Journal of Adolescent Health
Volume 44, Issue 6 , Pages 520-527, June 2009

Are Adolescents Being Screened for Emotional Distress in Primary Care?

  • Elizabeth M. Ozer, Ph.D.

      Affiliations

    • Division of Adolescent Medicine, University of California, San Francisco, California
    • Young Adult and Family Center, Department of Psychiatry, University of California, San Francisco, California
    • Corresponding Author InformationAddress correspondence to: Elizabeth M. Ozer, Ph.D., Division of Adolescent Medicine, University of California, San Francisco, 3333 California Street, Suite 245, San Francisco, CA 94118.
    • ,
  • Elaine G. Zahnd, Ph.D.

      Affiliations

    • Public Health Institute, Oakland, California
    • ,
  • Sally H. Adams, Ph.D.

      Affiliations

    • Division of Adolescent Medicine, University of California, San Francisco, California
    • ,
  • Sheila R. Husting, B.A.

      Affiliations

    • Division of Adolescent Medicine, University of California, San Francisco, California
    • ,
  • Charles J. Wibbelsman, M.D.

      Affiliations

    • Department of Pediatrics, Kaiser Permanente Northern California, San Francisco, California
    • ,
  • Kim P. Norman, M.D.

      Affiliations

    • Young Adult and Family Center, Department of Psychiatry, University of California, San Francisco, California
    • ,
  • Susan M. Smiga, M.D.

      Affiliations

    • Young Adult and Family Center, Department of Psychiatry, University of California, San Francisco, California

Received 10 June 2008; accepted 18 December 2008. published online 12 March 2009.

See Editorial p. 516

Article Outline

Abstract 

Purpose

To assess primary care providers’ rates of screening for emotional distress among adolescent patients.

Methods

Secondary data analysis utilizing data from: (1) well visits in pediatric clinics within a managed care plan in California, and (2) the 2003 California Health Interview Survey (CHIS), a state population sample. The Pediatric clinic sample included 1089 adolescent patients, ages 13 to 17, who completed a survey about provider screening immediately upon exiting a well visit. The CHIS sample included 899 adolescents, ages 13 to 17, who had a routine physical exam within the past 3 months. As part of the survey, adolescents answered a question about whether they had talked with their provider about their emotions at the time of the exam. Logistic regressions, controlling for age, gender, race/ethnicity, and adolescent depressive symptoms were performed.

Results

About one-third of adolescents reported a discussion of emotional health. Females were significantly more likely to be screened than males (36% vs. 30% in clinic; 37% vs. 26% in CHIS); as were older and Latino adolescents in the clinic sample. Although 27% of teens endorsed emotional distress, distress was not a significant predictor of talking to a provider about emotions.

Conclusions

Primary care clinicians/systems need to better utilize the primary care visit to screen adolescents for emotional health.

Keywords: Adolescents, Primary care, Depression screening, Preventive services

 

Most mental health problems begin in adolescence [1]. Half of all lifetime mental health disorders start by age 14 [2]. About 20% of youth experience depression prior to turning 18 [3], and 30% of teens report depressive symptoms at any given time [4]. Depression is a major risk factor for suicide, the third leading cause of death among adolescents [5]. Depression and depressive symptoms are also associated with unsafe health behaviors that are linked to morbidity and mortality among adolescents, such as substance use [6], [7], [8], risky sexual behavior [9], and fighting/weapon carrying [10].

Developing screening practices that assist with early recognition of depression and can lead to early intervention has the potential to make a huge difference in the lives of adolescents and their families. Because it is not feasible for mental health professionals to screen, diagnose, or treat all adolescents, more practical and effective systems for the screening and diagnosis of depression need to be developed [11].

