Let's Talk About Teens
Rachel Whitfield, a Family Nurse Practitioner at Children's Mercy, leads a discussion on care for adolescents and young adults; focusing on preventative medicine, brain development, and what providers should be addressing with their teen patients during clinic visits.
Featured Speaker:
Rachel Whitfield, APRN, FNP-C
Rachel Whitfield is a Family Nurse Practitioner working in Adolescent Medicine at Children’s Mercy Hospital in Kansas City. She manages the Title X reproductive health grant at Children’s Mercy and practices in both the primary care and residential mental health settings. Rachel has practiced in a variety of settings over the years including emergency medicine, family medicine, homeless outreach, and pediatrics. . She often encounters vulnerable youth in her practice and is passionate about teaching clinical staff how to recognize vulnerabilities that make youth particularly susceptible to trafficking and exploitation, teaching youth how to advocate for themselves and learn body autonomy and boundaries for healthy relationships with themselves and others and advocating for vulnerable populations. She co-founded and co-leads the Human Trafficking Work Group at Children’s Mercy Hospital Kansas City which aims to increase recognition of victims in the health care setting and provide support for vulnerable youth in our area. She serves as a board member with the Teen Pregnancy and Prevention Partnership and as the Agency Representative Committee Chair with Missouri Family Health Council. Transcription:
Let's Talk About Teens
Trisha Williams: Hi guys. Welcome to the second season of the Advanced Practice Perspectives. I'm Trisha Williams.
Tobie O'Brien: And I'm Tobie O'Brien. This is a podcast created by advanced practice providers for advanced practice providers. Our goal is to provide you with education and inspiration. We will be chatting with pediatric experts on timely key topics and giving you an inside look at the various advanced practice roles at Children's Mercy.
Trisha Williams: We are so glad that you're joining us. So sit back, tune in and let's get started. Today, we will be chatting with Rachel Whitfield. She is a nurse practitioner in our Adolescent Medicine Clinic at Children's Mercy. Welcome to the podcast, Rachel.
Rachel Whitfield: Thank you. I'm so happy to be here.
Trisha Williams: We are so excited that you're here today. can you tell us in our listeners a little bit about yourself?
Rachel Whitfield: Sure. I am Rachel Whitfield. I am a family nurse practitioner, and I practice at Children's Mercy Hospital in Kansas City. I have a background in emergency medicine and I've done some community health and internal medicine and homeless outreach clinics. But I've landed in pediatrics. I've found my place probably forever with taking care of adolescents and young adults. I manage our Title X Reproductive Health Grant along with co-founding and co-leading our human trafficking work group at Children's Mercy as well. I'm also a board member of the Teen Pregnancy and Prevention Partnership. And I serve as the agency representative committee chair with the Missouri Family Health Council, who is our grantee for Title X.
Tobie O'Brien: Well, thank you for joining us, Rachel. Your work with human trafficking and our vulnerable youth is super inspiring. Will you tell us some ways that providers can recognize vulnerabilities in our patients?
Rachel Whitfield: Sure. I think it's important when talking about recognizing vulnerabilities, especially in a young adult, teen, adolescent population and even children. It can be really, really challenging to pinpoint vulnerabilities. Kids and teens and young adults are really good at making people around them believe that everything's okay and that they're doing okay when in fact they're often struggling with developing their identity and everything that's happening kind of around them and to them.
And so as pediatric healthcare providers specifically, we talk a lot about adverse childhood events, also known as ACEs. ACEs can cause toxic stress, which can lead to mental health diagnoses, such as anxiety, depression, PTSD, and can also lead to chronic illnesses, high blood pressure, heart disease, cancer, et cetera.
