 |
|
Adolescent Patients—Healthy or Hurting?
Missed Opportunities to Screen for Suicide Risk in the Primary Care Setting
Diane L. Frankenfield, DrPH;
Penelope M. Keyl, PhD ;
Andrea Gielen, ScD;
Lawrence S. Wissow, MD;
Lisa Werthamer, MSW, ScD;
Susan P. Baker, MPH
Arch Pediatr Adolesc Med. 2000;154:162-168.
ABSTRACT
| |
Context Adolescent suicide rates have increased dramatically in recent decades. Suicide is the third leading cause of mortality among persons aged 10 to 19 years. Several official guidelines recommend screening for suicidal behavior in the primary care setting.
Objectives To determine the prevalence of adolescent suicidal behavior known to primary care providers and to determine the knowledge, attitudes, and practice of primary care physicians in Maryland regarding screening for risk factors for adolescent suicide.
Design Cross-sectional study using mailed survey.
Setting Maryland from May to July 1995.
Participants All pediatrician (n = 816) and family physician (n = 592) members of the state chapter of the American Academy of Pediatrics and the American Academy of Family Physicians, respectively, who were actively providing ambulatory care.
Main Outcome Measures Adolescent suicidal behavior known to primary care providers and predictors of routine screening for risk factors for adolescent suicide.
Results The response rate was 66%. Three hundred twenty-eight physicians (47%) reported that 1 or more adolescent patients attempted suicide in the previous year, but only 158 (23%) either frequently or always screened adolescent patients for suicide risk factors. Significant factors correlating with routine screening for suicide risk factors included frequently or always counseling about the safer storage of firearms in the home (odds ratio [OR], 5.3; 95% confidence interval [CI], 2.8-10.2); agreeing or strongly agreeing that they were sufficiently trained and knew how to screen for risk factors (OR, 3.2; 95% CI, 1.7-6.3); agreeing or strongly agreeing that they had enough time during the well visit to screen for mental health problems (OR, 2.9; 95% CI, 1.6-5.3); frequently or always counseling about child passenger safety (OR, 2.7; 95% CI, 1.6-4.7); spending more than 5 minutes in anticipatory guidance during the well visit (OR, 2.7; 95% CI, 1.5-4.6); practicing in an urban setting (OR, 2.3; 95% CI, 1.2-4.7); agreeing or strongly agreeing that physicians can be effective in preventing adolescent suicide and that what they do during an office visit may help prevent adolescent suicide (OR, 2.0; 95% CI, 1.2-3.4); and female sex (OR, 1.9; 95% CI, 1.1-3.2).
Conclusions Despite the substantial proportion of primary care providers who encountered suicidal adolescent patients, most providers still do not routinely screen their patients for suicidality or associated risk factors. More training is needed and desired by the survey respondents. Patient confidentiality issues must be addressed. Development and widespread use of a short, easily administered, reliable, and valid screening tool are recommended to help busy clinicians obtain more complete information during all visits.
INTRODUCTION
VIOLENT OR unnatural death is the primary cause of mortality for adolescents in the United States. Each year, more than 2000 people between the ages of 10 and 19 years complete suicide in this country.1 Nationally and in Maryland, suicide is the third leading cause of death in this age group, surpassed only by motor vehicle crashes and homicide fatalities.1 Completed suicide rates for adolescents have risen dramatically in recent decades,1-2 causing the US Department of Health and Human Services to set a national health objective for the year 2000 to reduce the suicide rate among adolescents aged 15 to 19 years by 25%.3
Completed suicide represents only the tip of this public health iceberg. The most recent Youth Risk Behavior Surveillance System survey4 found that during the 12 months prior to the survey, 20% of students in grades 9 through 12 had seriously considered attempting suicide, 16% had made a specific plan to attempt suicide, 8% had actually attempted, and 2.6% had made a suicide attempt requiring medical attention.