The majority of adolescents visit a healthcare provider once a year, providing an ideal opportunity to integrate emotional health screening into clinical care [12]. For close to 15 years, adolescent clinical preventive guidelines have recommended screening and counseling adolescents for risky health behaviors and emotional health [13], [14], [15], [16]. Recently, clinical practice guidelines have been developed specifically to assist primary care providers in the identification and management of adolescent depression [17]. Research indicates that depression screening results in higher rates of mental health interventions [18], and that interventions within primary care are associated with improvements in adolescent depression [11], [19].

Few studies, however, have examined rates of screening adolescents for depression or emotional distress within primary care settings [20]. Two studies published since the year 2000 (postadolescent preventive guideline development) have found varying results for provider reported practice. In a study of screening practices within a health maintenance organization, pediatric primary care clinicians (n = 366) reported screening 46% of their pediatric patients for depression; however, only 17% of clinicians said that they screened most of their pediatric patients (at least 80%) for depression [21]. In another study of clinicians (n = 79) in community health centers, 64% reported screening adolescent patients for depression [22].

In addition to the dearth of studies on rates of screening for depression in primary care, there are several limitations to the current data. First, almost all data on provider screening for depression has utilized provider report of delivery of services [20]. Adolescents’ self-report of preventive health service delivery has been found to be a valid method of determining the content of a visit [23], and adolescent self-report measures have been incorporated into the development of quality performance measures [24]. In the only published study on depression screening rates utilizing adolescent report, adolescents reported being screened for depression only 16% of the time, a rate far lower than provider reported rates [22].

Second, previous studies have largely limited their data collection to healthcare clinics and have not used population-based samples of adolescents to obtain data on screening rates. Third, although the available data suggests that not all teenagers are being screened for depression as recommended, it is not known which teenagers are being screened and which teenagers are being missed. Specifically, are providers more likely to screen teenagers who are emotionally distressed? No prior research has assessed primary care provider screening rates for emotional distress in conjunction with an adolescent measure of depression.

The current study attempts to address these gaps in the literature on screening adolescents for depression in primary care. First, we utilize two large existing datasets to assess providers’ rates of discussing emotional distress: (1) a sample of teenagers who attended well-visits across multiple pediatric primary care clinics within a managed care health plan that serves the largest number of teenagers in the state of California; and (2) a population-based household sample of adolescents throughout the state of California who reported recently having a physical examination. Second, each dataset utilizes an independent report of provider delivery of emotional health screening, with reference to a specific clinic visit. Third, the California Health Interview Survey (CHIS) includes an assessment for depression, allowing us to examine what percent of the population-based sample endorsed symptoms of distress.

In summary, the main focus of this study was to utilize two large independent datasets to assess providers’ rates of discussing emotional health among a clinic-based and population-based sample in California. A secondary purpose was to assess the degree to which provider screening rates varied if a teen endorsed emotional distress.

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Methods 

Sample design 

We utilized data from two independent datasets: (1) adolescent data collected in outpatient pediatric clinics within a large managed care organization, and (2) adolescent data collected from the 2003 CHIS.

Survey samples 

Managed care—pediatric clinic sample 

For the pediatric clinic sample, we conducted a secondary analysis of provider screening behavior based on adolescent patient reports in four outpatient clinics with a total of 86 providers. The managed care dataset was initially gathered as part of a larger primary care intervention study designed to increase preventive service screening and counseling of adolescents for risky health behaviors [25]. Adolescent patients, ages 13 to 17 years, were surveyed upon exiting their clinic well visit. A total of 1089 adolescents, ages 13 to 17 years, who completed a survey about provider screening behavior, prior to any clinic intervention, were selected for the present analyses. Data were collected from Fall 2001 through Summer 2002. All procedures were approved by the internal review boards at the University of California, San Francisco, and at the participating HMO. We estimate that 75% of the adolescents who were asked to complete questionnaires agreed to do so.

Slightly over half of the pediatric sample was older, aged 15 to 17 years (52.6%) with 47.4% falling into the 13- to 14-year-old age group (see Table 1). The mean age was 14.8 years (SD = 1.33). Almost three-fifths of the adolescents (57.6%) were female. As shown in Table 1, approximately one-third of the pediatric sample adolescents (32.4%) were white, 29.6% were Latino/Hispanic, 22.9% were African American, and 15.2% were Asian.

