent care, covered a wide variety of topics, including nutrition, minors’ rights, and the law. The seminars’ success demonstrated both the demand for special training and the need for it. As a result, in 1967, the program provided funding to expand or develop new adolescent programs at six sites. The grants paid for 14 physician fellowships in adolescent medicine, and these programs defined the adolescent fellowship experience.
The 1968 Adolescent Medicine Seminar led directly to the development of a new professional association devoted to adolescents, The Society for Adolescent Medicine (SAM), of which Dr. Heald was president and chair. SAM’s first meeting occurred in 1971 at that year’s Adolescent Medicine seminar. Thus, through MCH support, an organization was born that for almost three decades now has provided a forum for the exchange of information on adolescent health issues, promoted research related to adolescents, and served as an advocacy group for adolescent health needs. During the early 1970's, adolescent health advocates—many of whom the MCH Training Program had either supported in the past or were supporting at the time—continued to press for specialized training for adolescent health practitioners. For example, SAM worked to establish a core curriculum for medical students on the health care of adolescents, and adolescent health advocates participated in an AAP Task Force on Pediatric Education. The 1976 task force report concluded that the lack of training in adolescent health constituted a serious gap in health care services, despite the progress that had been made. An AAP survey undertaken as a part of the task force’s work found that 66 percent of recent pediatric residency program graduates felt inadequately trained in adolescent medicine.
At the same time, national data documented the fact that adolescents were the one age group not receiving good health care and that, in addition, young people were subject to the “new morbidities” (for example, injuries and mental and emotional disorders), which professionals received little training on how to address. In 1976, the MCH office renewed and increased its commitment to adolescent health when it funded nine new training programs.
The information from a variety of sources on the unmet needs of adolescents supported the MCH office in its decision to support these grants. Progress had been made in adolescent health training by this time; for example, about half of all pediatric departments had adolescent wards or outpatient clinics, and by 1978, 40 fellowship programs in adolescent health care existed. However, the need for health care professionals trained to serve adolescents did not abate, and the numbers of trained persons couldnot keep pace with the number of young people who needed their services. In 1990, the Office ofTechnology Assessment documented adolescents’ continuing health care problems and emphasized the ongoing need for specialized training.
The first MCH-supported adolescent health training grants—the fellowship traineeships— were physician-oriented, but the grant program established in 1976 was interdisciplinary, and the program has continued to be interdisciplinary to the present day. Currently included among trainees in the program are physicians, nurses, social workers, nutritionists, and psychologists. The adoption of an interdisciplinary method was built on the concepts proposed in the 1950's when the field came into existence, namely, the importance of a holistic approach to adolescent health. Other changes in the field of adolescent health supported this approach as well: SAM, for example, was moving away from its original physician-only membership policy to include among its members representatives from a broad mix of disciplines. As the adolescent-health training priority has developed over time, a number of challenges have arisen. For example, as adolescents with chronic illnesses began living longer, the need for trained professionals who could address their sexual behavior became apparent. Also, the number of adolescents with mental health problems appears to be increasing, but health care professionals continue to lack the skills they need to identify these problems, and health care plans’ coverage of mental health care services is frequently limited.
In addition, although adolescents’ health care needs continue to increase, the supply of persons trained in adolescent health is still not keeping up. The number of fellowship programs for physicians specializing in adolescent medicine fell from 51 in the mid-1980's to 38 in the late 1990's. Moreover, some medical schools have begun to phase out their divisions of adolescent medicine. Ironically, this may be related to the fact that in 1994, adolescent medicine achieved subspecialty status; as a result, fellowship programs became 3-year programs, which are costly. Fewer newly minted physicians are willing or financially able to make the commitment to enrolling in them. It remains to be seen what the implications of managed care will be for adolescent health care, but in general, such plans tend to discourage specialty care, and declining reimbursements from managed care organizations to pediatric academic institutions further endanger adolescent health training. On the other hand, whereas subspecialty training is declining, training in adolescent care for general pediatricians has improved somewhat. In 1997, the Residency Review Committee for Pediatrics adopted guidelines that required pediatric residents to complete a 1-month block rotation in adolescent medicine. A 1998 study found that most training programs in pediatrics now require this rotation, which was a marked improvement over the situation in the early 1980's, when only about half did so. With a decline in adolescent subspecialty training but an increase in emphasis on adolescent training among general pediatricians, concerns have been raised over who in the future will have the knowledge and skills to serve as teachers and researchers. Even now, Emans and colleagues found that only 39 percent of residency programs believe they have adequate faculty to teach adolescent medicine to pediatric residents.
Although this discussion has focused largely on physician training, social workers, nurses, nutritionists, and psychologists also receive adolescent health training, and in fact it is only through MCH Training Program grants that students in these disciplines can receive any public health training in adolescent health care. The interdisciplinary nature of the training emphasizes the key roles of these disciplines in the health care of adolescents, but, again, the number of trainees is severely limited.
In addition to training students, grantees of what is now called the Leadership Education in Adolescent Health (LEAH) program promote improvements in adolescent health care through a variety of means. The program also provides continuing education for diverse audiences and offers consultation and technical assistance to Title V programs and other groups. The number of grantees in the LEAH program has ranged from seven to nine at any given time over the history of the program; in 1999, it was seven.
MCH office support has been critical to the movement to achieve improved health care for adolescents. No other federal support has ever been provided for such training programs in adolescent health. The program’s grants have been responsible not only for helping launch training programs and for expanding their scope, but also for providing leaders in the field with opportunities to share ideas, resources, and strategies at conferences and meetings. Largely as a result of these grants, over the last 40 years or so, a dedicated group of health care professionals has been afforded the means to work together to address adolescents’ needs. However, as is evidenced by the ongoing health disparities between adolescents and other groups, the group has not yet gained sufficient strength to accomplish its goals. Much work remains to ensure that adolescents will receive the preventive services and health care to enable them to become strong, productive, and healthy adults.
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