Almost all of the increase in the suicide rate may be attributed to the increase in deaths by firearms during the 1960s through the 1980s.5 The Centers for Disease Control and Prevention have attributed 81% of the increase in the suicide rate from 1980 to 1992 among 15- to 19-year-olds to firearm-related suicides.3 In 1992, firearm-related suicides accounted for 57% and 68% of all suicides in the 10- to 14-year-old and 15- to 19-year-old age groups, respectively.6
Primary care providers are in a unique position to help prevent suicide in adolescents. More than 70% of adolescents see a physician at least once each year, and more than 50% visited a physician for routine health care during the previous year.7-9
Both adolescents and parents are receptive to and desire discussion of psychosocial problems with their primary care provider,10-12 yet several investigators have demonstrated that primary care providers do not routinely screen children or adolescents for psychosocial problems and that youth with emotional disorders are underidentified.13-16 Barriers to screening for psychosocial problems cited by primary care providers include environmental factors such as time constraints,17-20 insufficient reimbursement,17 inadequate referral services,17 lack of reminder or prompting mechanisms in the office setting,21-24 and lack of clearly defined and noncontroversial guidelines.17 Physician factors include inadequate training,17, 19, 22, 25-28 reluctance to discuss sensitive issues,17 and ineffective communication skills.29-32 Patient factors include reluctance to bring up the topic33 and concern about breaches of confidentiality.34-39
This study was undertaken to determine the proportion of primary care providers encountering the attempted or completed suicide of an adolescent (defined for this study as 10 to 19 years old) patient, identify the prevalence of screening for suicide risk factors, and identify predictors of screening to target educational efforts. Pediatricians and family physicians composed the primary care physician group for this study, as the literature indicates most adolescents visit a practitioner in one of these specialties for their primary care.40-41
MATERIALS AND METHODS
SAMPLE AND DATA COLLECTIONS
In May 1995, a questionnaire was mailed to all currently practicing pediatricians (n = 816) and family physicians (n = 592) on the mailing list of the Maryland chapters of the American Academy of Pediatrics and the American Academy of Family Physicians, respectively. The total design method of Dillman42 was used to format the instrument and develop the data-collection protocol. The questionnaire was pilot-tested in a cognitive-iterative manner.43 Confidentiality of responses for both pilot and study participants was assured. Three mailings were conducted from May through July 1995, with only the nonresponders receiving the second and/or third mailing. Analysis was restricted to primary care physicians currently providing ambulatory care.
ANALYSIS
The dependent variable (routine screening for selected risk factors for adolescent suicide) was constructed by adding the scores of the individual items that constituted this overall construct to create one overall screening score. Screening practice was defined in the questionnaire as "either through your clinical assessment, or by the use of a questionnaire completed by the patient or the parent(s), or a combination of these methods." The items contributing to this score included screening for depression, prior suicide attempt(s), alcohol use, other substance use, history of physical abuse, and history of sexual abuse. The responses to these items ranged from 1 to 5 on a 5-point Likert scale (never, 1, to always, 5). The overall screening score was then categorized into tertiles. The respondents in the highest tertile were defined as routine screeners (primarily with responses of frequently or always screens); they were compared with those responders in the lowest tertile (primarily with responses of never or infrequently screens).
The independent variables were categorized as physician characteristics, practice characteristics, risk factors for adolescent suicide, barriers to intervention, injury prevention counseling practices, and prevalence of adolescent patient suicidal behavior (Table 1).
|
|
|
|
Table 1. Independent Variables Examined*
|
|
|
The items that composed the physician's reported frequency of counseling about injury prevention, perception of importance of risk factors, and perception of barriers to intervention were submitted to factor analytic techniques. Any item not significantly loading onto a factor was retained as an individual item for subsequent logistic regression analysis.
The independent variables that were significantly (P<.01 because of the multiple comparisons being assessed)44 associated with screening in the bivariate analyses or that were considered conceptually important were introduced into a logistic regression model.45
The collected data were entered into a computerized data entry software package, EpiInfo, version 6.1,46 and analyzed using SPSS for Windows, version 6.1.47
RESULTS
RESPONDENTS
Six hundred ninety-three completed surveys were returned by 1054 eligible respondents, for a response rate of 66%, a rate comparable with or greater than that reported by others for mailed surveys to physicians.19, 48-51 Respondents were 63% male, with a median age of 44 years (Table 2). Practices were predominantly located in suburban settings without on-site mental health services. Physicians reported spending a median of 20 minutes per adolescent well visit, with 5 minutes devoted to anticipatory guidance.
|
|
|
|
Table 2. Characteristics of the Sample
|
|
|
Compared with nonrespondents, there were significantly more respondents from the Baltimore, Md, metropolitan area and fewer from Baltimore City and the Washington, DC, metropolitan area (P<.001). Respondents were similar as to sex, but were significantly younger than nonrespondents (P = .01).