Table 1. Adolescent sample sizes
Pediatric clinic sampleaCHIS 2003 sampleb
Age groupNumberPercentNumberWeighted percentPopulation estimates
13–14 years51647.442447.9389,000
15–17 years57252.647552.1423,000
Gender
Male45942.445550.6411,000
Female62357.644449.4402,000
Race/ethnicity
White35332.447340.7331,000
Latino/ Hispanic32229.628438.3311,000
African American24922.97211.190,000
Asian16515.2709.980,000
Total1089100.0899100.0813,000

aAmong those exiting a well visit.

bAmong those reporting a physical exam in the past 3 months.

CHIS 2003 sample 

For our second sample, we conducted a secondary analysis of provider screening behavior based on adolescent reports gathered as part of CHIS. The largest multiethnic, multilinguistic state survey in the United States, CHIS is a random digit dial telephone survey of the California population that is conducted every 2 years, starting in 2001 [26]. CHIS includes three separate components: (1) a survey of adults, (2) a survey of adolescents aged 12 to 17 years, and (3) a survey of children under the age of 12 with the parent or guardian most knowledgeable of that child's health. This study utilized CHIS 2003 adolescent survey data collected over a 9-month period during 2003. Adolescent survey topics include physical and emotional health status, provider screening rates, and risky health behaviors.

Households were scientifically sampled from every county in the state, and interviews were conducted with one randomly selected adult from each household. In households with adolescents, one adolescent was randomly selected for an interview. When an adolescent was selected, parental or legal guardian verbal consent was required. All procedures were approved by the internal review boards at the University of California, Los Angeles, the State of California, Westat, and the federal Office of Management of the Budget. Detailed descriptions of the sampling and weighting methods can be found in the CHIS 2003 Methodology Series, posted on the Web site at www.chis.ucla.edu [27].

For this secondary analysis on provider screening behaviors, we restricted the CHIS 2003 sample to a total of 899 adolescents, ages 13 to 17 years, who reported that they had a physical examination within the past 3 months (see Table 1). By selecting “within the past 3-month” time frame, we both shortened the recall period and allowed for closer comparability with the pediatric clinic dataset in which adolescent patients were asked about provider screenings when exiting a clinic well-visit.

Given small racial/ethnic samples of American Indian/Alaska Natives and “others,” we only included white, Latino/Hispanic, African American, and Asian adolescents for our CHIS analyses. The racial/ethnic groups included in our population-based dataset, CHIS 2003, were comparable to the racial/ethnic groups included in our clinic-based adolescent sample.

Among the CHIS sample, the 15- to 17-year-old age group was slightly larger (52.8%) compared to the younger group (47.2%), although males and females were similar in size. The majority of the CHIS 2003 adolescent sample was either white (52.6%) or Latino/Hispanic (31.6%) (see Table 1).

For the CHIS 2003 sample, Table 1 includes the weighted prevalence rates and population estimates for the demographic groups. To provide prevalence rates, the CHIS 2003 sample is weighted to represent the total population. As shown in the table, a sample size of 899 teens corresponds to a population estimate of 813,000 adolescents in California (see Table 1).

Measures 

A measure of provider screening for emotional distress was included in each dataset.

Pediatric clinic measure of provider screening for emotional distress 

Provider behavior was assessed through adolescent patient reports collected during clinic visits. The teens filled out the “Adolescent Report of the Visit Survey” immediately following their provider well-care visit [25]. The survey asked about provider screening for risky health behaviors and emotional distress. The specific measure used for this analysis was the question: “Did your doctor talk to you about getting help if you feel sad or depressed?”

CHIS measure of provider screening for emotional distress 

To measure the percentage of teens who had talked to their provider about their emotions, we analyzed adolescent responses to the CHIS 2003 survey question: “When you had your last routine physical exam, did you and a doctor or other health provider talk about your emotions or moods?”