As I said, I was trained in family practice and I landed here in pediatrics because we really do a good job with preventative medicine and addressing ACEs is a great form of preventative medicine. But we don't do a good job of teaching people how to carry that into adulthood, which is kind of my goal in adolescent medicine. So as kids get older and they grow into young adults, we forget the impact of unaddressed ACEs that they can have on a young person's development and decision-making as they're transitioning into adulthood. And so I just cannot stress enough the importance of evaluating for those adverse childhood events and having these discussions with your adolescents and their caregivers about the importance of addressing those adverse events now, because of the potential long-term health effects later.
You know, and adverse childhood events, if you are not familiar include, but are not limited to, experiencing witnessing violence in your home or in the neighborhood or areas around you, any type of violence towards you or witnessing sexual, verbal or physical abuse, any type of neglect would be considered an adverse childhood, physical or emotional. And then experiencing intimate partner violence between your caregivers is also a huge adverse childhood event. Any type of parental or caregiver mental health or substance use disorder and any type of parental separation, so divorce is considered an adverse childhood event, death or parental incarceration.
So we really should be talking about these adverse childhood events with every clinic visit. It can be hard sometimes, and a lot of times opens up Pandora's box, right? But it's really, really, really important for us to look at this and consider how certain generational traumas can contribute to adverse childhood events. It can really take time to build that rapport between our patients and our caregivers and ourselves to get to a place where they would feel comfortable discussing that at a clinical visit. But it's really, really, really important.
I also think we can't talk about vulnerabilities in adolescents and young adults without considering brain development. So, I could do a whole podcast on this, but I will try to make it really short and really sweet. So the brain continues to kind of refine these neural pathways throughout the brain in response to experiences well into early adulthood. So it's believed that the frontal cortex isn't fully developed until between the ages of 23 and 25. The frontal cortex and the amygdala, they're both really responsible for what we would call emotional intelligence or emotional maturity, our judgment, our goal planning, motivation, impulse control, decision-making, memory, attention span.
Trisha Williams: All the things.
Rachel Whitfield: All of the things, right? And all of the things that people joke that teens are lacking, right? And it's really because it's developing, it's changing all the time based on the experiences that they're having. So this makes adolescents and young adults uniquely vulnerable to everything that happens around them. If they're experiencing healthy thoughts, healthy interactions, receiving healthy information or relationships, familial, romantic, platonic, all of those types of relationships, they're able to develop healthy relationships, develop healthy daily behaviors and use healthy thoughts every day. But if they're experiencing unhealthy thoughts, interactions, behaviors, they're going to have a really difficult time with developing these healthy behaviors throughout their lifetime.
Trisha Williams: I'm currently raising two teenagers now as a lot of our listeners know because I feel like I talk about them a lot. But it's true, like my teenagers will say something and they're like, "Well, why can't I make my own decision?" I'm like, "Because your brain's not fully developed. Like, that's my responsibility as your parent, that's your dad's responsibility as your parent." Like, we'll help you we'll guide you kind of things. But I feel like there's so much to be addressing with our teens, you know, at every clinic visit. And I know that ACEs is one of them for certain. Are there other things that providers should be addressing when meeting with our teens during a well kid visit?
Rachel Whitfield: Absolutely. There's so many things. And oftentimes, especially when I have learners or people who are in orientation with me, I'm like, "We really have to talk about this every single visit." And they're like, "How do you ever actually get anything done?" And it just takes time, right? But as with anything with practice, you just figure out ways to make it work. Clearly, obviously I'm passionate about assessing for adverse childhood events, but I really feel like the HEADSS assessment, doing that in some capacity at every visit. So you'd do it more in depth one at a well visit, a more kind of pointed one at a more acute visit. It's really important.
So if you're not familiar with HEADSS, HEADSS is an acronym we use to obtain history in adolescent visits. And so HEADSS, the H is for home, E is for education, A is for activities, D is for drugs. The first S is for suicidality. The second S is for sexuality. And so with home, you just want to assess do they have a safe home? Do they have everything they need at home? Or do they have supportive families, good support systems around them? Or are they in a more dysfunctional home? Do they have unstable home? Do they not have enough food in their home? Do they not have a good support system surrounding them?