PREVALENCE OF SUICIDAL BEHAVIOR ENCOUNTERED IN PRACTICES
Three hundred twenty-eight physicians (47%) reported having an adolescent patient who attempted suicide in the past year; the number of attempts during the past year ranged from 1 to 15 per practice. Seventy-four percent of physicians reported having 1 or 2 patients who attempted suicide. Thirty-five physicians (5%) in the sample reported ever having an adolescent patient complete suicide.
PREVALENCE OF SCREENING
Table 3 depicts the distribution of screening frequency for the selected risk factors for adolescent suicide. Frequently or always screening for alcohol use or abuse was reported by 75% of respondents, for other substance use by 71%, for depression by 54%, for physical abuse by 28%, for sexual abuse by 26%, and for prior suicide attempt(s) by 22%. Overall, 158 respondents (23%) either frequently or always screened adolescent patients for the selected suicide risk factors.
|
|
|
|
Table 3. Frequency Distribution of Screening Practice for Components of the Overall Screening Score*
|
|
|
PREVALENCE OF INJURY PREVENTION COUNSELING
Figure 1 depicts the frequency distribution of reported injury prevention counseling practices. Frequently or always counseling ranged from 67% for child passenger safety to 34% for the safer storage of firearms in the home.
|
|
|
|
Figure 1. Frequency distribution of injury prevention counseling practices.
|
|
|
PHYSICIAN BELIEFS AND ATTITUDES
Histories of attempt(s) and depression were considered to be the most important risk factors for adolescent suicide (Figure 2); testing positive for the human immunodeficiency virus, having a conduct disorder, and concern about sexual orientation were considered to be the least important.
|
|
|
|
Figure 2. Frequency distribution of perceived importance of risk factors for adolescent suicide. HIV indicates human immunodeficiency virus.
|
|
|
Most respondents indicated concerns about adequate reimbursement and insurance coverage for screening for mental health problems (Figure 3). Most respondents thought that they and physicians in general can be effective in preventing adolescent suicide. Most did not consider maintaining confidentiality for their adolescent patients' issues or concerns to be problematic. Approximately one third of respondents thought they had enough time during a well visit to screen for mental health problems (no significant difference for capitated vs fee-for-service practice) and considered themselves to be sufficiently trained to screen for adolescent suicide.
|
|
|
|
Figure 3. Frequency distribution of perceived barriers to intervention in the office setting.
|
|
|
Most physicians (72%) reported an interest in more training on preventing adolescent suicide. There was no association between desiring more training and screening behavior. The most frequently mentioned topic of interest was screening and assessment (mentioned by 69% of physicians), followed by clinical indicators (65%), referral options (58%), legal issues (53%), and treatment (48%).
PREDICTORS OF ROUTINE SCREENING
Forty-two percent (138/328) of physicians who reported having 1 or more adolescent patients who attempted suicide in the past year routinely screened for risk factors for suicide, compared with 33% (113/346) of physicians who reported not having an adolescent patient attempt suicide in the past year ( 2 = 7.6; P = .02).
Table 4 lists the independent factors significantly correlating with routine screening for risk factors for adolescent suicide in the final logistic regression model.