The wording used in CHIS is the same as used in the Young Adult Health Care Survey, a quality measure developed to assess adherence to adolescent preventive guidelines [24].

In addition to an assessment of provider screening, the CHIS dataset included a measure of depressive symptoms completed by all teens.

CHIS measure of depressive symptoms 

We used an eight-item depression scale, developed for CHIS, that was modified from the Center for Epidemiologic Studies Depression Scale (CES-D) [28]. The eight-item scale was developed to provide a brief assessment suitable for use with adolescents in the CHIS-administered telephone survey. The short scale was developed from a large sample of adolescents who completed the full CES-D as part of an intervention study in a primary care setting. Factor analyses were conducted to determine the factor structure of the scale. Our analyses showed that the full CES-D scale primarily consists of one large unrotated factor, with 18 of the 20 items loading on the first factor at .45 or above, indicating moderate coherence of the items. We selected the eight items that loaded most highly on the first factor (.6 or above), indicating that the items were strongly related or intercorrelated with one another. This eight-item scale has an alpha reliability of .79 and is correlated .94 with the full CES-D scale, suggesting that there is considerable redundancy in the 20-item full scale [29].

In the telephone administration, the CHIS interviewer asked the following question: “In the past 7 days, were the following things true for you:” “none of the time (scored as 0), sometimes (scored as 1), a lot of the time (scored as 2), or most of the time (scored as 3)”? The following items were then read to the adolescent by the interviewer who gave them time to respond to each item before proceeding to the next: (1) “You enjoyed life” (reverse scored); (2) “You felt you could not shake off feeling sad and unhappy, even with help from your family and your friends”; (3) “You felt depressed”; (4) “You were happy” (reverse scored); (5) “You felt lonely”; (6) “You felt your life was a failure”; (7) “You felt sad;” and (8) “You did not want to do the things you usually do.” The resulting range for scores was 0–24. A score greater than or equal to 7 indicates “psychological distress,” equivalent to a 21 (males) and 23 (females) score on the CES-D [9], [30].

Analysis plan 

The main focus of the analyses with the two independent datasets was to assess providers’ rates of screening for emotional distress among a clinic-based and population-based sample in California. A secondary purpose was to assess the degree to which provider screening rates varied if a teen endorsed emotional distress on the CHIS-administered, CES-D measure.

Rates of provider screening for emotional distress 

For both the clinic-based and population-based datasets, rates of screening for emotional distress by primary care providers were calculated on the basis of adolescent patient self-report. Adolescent-based reports assessing provider screening behavior allow for valid appraisals free of the confounding influences of provider self-report and social desirability biases [23].

Simple descriptive frequencies of adolescent report of provider screening were initially conducted. Based on the group differences we observed from our chi-square results, we conducted logistic regression models. Because research indicates gender, age, and racial/ethnic differences may influence rates of provider screening for preventive healthcare, we included these demographic variables in our analyses [4], [9], [31], [32].

For the CHIS population-based sample, we calculated design-adjusted prevalence rates for each demographic subgroup. Weighted logistic regression analyses were conducted to model the association between prevalence rates of screening for emotional health and each of the demographic variables. Sampling weights in all CHIS 2003 analyses were applied to generalize results to the adolescent population who visited a provider in the past 3 months. Standard error estimates from the logistic regression models were adjusted for the complex sampling design, and we conducted significance tests for differences among estimates using a design adjusted Wald test.

For both datasets, odds ratios were also calculated for all of the models. STATA statistical software package (version 9.0) was used to conduct all analyses.

Do rates of provider screening vary by adolescent distress? 

Using the CHIS 2003 dataset, we next investigated whether any variation in screening rates emerged if a teen endorsed depression. We performed crosstabulations by age, gender, and race/ethnicity, and calculated chi-square statistics. Logistic regression analyses were conducted using emotional distress as a covariate as determined by the CES-D score, controlling for age group, gender and race/ethnicity.