And then for education, you just want to check and make sure that they're on track, their educational needs are being met and even starting to explore kind of career planning and what they want to do in the future, what they're thinking about doing in the future. And if they don't know, affirming that and telling them that it is A-okay to not know what you want to do for the rest of your life at 18. It's okay to explore and get to know what you like to ensure that you're going to have that job satisfaction later in life.
Activities, so looking at their peer groups, ensuring that they have peers around them who are similar age, having similar experiences that they're doing healthy, positive activities with; assessing whether they're involved in extracurricular activities within school or outside of school; assessing if they're working outside of, you know, their school responsibilities and then again, assessing for support systems. So this is going to be more adults outside of their guardianship who are also providing them with support because, as we know, having more positive adult influences other than parents on teens has a greater impact on their life later.
And then drugs, so drug, alcohol and vape or e-cigarette use, you always want to assess for that. And not just are they doing drugs, but are people around them doing any drugs or vaping or they're drinking alcohol?
And then suicidality, that's really just the mental health assessments, assessing for depression, anxiety or suicidal thoughts, self-harm. Eating disorders is really important to talk about, especially now with COVID-19 and we'll touch on that a little bit later in our talk, I think.
And then sexuality. So I would love to see more providers consistently discussing things like gender identity. As we know, LGBTQ+ youth are more likely to experience mental health disorders due to the nature of generally just not being or not feeling accepted by the people around them at school, at home and family, social places. It's important to make sure places where this population is seeking care, they feel safe and accepted. And a very easy way to do this is to ensure that we're not misgendering the people that we're caring for. I'm a huge advocate for reproductive health things also and so ensuring that we're discussing those attributes of healthy relationships, preventing sexual coercion and exploitation, talking about trafficking and what that really looks like with teens and that it does not look like the movies where they snatch you. It looks more like building unhealthy relationships, et cetera, right? But we'll talk about that a little bit more, I think, as well later.
But I also think it's really important for providers and just adults who are in the lives of teens to really understand gender identity versus sexual orientation versus gender pronoun and gender expression. Teens really get it. And if you just ask them, they will explain it to you. As adults, we really struggle because this is such a new concept for us.
And so, you know, really over simplifying this, I think, understanding gender identity versus assigned sex. So your assigned sex, or also known as gender at birth, is a label that you're given at birth. It's based on your genitals. It's based on hormones and chromosomes, et cetera. So when someone's born, they have a vagina, assigned female at birth. Gender identity is more of who a person is on the inside. It's their internal sense of self, so it can differ from that gender assigned at birth.
Terms include, but are not limited to cisgender, so that means that your gender identity matches with your gender at birth. Transgender male or female would be someone whose gender identity does not align with their gender assigned at birth. Gender fluid or gender non-conforming and gender non-binary are all terms-- they're not used interchangeably, but I'm just going to lump them together for time's sake to say they're all terms that apply to people who don't really want to or don't really feel that they align with any specific gender label per se. They really express attributes of all genders and that's how they want to express their gender or prefer their gender to be expressed.
And then sexual orientation is more of like think of it as who you want to be with, who you're attracted to both romantically, sexually, emotionally and physically. And then pronouns are just those terms that we use to reflect one's gender identity. And so it includes, but not limited to he, she, them or none. Some people prefer not to have a gender pronoun at all and we honor that.
And then I have some honorable mentions here just really quickly, if you have extra time, because you know, we all have so much time in our clinic visits, right?
Tobie O'Brien: Sure.
Rachel Whitfield: But just talking about self-care routines, the importance of good quality sleep habits and getting good sleep; the importance of daily physical activity, getting outside, getting some sun. It doesn't have to be a Peloton workout, but just getting outside and getting a walk a few times a day. Healthy diets focusing on health, not weight. Focusing on health is so important with teens.