|
|
|
|
Table 4. Final Model Indicating Variables Correlating With Routine Screening for Risk Factors for Adolescent Suicide*
|
|
|
COMMENT
IMPORTANT FINDINGS
Almost one half of respondents reported having encountered 1 or more adolescent patients who had attempted suicide sometime in the past year, and 5% reported that an adolescent patient had completed suicide. Despite such exposure to this health problem in their practice, routine screening ranged from approximately 22% for prior suicide attempts to 75% for alcohol use or abuse, indicating substantial room for improvement. Other investigators52-53 have found rates of screening for psychosocial risks among adolescent patients well below what is recommended by official guidelines (ie, the American Medical Association's Guidelines for Adolescent Preventive Services).54
Physician knowledge of risk factors for adolescent suicide is incomplete. Although most physicians recognized that histories of attempt(s) or depression are important risk factors for adolescent suicide, most did not recognize the importance of conduct disorder55 or concerns about sexual orientation56 as strong risk factors. This finding, coupled with our finding that physicians who agreed or strongly agreed that they were sufficiently trained and knew how to screen for suicide risk factors were more than 3 times as likely to routinely screen for these risk factors, suggests the need for more education and training in this area. Training has been recommended by several investigators to promote prevention counseling,57-58 desired and perceived as lacking by physicians themselves,59-60 and has been shown to have a beneficial effect on physician counseling skills, practice, and outcomes.48, 61-70
Physicians who more strongly believed that they had enough time during a well visit to screen for mental health problems were almost 3 times as likely to screen for suicide risk factors as those who did not. There is evidence in the literature that increased information exchange does not necessarily increase visit length.62, 71 Managed care organizations, as well as individual practitioners, should closely examine the competing issues for the physician's time during a well visit and devise an approach to prioritizing these issues. More attention should be given to the environmental factors that could increase the amount and quality of information exchanged during the well visit without lengthening the visit. A short, acceptable, reliable, and valid screening tool for psychosocial or mental health problems in adolescent patients is needed. Completion of this form by the patient and/or family immediately prior to the encounter with the physician could provide helpful information and allow him or her to follow up with more in-depth probes in potential problem areas. Ancillary health professionals in the practice setting could be used to administer the assessment tool to maximize the amount and quality of information exchange during the office visit. Computer-aided self-administered interviews have proved useful in eliciting information about sensitive behaviors/issues72-74 and are well accepted by adolescents.75-80
Female physicians were almost twice as likely as male physicians to routinely screen for risk factors for suicide. This finding is not consistent with a Nebraska study that found no difference by physician age or sex in patterns of treatment or referral of adolescent suicide attempters,81 or with a national mail survey of pediatricians28 that found no difference by sex or year of graduation in the physician's perceived ability to treat adolescent psychosocial problems.
Routinely counseling about the safer storage of firearms in the home remained the most significant predictor in the final model. In addition to regarding site storage of firearms as general safety counseling, counseling about this safety topic may also be regarded in the context of suicide prevention.
LIMITATIONS
Because of the cross-sectional study design, causal relationships cannot be determined. All data were self-reported. Recall error may have been present, with respondents "telescoping" certain responses (ie, suicide attempts in the past year). Although the confidentiality of completed questionnaires was assured, some respondents may have provided socially desirable responses. The median of 20 minutes per well visit, with a median of 5 minutes devoted to anticipatory guidance, is significantly longer than reported in the literature. According to national statistics, one half of adolescent visits to primary care providers last 10 minutes or less; another 30% last 11 to 15 minutes.82-83 Other investigators have found that the average visit length for patients aged 2 weeks to 18 years was 10.3 minutes, with 7 seconds the average amount of time spent in anticipatory guidance.84
While the response rate of 66% is comparable to or greater than response rates reported for mailed surveys to physicians, a higher response rate would have been desirable. We do not have any information on the prevalence of nonrespondent physicians' encounters with adolescent patients who are suicidal. Even if none of the nonresponding physicians had encountered a suicidal patient, almost one third (31%) of all those to whom surveys were sent would have encountered adolescent patients who were suicidal.
Finally, this survey captured information solely on physicians; no information was obtained concerning adolescent patient or family issues or concerns. These are important components of physician-patient interactions; lack of this information results in a less complete understanding of the physician-patient information exchange.
CONCLUSIONS
Primary care providers either may be the sole source of medical care for this population or may serve a gatekeeper role in identifying and referring high-risk youths and families. They are in a key position to offer preventive counseling to their patients and families. Medical groups have long recognized the importance of providing preventive services to adolescents. In addition to Guidelines for Adolescent Prevention Services, the American Academy of Pediatrics has published recommendations for preventive pediatric health care and the American Academy of Family Physicians has published guidelines for periodic health examinations for all age groups. Both documents describe the need to address psychosocial issues in the pediatric and adolescent age groups and provide suggested areas to cover for specific age groups.
We recommend that adolescent patients be screened for psychosocial problems at all visits. This would include screening during sports physical examinations, physical examinations for camp attendance, any short-term care visit, and any visit to the emergency department. Within the context of diminishing resources and increasing expectations and demands on their time and expertise, physicians must be able to optimize their delivery of health care services. It is incumbent on those in a position to effect change that these gatekeepers in the trenches be provided with the tools they need to provide optimal health care. This would include appropriate training during all stages of education and, after formal education has been completed, provision of helpful screening tools, reminder systems, and sufficient ancillary health care professionals to maximize or extend the services provided. Public policies and organizational goals that support preventive strategies and services and remove or diminish barriers to intervention are needed. Advocacy for reimbursement of preventive services by organized groups, such as the American Medical Association, American Academy of Pediatrics, and American Academy of Family Physicians, is required. Only with concerted comprehensive efforts will the goal of optimized appropriate health care delivery to adolescents be realized.
| Editor's Note: One of the most dramatic bits of information from this study is that about half of the physicians encountered 1 or more adolescents who attempted suicide in the past year. What's wrong with this picture?—Catherine D. DeAngelis, MD
|
|
AUTHOR INFORMATION
Accepted for publication June 29, 1999.