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Results 

Rates of provider screening for emotional distress 

Rates of provider screening in the pediatric clinic sample 

Overall, as illustrated in Table 2, slightly over one-third of teens (34%) reported that their doctor talked to them about getting help if they felt sad or depressed. Crosstabulations using chi-square statistics revealed that younger teens, ages 13 to 14 years, were significantly less likely to report the discussion (30.6%) than older teens, ages 15 to 17 years (37.0%) (p < .05). Female adolescents reported significantly higher rates of talking about getting help if they felt sad or depressed (36.4%) compared to males (30.4%) (p < .05). Among the racial/ethnic groups, chi-square statistics indicated that Latino adolescents were more likely to say that their doctor talked to them about sadness or depression than their white counterparts (p < .05) (see Table 2).

Table 2. Rates of provider screening for emotional distress
Provider clinic sampleaCHIS 2003 sampleb
Number screenedPercent screenedNumber screenedWeighted percent screenedPopulation estimate screened
Age group ∗
13–14 years14830.612929.1113,000
15–17 years19737.015933.2141,000
Gender ∗ ∗∗
Male13030.410925.1103,000
Female21236.417937.5151,000
Race/ethnicityc
White10431.415733.3105,000
Latino/ Hispanic12039.9∗8333.098,000
African American7733.62522.019,000
Asian4428.42325.219,000
Total34534.028831.2254,000

aBy adolescent report after a clinic visit.

bAmong adolescents reporting a physical exam in the past 3 months.

cFor comparisons, white served as the referent group.

∗p ≤ .05.

∗∗p < .01.

We conducted a logistic regression analysis for the pediatric clinic sample entering age group, gender, and race/ethnicity into the model, with white teens selected as the referent group. Controlling for gender and race/ethnicity, age remained significant, with older teens 1.3 times more likely to report talking to their provider about sadness or depression compared to younger teens (p < .05). Differences in provider screening rates between males and females also remained significant (p < .05), with males less likely to report talking to their provider about sadness or depression compared to females (OR = .75). Latino adolescents were 1.5 times more likely to report being screened compared to whites (p < .05).

Rates of provider screening in CHIS sample 

In California, among adolescents who visited a provider in the past 3 months, almost one-third (31.2%) indicated that they talked to their provider about their emotions or mood. Table 2 shows that prevalence rates of provider screening for emotional distress were significantly higher among females (37.5%) than among males (25.1%) (p < .01). Although older teens were slightly more likely to report screening than younger teens, the differences were not significant. African American teens were less likely to be screened for emotional distress than white adolescents, but the significance was marginal (p = .08). The prevalence rates between screening of Asian or Latino adolescents and screening of white adolescents were not significantly different.

When the effects of age group, gender, and race/ethnicity were entered into a logistic regression model, gender was significantly related to screening, with females more likely to talk to their provider about their emotions than males (p = .01; OR = 1.65). No significant effects were found by adolescent age. There were also no significant differences in provider rates of screening by adolescent racial/ethnic background, after controlling for the effects of adolescent age and gender.

Do rates of provider screening vary by adolescent emotional distress? 

Using the CHIS dataset, we next examined whether reports of talking to a provider about emotions or mood differed by adolescent emotional distress. Among adolescents who visited a provider in the past 3 months, about one-quarter of the sample (26.7%) screened positive for emotional distress based on the CES-D eight-item measure. More than one-third of females (37.5%) and one-fourth of males (25.1%) endorsed emotional distress.

As Table 3 demonstrates, among teens endorsing emotional distress, about one-third (34.7%) reported talking to their provider about their emotions or mood. This difference was not significantly higher than the rate of screening nondistressed teens, 30.0% of whom reported talking about their emotions/mood with their health provider (data not included on the table). Distressed adolescent females were significantly more likely (41.7%) to be screened than distressed adolescent males (24.7%) (p < .05) (see Table 3).