Trisha Williams: Yeah, so important. I mean, I feel like we could do a whole podcast just talking about gender identity and the topics that you had mentioned. So I really appreciate you just talking on that, but I think, you know, like you said, for adults, it's kind of a hard concept for-- it's a newer concept, right? I'm not going to say it's a hard concept for us to wrap our heads around. It's just a newer concept that we need to educate ourselves about to be able to help our patients. So I think that that's a good podcast for the future discussions because I really feel like that there's a lot to dive in there with.
Rachel Whitfield: I absolutely agree with that. It's not being afraid to ask, right? And that's what I hear from teens all the time. Just ask if you don't understand. And if you mis-gender someone, just apologize, "I'm so sorry," and just get it right, you know.
Trisha Williams: Yeah.
Rachel Whitfield: Definitely.
Trisha Williams: And be respectful about it, you know, and just get it, get it right. Be respectful.
Tobie O'Brien: So thank you so much for that HEADSS acronym. That is very helpful. So as we in a subspecialty clinic might be visiting with families, a lot of times I will ask the teen how's school going, tell me about your friends and that sort of thing, hit on all of those. But say I did and somebody gave me an answer that was worrisome or concerning, what would be the best action for me to take afterwards?
Rachel Whitfield: So that's a great question. I think always starting with acknowledging that what someone has shared with you could have been very hard and that they entrusted you with that answer, it's always really important, so "Thank you for telling me that. I know that must have been hard for you to share." Social work is always a great resource anytime we get kind of a positive response in the HEADSS assessment. Depending on what their responses too would depend on your level of response, right? And so if they disclose to you, "Yeah, I did smoke marijuana last week. I felt terrible. I hated it. I never want to do it again," then it's, you know, just affirming like, "It's totally normal as an adolescent to want to try these things or be curious or understand why other people do them. Sounds like you did not love it. And so in the future prior to doing those things, I think it's really important for you to have an adult identified that you talk to about that before you were to try those things and then ensuring safety, you know, making sure you were around people that you trusted, you weren't driving a car while you were under the influence," et cetera.
If they were to disclose they went to a party and smoked marijuana and they were sexually assaulted, that is a whole d ifferent level of response, right? But really just affirming them, making them feel safe and then calling in social work is really probably the best response for most situations. Does that answer your question?
Tobie O'Brien: It does. Yes, you know, we think about pediatrics, but like, really, I feel like teens, it's so different than just pediatrics because what a different lens to look through as you're talking with these kids, and they are so kids, because like you said, their brain is not developed really until they're 23, 25. And so I'm just thinking about just how much there is to like how their brain is growing and how we interact with them so differently at age 8 versus age 12 to 15 and then 18 and... Oh, it's just a lot. So I think it's so fantastic that we have people like you that are just so specialty trained in adolescents. I am thankful for that.
Rachel Whitfield: Yeah. Thank you. What you're saying is spot on. It's absolutely correct.
Trisha Williams: It's definitely a challenge all in itself, you know, and with the ever changing world that we are living in right now, can we share or can we talk a little bit about what you see as the biggest hurdles for our teens, you know, now in 2022, after we've been through two years of a pandemic with COVID-19? I feel like in my own home, we have challenges, but if you're not raising teens, I don't know if you're abreast as to what is going on with our teenage population. So can you share a little bit about what you see as the biggest health hurdles for our kiddos or teenagers? They're not kiddos, they're teens.
Rachel Whitfield: No, absolutely. I think historically, if you would have asked me this pre-COVID-19, I really would have focused on-- you know, I think we all know this, but the number one cause of death for those age 10 to 24 is going to be unintentional injury. So that includes traffic accidents, which would be even considered under cycling accidents or ATV accidents, et cetera, and then drowning falls under that unintentional injury. And then kind of close second or runners up would be violence, mental health, substance abuse, communicable diseases or infections, and then chronic diseases. But COVID-19 has really exposed glaring deficiencies in our ability to care for adolescents and young adults, specifically in the areas of mental health, substance abuse and sexual and reproductive health. And so, it's still really important to keep them that unintentional injuries are the number one cause of death for adolescents and young adults. And so always doing kind of that safety planning with them, "Wear your seatbelt," "Don't drink and drive," "Wear a helmet when you ride your bike," et cetera.