Corresponding author: Diane L. Frankenfield, DrPH, Johns Hopkins Injury Center, Room 537, Hampton House, 624 N Broadway, Baltimore, MD 21205 (e-mail: sbaker{at}jhsph.edu).
From the Center for Injury Research and Policy (Drs Frankenfield, Keyl, and Gielen and Ms Baker) and the Departments of Health Policy and Management (Drs Gielen and Wissow) and Mental Hygiene (Dr Werthamer), School of Public Health, and the Department of Emergency Medicine, School of Medicine (Dr Gielen), Johns Hopkins University, Baltimore, Md.
REFERENCES
1. National Center for Injury Prevention and Control. Injury Mortality: National Summary of Injury Mortality Data, 1986-1992. Hyattsville, Md: National Center for Health Statistics; February 1995.
2. O'Carroll PW, Potter LB, Mercy JA. Programs for the prevention of suicide among adolescents and young adults. MMWR Morb Mortal Wkly Rep. April 22, 1994;43(RR-6):1-7.
3. Suicide among children, adolescents and young adults—United States 1980-1992. MMWR Morb Mortal Wkly Rep. 1995;44:289-291.
PUBMED
4. Kann L, Kinchen SA, Williams BI, et al. Youth risk behavior surveillance—United States, 1997. MMWR CDC Surveill Summ. August 14, 1998;47(SS-3):1-89.
5. Boyd JH, Moscicki EK. Firearms and youth suicide. Am J Public Health. 1986;76:1240-1242.
FREE FULL TEXT
6. Baker SP, Fingerhut LA, Higgins L, et al. Injury to Children and Teenagers: State-by-State Mortality Facts. Baltimore, Md; Center for Injury Research and Prevention, Johns Hopkins School of Public Health; 1996.
7. Bloom B. Health Insurance and Medical Care: Health of Our Nation's Children, United States, 1988. Hyattsville, Md: National Center for Health Statistics; 1990. Advance Data From Vital and Health Statistics, No. 188.
8. Gans JE, McManus MA, Newacheck PW. Adolescent Health Care: Use, Costs and Problems of Access. Chicago, Ill: American Medical Association; 1991.
9. Elster AB, Levenberg P. Integrating comprehensive adolescent preventive services into routine medicine care. Pediatr Clin North Am. 1997;44:1365-1377.
FULL TEXT
|
ISI
| PUBMED
10. Cavanaugh RM, Hastings-Tolsma M, Keenan D. Anticipatory guidance for the adolescent: parents' concerns. Clin Pediatr (Phila). 1993;32:542-545.
11. Joffe A, Radius S, Gall M. Health counseling for adolescents: what they want, what they get, and who gives it. Pediatrics. 1988;82:481-485.
FREE FULL TEXT
12. Kaufman KL, Brown RT, Graves K. What, me worry? a survey of adolescents' concerns. Clin Pediatr (Phila). 1993;32:8-14.
13. Costello EJ, Edelbrock C, Costello AJ, Dukan MK, Burns BJ, Brent D. Psychopathology in pediatric primary care: the new hidden morbidity. Pediatrics. 1988;82(3 pt 2):415-424.
14. Dulcan MK, Costello EJ, Costello AJ, Edelbrock C, Brent D, Janiszewski S. The pediatrician as gatekeeper to mental health care for children: do parents' concerns open the gate? J Am Acad Child Adolesc Psychiatry. 1990;29:453-458.
ISI
| PUBMED
15. Costello EJ, Shugart MA. Above and below the threshold: severity of psychiatric symptoms and functional impairment in a pediatric sample. Pediatrics. 1992;90:359-368.
FREE FULL TEXT
16. Blum RW, Beuhring T, Wunderlich M, Resnick MD. Don't ask, they won't tell: the quality of adolescent health screening in five practice settings. Am J Public Health. 1996;86:1767-1772.
FREE FULL TEXT
17. Igra V, Millstein SG. Current status and approaches to improving preventive services for adolescents. JAMA. 1993;269:1408-1412.