Table 3. Rates of provider screening for depressive symptoms among emotionally-distressed teens (CHIS 2003)a
Number screenedWeighted percent screenedPopulation estimate screened
Age group
13–14 years3632.334,000
15–17 years4636.941,000
Gender∗
Male2324.722,000
Female5941.753,000
Race/ethnicity
White3949.030,000
Latino/Hispanic2825.727,000
African American1233.910,000
Asian321.03,000
Total8234.775,000

aAmong adolescents reporting a physical exam in the past 3 months.

∗p < .05.

An additional logistic regression was performed on provider screening rates in the CHIS 2003 population-based dataset, to gauge the effect of adolescent distress within the context of the full model of provider screening factors. We included the CES-D- eight-item emotional distress score as a covariate, along with age group, gender, and race/ethnicity. In the weighted regression, gender remained a significant factor related to provider screening for adolescent distress. Among distressed teens, females were significantly more likely to talk to their provider about their emotions/mood (41.7%) than males (24.7%) (p < .05).

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Discussion 

Utilizing two large independent datasets to assess providers’ rates of screening for emotional distress among a clinic-based and population-based sample in California, we found that provider rates of talking to adolescents about their emotional health were remarkably similar across both the health plan and population dataset: About one-third of California teenagers report being screened for emotional distress during a visit with their primary care provider.

The most significant factor determining screening rates was being female. Female adolescents were more likely than males to report that they talked about their emotions/mood with their provider in the population sample (37% vs. 26%); and that their doctor talked to them about getting help if they felt sad or depressed in the clinic sample (36% vs. 30%). It is not known whether female adolescents are more likely to initiate conversations about their emotional health, or providers are more likely to query females given higher rates of depression among females [33].

Within the pediatric clinic dataset, being an older teen and Latino teen also positively influenced screening. This pattern is consistent with increasing rates of depression throughout adolescence, and Hispanics reporting the highest rates of depressive symptoms interfering with their usual activities [10]. However, in the population dataset, after taking into account gender, age, ethnic/racial background, and distress level, gender was the only significant factor influencing reports of talking about emotions/mood with a provider.

Within the population-based CHIS dataset, over one-fourth (27%) of the adolescents screened positive for emotional distress based on the modified CES-D measure. These rates are similar to rates of depressive symptoms reported among adolescents in the National Longitudinal Study of Adolescent Health survey using the CES-D, where 28% of all teens reported emotional distress across two different waves of data collection [4]. We found that only about one-third of teens endorsing emotional distress reported having been screened for emotions/mood, a rate not significantly higher than the rate for screening nondistressed teens. Even among females endorsing distress, 60% did not report having a discussion with their doctor.

A limitation of the study in assessing rates of screening among emotionally distressed teens is that the teens completed the depression measure at the time they participated in the CHIS survey, within 3 months of their primary care visit. It is possible that some teens who reported depressive symptoms at the time of the survey may not have been distressed 1 or 2 months before at the time of their clinic visit. However, given that rates of depressive symptoms in the population-based sample in California is almost identical to national rates, it is likely that a similar percentage of teens (27%) were distressed at the time of their well-visit [4].

An additional study limitation involves the use of different questions for assessing provider screening rates across the two datasets. The CHIS survey asked teenagers “When you had your last routine physical exam, did you and a doctor or other health provider talk about your emotions or moods?” An inquiry about mood or emotions is an initial screening question for a variety of mental health concerns, including depression, as indicated in quality improvement measures [24].

In the pediatric outpatient sample, teenagers were asked “Did your doctor talk to you about getting help if you feel sad or depressed?” The health plan's adolescent preventive guidelines recommended that providers assess whether patients had a “persistent problem with being depressed, sad, or irritable” [34]. Although we cannot say with certainty that all providers who discussed “getting help if you feel sad or depressed” queried teens about their emotional health, it seems safe to assume that the topic of feeling sad or depressed was at least addressed in some manner in the visit. It is important to note that although the wording of the screening questions in the two California datasets were different, adolescents reported strikingly similar rates of discussing emotional health topics with their providers.