The mental health substance abuse and reproductive health concerns really have come to the forefront since COVID-19. And so I think first and foremost, living through a pandemic during this formative time of life really is something that we all have to remember. I just this week had a patient come in a young lady who we had seen before, and we hadn't seen her since pre-pandemic and she was just, you know, going along in adolescence, doing great in school, and she was a whole different kid. And I really couldn't get out of her, kind of like, "Did something happened? Have you experienced something?" And as I was thinking about it, I was like, "She experienced the whole pandemic." That's what happened. That's what led us to this. And so it was really glaring that I think, as adults, we're kind of like, "Well, it's a pandemic, but we did this or we did that. But for adults. It's a pandemic and that's a statement in itself. I hope that makes sense.
Trisha Williams: It does. And I'm wondering, like, you know, in the beginning of this podcast, we talked about ACEs, is going through the pandemic going to be an ACE for every single one of these teenage people? And how are we going to address that? Because every single person has gone through this and they're all gonna have their different responses. So is this going to be an ACE or should it be considered an ACE for everybody?
Rachel Whitfield: So absolutely, I think that this kind of leads right into my mental health piece of talking about what COVID has done to change what we're focusing on with adolescents and young adults. Suicide is the second leading cause of death for adolescents and young adults. And the rates of suicide has steadily increased since 1999. OPA reports that approximately 49% of adolescents have had a mental health diagnosis in their lifetime. All of these diagnosis have increased since COVID-19 emerged. So 32% of youth ages 13 to 18 have been diagnosed with an anxiety disorder, 13% of youths ages 12 through 17 have been diagnosed with depression, and 3% of youth ages 13 to 18 have been diagnosed with an eating disorder.
COVID-19 has exacerbated the feelings of isolation. It's decreased availability of our mental health care, which which was already insufficient prior to the pandemic. And so our healthcare systems are already lacking the infrastructure and the availability of mental health providers and services and preventative services to prevent anxiety and depression and eating disorders in youth. But COVID-19 has made the ability for youth and their caregivers to seek care worse and it has multiplied the demand for mental health care.
You know, and then that kind of leads right into substance use. One of our worries as adolescent health care providers is if we do have an undiagnosed mental health disorder, and I'm going to just kind of bring in ADHD for this, because it's a huge concern with kids that have undiagnosed ADHD that they're going to self-medicate. And we'd find a lot of youth who report using marijuana regularly. They have an underlying anxiety disorder and they're self-medicating with marijuana. And if we are not seeing them in clinic and able to address this early on, they're going to start medicating, which can lead to bigger problems later.
Thinking about marijuana, for instance, 7% of eighth graders and 30% of high school seniors report using marijuana within the last year. Marijuana has effects on your brain development, learning, and memory, all the parts of the brain that's developing at that time. And it's linked with development and mental health disorders into adulthood. We don't know if, you know, the use of marijuana is causative or, if again, they're self-medicating because a lot of times they don't have access to healthcare to receive that diagnosis prior to their use. And then the legalization of marijuana in recent years has caused a lot of mixed messaging for adolescents and young adults around the safety of its use. And so while actually the research does show that it is much safer if one delays use of marijuana into their late 20s, early 30s, it still has its health consequences, don't get me wrong. But it is detrimental when you're using it through adolescence and young adulthood regularly. It is detrimental to the brain, And so I think that because there's so much positivity around marijuana use for adults, teens perceive it as safe for themselves, which is not accurate.
Trisha Williams: Because they don't think about their brain development the way that we do.
Rachel Whitfield: Exactly. And they look like adults.
Trisha Williams: Oh, right. They do
Rachel Whitfield: I mean, we have 14-year-old kids who look like they're 20, which is normal, right? That's physical development. So then people start to treat them like adults and they are really still children learning and developing, absolutely.