FULL TEXT
|
ISI
| PUBMED
18. Committee on Psychosocial Aspects of Child and Family Health. The pediatrician and the "new morbidity." Pediatrics. 1993;92:731-733.
FREE FULL TEXT
19. Blum RW, Bearinger LH. Knowledge and attitudes of health professionals toward adolescent health care. J Adolesc Health Care. 1990;11:289-294.
FULL TEXT
| PUBMED
20. Frank E, Kunovich-Frieze T. Physicians' prevention counseling behaviors: current status and future directions. Prev Med. 1995;24:543-545.
FULL TEXT
|
ISI
| PUBMED
21. Cohen SJ, Halvorson HW, Gosselink CA. Changing physician behavior to improve disease prevention. Prev Med. 1994;23:284-291.
FULL TEXT
|
ISI
| PUBMED
22. Harris RP, O'Malley MS, Fletcher SW, Knight BP. Prompting physicians for preventive procedures: a five-year study of manual and computer reminders. Am J Prev Med. 1990;6:145-152.
ISI
| PUBMED
23. Hahn DL, Berger MG. Implementation of systematic health maintenance protocol in a private practice. J Fam Pract. 1990;31:492-504.
ISI
| PUBMED
24. Gilchrist V, Alexander E. Preventive health care for adolescents. Prim Care. 1994;21:759-779.
ISI
| PUBMED
25. Middleman AB, Binns HJ, Durant RH. Factors affecting pediatric residents' intentions to screen for high risk behaviors. J Adolesc Health. 1995;17:106-112.
FULL TEXT
|
ISI
| PUBMED
26. Moser R, McCance KL, Smith KR. Results of a national survey of physicians' knowledge and application of prevention capabilities. Am J Prev Med. 1991;7:384-390.
ISI
| PUBMED
27. Scott CS, Neighbor WE, Brock DM. Physicians' attitudes toward preventive care services: a seven-year prospective cohort study. Am J Prev Med. 1992;8:241-248.
ISI
| PUBMED
28. Chastain DO, Sanders JM, DuRant RH. Recommended changes in pediatric education: the impact on pediatrician involvement in health care delivery to adolescents. Pediatrics. 1988;82:469-476.
FREE FULL TEXT
29. Wissow LS, Roter D. Toward effective discussion of discipline and corporal punishment during primary care visits: findings from studies of doctor-patient interaction. Pediatrics. 1994;94:587-593.
ABSTRACT
30. Wissow LS, Roter DL, Wilson ME. Pediatrician interview style and mothers' disclosure of psychosocial issues. Pediatrics. 1994;93:289-295.
FREE FULL TEXT
31. White J, Levinson W, Roter D. "Oh, by the way . . . ": the closing moments of the medical visit. J Gen Intern Med. 1994;9:24-28.
ISI
| PUBMED
32. Robbins JM, Kirmayer LJ, Cathebras P, Yaffe MJ, Dworkind M. Physician characteristics and the recognition of depression and anxiety in primary care. Med Care. 1994;32:795-812.
ISI
| PUBMED
33. Marks A, Malizio J, Hoch J, Brody R, Fisher M. Assessment of health needs and willingness to utilize health care resources of adolescents in a suburban population. J Pediatr. 1983;102:456-460.
FULL TEXT
|
ISI
| PUBMED
34. Resnick MD, Litman TJ, Blum RW. Physician attitudes toward confidentiality of treatment for adolescents: findings from the Upper Midwest Regional Physicians Survey. J Adolesc Health. 1992;13:616-622.
FULL TEXT
|
ISI
| PUBMED
35. Cheng TL, Savageau JA, Sattler AL, DeWitt TG. Confidentiality in health care: a survey of knowledge, perceptions, and attitudes among high school students. JAMA. 1993;269:1404-1407.
ABSTRACT
36. Council on Scientific Affairs, American Medical Association. Confidential health services for adolescents. JAMA. 1993;269:1420-1424.
FULL TEXT
|
ISI
| PUBMED
37. Ginsburg KR, Slap GB, Cnaan A, Forke CM, Balsley CM, Rouselle DM. Adolescents' perceptions of factors affecting their decisions to seek health care. JAMA. 1995;273:1913-1918.
ABSTRACT
38. Cheng TL, Klein JD. The adolescent viewpoint: implications for access and prevention. JAMA. 1995;273:1957-1958.
FULL TEXT< |