Recent guidelines for identifying adolescent depression in primary care indicate that primary care clinicians should routinely monitor the psychosocial functioning of adolescents as an indicator of a variety of problems, including depression [17]. Likewise, the recent guidelines for general adolescent care advise providers to query about emotional functioning, and to tell adolescents that they should talk with a health professional if “you are sad or nervous or feel that things are just not going right” [16]. Thus, although the wording may vary, the consistent message behind the guidelines is to bring the discussion of emotional health into a visit with the primary care provider. This is the first step in identifying depression or any emotional health problem.

This was the first study to examine rates of preventive screening for emotional distress among adolescents in primary care, with data from both clinical and population-based samples. In extending the literature beyond provider self-report of screening practices, the adolescent-report findings indicate that despite the prevalence of depressive symptoms, rates of screening adolescents for emotional distress are lower than for most other risk areas, such as smoking, substance use, and sexual activity [35]. Even teens who endorse depressive symptoms, and are potentially at greater risk, are not being screened consistently.

Our findings indicate that the opportunity for screening adolescents for depression in primary care is not being well utilized. This is likely because of physicians' lack of confidence that they can treat depression [36], and lack of integrated systems to screen and conduct brief interventions in this area [37]. Previous research has established that clinicians with higher self-efficacy are more likely to deliver clinical services to adolescents across multiple risk areas [38]; that training and tools for primary care providers improves clinicians’ self-efficacy [39]; and that interventions involving training and tools increase rates of screening and counseling of adolescents for risky health behaviors [22], [25], [40].

Guidelines have been published focusing on screening adolescents for depression in primary care [17]; data indicates that a brief standardized depression screening instrument is well accepted in primary care [37]; and there is evidence of the potential effectiveness of primary care delivered interventions for adolescent depression [11]. These recent developments lay the groundwork for further intervention research in the area of increasing rates of screening for depression among adolescents. Our findings indicate that close to 70% of teens who endorsed depressive symptoms had not had a recent discussion with their provider about their mood. In this California population-based sample, this translates to close to 49,000 distressed adolescents who “missed” talking with their provider. Primary care clinicians/systems need to better utilize the opportunity to positively influence the health of adolescents.

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Acknowledgments 

This research was supported primarily by a grant from the Staglin Family Music Festival for Mental Health to the Young Adult & Family Center, Department of Psychiatry, University of California, San Francisco. Additional support was provided by The Agency for Healthcare Research & Quality (U18 HS11095); by a cooperative agreement from the Centers for Disease Control and Prevention through the Association of American Medical Colleges (MM-0162-02/02); DHHS, the National Institutes of Health & the National Institute of Nursing Research (NR009397); the Hellman Family Award for Early Career Faculty; and the Maternal and Child Health Bureau, Health Resources and Services Administration, Department of Health and Human Services. We thank David Grant, Sunghee Lee, and Jenny Chia from the UCLA Center for Health Policy Research for their valuable suggestions about analyzing CHIS data, and E. Richard Brown, CHIS Principal Investigator, for insuring that the CHIS public use data files (PUFs) are available to all researchers as part of his vision of CHIS as a public service. We appreciate the contribution of Sonal Rana to the literature review, and the assistance of Anthony Kung in the preparation of the manuscript. Finally, we are grateful to the Chiefs, physicians, and adolescents in the Kaiser Permanente clinics who participated in the original study and demonstrated a commitment to improving preventive healthcare for adolescents; and to the adolescents who participated in the pediatric clinic and CHIS surveys.

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PII: S1054-139X(08)00685-X

doi:10.1016/j.jadohealth.2008.12.016

Journal of Adolescent Health
Volume 44, Issue 6 , Pages 520-527, June 2009

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