Trisha Williams: Yeah, correct. I mean, I feel like we just hit the tip of the iceberg with our conversations today and I feel like we can, you know, spend hours talking about each specific topic. I really appreciate your knowledge set and the information that you are able to share with us today. I'm going to switch to kind of a little brighter side of things and, you know, what do you see in our teens today that gives you hope for the next generation?
Rachel Whitfield: Oh, my goodness. My favorite topic. And I get a little worked up when I talk about this, because teens are so resilient and that we use that term a lot. But when we all look back, I think, and say, "Man, I would never go back to eighth grade." I don't know many people who are like, "I loved middle school," you know.
Tobie O'Brien: Sure.
Rachel Whitfield: Most of us don't look back and think, "I would have to get back to eighth grade." And to do that in a world where there's the internet-- we didn't even talk about the internet, right?
Trisha Williams: No.
Tobie O'Brien: We didn't even talk about the internet.
Trisha Williams: That's like a two-hour podcast, right?
Rachel Whitfield: Yes.
Tobie O'Brien: I see mini series ahead of us for this.
Rachel Whitfield: Yeah. Right? I mean, we didn't even touch on the effects of internet and texting and sexting and all of these other pieces.
Trisha Williams: Social media.
Rachel Whitfield: Yes. That we did not have to endure growing up, right? And I didn't get my first cell phone until college and it was a flip phone. There were no pictures on it, you know? And so I think that it's really important to understand that we can relate to the teen experience, we can relate to kind of the coming of yourself and navigating who you are and what kind of person you want to be as you get older and what you want to do. Teens are doing such a fantastic job of growing up really fast in unprecedented times and making the best of it and focusing on self-care and really standing up for themselves and their needs, and that is so inspiring to me.
And I think that teens are also doing a great job of recognizing those ACEs and calling out things in their families or in ways that their parents were raised to say, "That's not healthy and I'm not going to do that moving forward. I'm going to stop that here." And I just see so much hope for the future. It can look very bleak sometimes day to day to day in our clinics or watching the news or being on social media, but then when you really sit down and start talking to adolescents and young adults, you realize, "Wow, these kids get it. They get it." And they are going to make some really, really great changes and they are so compassionate for the experiences of other people, which also really gives me hope. They're really aware of what everyone else is experiencing. I have a 13-year-old daughter who is in seventh grade. And writing statistics, as I was preparing for today really was like, "Oh my gosh, we're entering into the thick of it here."
Trisha Williams: Into the thick of it, for sure. I would have to say that I am inspired by their courage. I mean, they are just so courageous and, you know, I have a 17 and a 15-year-old and their friends and their ability to articulate their needs and their ability to, you know, even get up and give class presentations in front of 50 some students and classmates, I was never able to be that courageous at this age, so their courage, for sure.
Rachel Whitfield: Yeah, absolutely. And they really are still accepting, which we do deal with bullying and all of that too still, especially with the internet, but I just listened to my daughter and her friends talk and I'm like, "Well, what do you think about that?" And they're like, "You know..." I think they can take into account experiences that people have and that's what shaped them into who they are. And they're like, "You know, I wouldn't do that,, but that's what they do and I just want to show them better" kind of situation. I'm like, "Yes. Yeah."
Trisha Williams: Yup.
Tobie O'Brien: Well, Rachel, thank you so much for chatting with us today. And like we've said, we really would love to have you back again. There's so much more that we could talk about. We left in each episode with a question that we ask all of our guests. So the question is, what is the best overall piece of advice you have read or heard lately?
Rachel Whitfield: Okay. I haven't heard it lately. I mean, it's not new for me, but I think it's a great reminder, and it's Black History Month. So I'm going to go with Frederick Douglass' quote, "It's easier to build strong children than to repair broken men."
Tobie O'Brien: Hmm. Yeah.
Trisha Williams: That gave me the chills right now. That is beautiful. Beautiful. I love that so much. So thank you so much, Rachel, for sharing your knowledge, your wonderful piece of advice, and just spending your morning with us here on our podcast. And listeners, thanks so much for tuning in today.
Rachel Whitfield: Thank you so much.
Tobie O'Brien: If you guys have a topic you want to hear more about or interested in being a guest, please email us at either tdobrien@cmh.edu or tWilliams@cmh.edu. Thanks again, Rachel. And thank you to our guests for tuning in today.
Let's Talk About Teens
Trisha Williams: Hi guys. Welcome to the second season of the Advanced Practice Perspectives. I'm Trisha Williams.
Tobie O'Brien: And I'm Tobie O'Brien. This is a podcast created by advanced practice providers for advanced practice providers. Our goal is to provide you with education and inspiration. We will be chatting with pediatric experts on timely key topics and giving you an inside look at the various advanced practice roles at Children's Mercy.
Trisha Williams: We are so glad that you're joining us. So sit back, tune in and let's get started. Today, we will be chatting with Rachel Whitfield. She is a nurse practitioner in our Adolescent Medicine Clinic at Children's Mercy. Welcome to the podcast, Rachel.
Rachel Whitfield: Thank you. I'm so happy to be here.
Trisha Williams: We are so excited that you're here today. can you tell us in our listeners a little bit about yourself?
Rachel Whitfield: Sure. I am Rachel Whitfield. I am a family nurse practitioner, and I practice at Children's Mercy Hospital in Kansas City. I have a background in emergency medicine and I've done some community health and internal medicine and homeless outreach clinics. But I've landed in pediatrics. I've found my place probably forever with taking care of adolescents and young adults. I manage our Title X Reproductive Health Grant along with co-founding and co-leading our human trafficking work group at Children's Mercy as well. I'm also a board member of the Teen Pregnancy and Prevention Partnership. And I serve as the agency representative committee chair with the Missouri Family Health Council, who is our grantee for Title X.
Tobie O'Brien: Well, thank you for joining us, Rachel. Your work with human trafficking and our vulnerable youth is super inspiring. Will you tell us some ways that providers can recognize vulnerabilities in our patients?
Rachel Whitfield: Sure. I think it's important when talking about recognizing vulnerabilities, especially in a young adult, teen, adolescent population and even children. It can be really, really challenging to pinpoint vulnerabilities. Kids and teens and young adults are really good at making people around them believe that everything's okay and that they're doing okay when in fact they're often struggling with developing their identity and everything that's happening kind of around them and to them.
And so as pediatric healthcare providers specifically, we talk a lot about adverse childhood events, also known as ACEs. ACEs can cause toxic stress, which can lead to mental health diagnoses, such as anxiety, depression, PTSD, and can also lead to chronic illnesses, high blood pressure, heart disease, cancer, et cetera.
As I said, I was trained in family practice and I landed here in pediatrics because we really do a good job with preventative medicine and addressing ACEs is a great form of preventative medicine. But we don't do a good job of teaching people how to carry that into adulthood, which is kind of my goal in adolescent medicine. So as kids get older and they grow into young adults, we forget the impact of unaddressed ACEs that they can have on a young person's development and decision-making as they're transitioning into adulthood. And so I just cannot stress enough the importance of evaluating for those adverse childhood events and having these discussions with your adolescents and their caregivers about the importance of addressing those adverse events now, because of the potential long-term health effects later.
You know, and adverse childhood events, if you are not familiar include, but are not limited to, experiencing witnessing violence in your home or in the neighborhood or areas around you, any type of violence towards you or witnessing sexual, verbal or physical abuse, any type of neglect would be considered an adverse childhood, physical or emotional. And then experiencing intimate partner violence between your caregivers is also a huge adverse childhood event. Any type of parental or caregiver mental health or substance use disorder and any type of parental separation, so divorce is considered an adverse childhood event, death or parental incarceration.
So we really should be talking about these adverse childhood events with every clinic visit. It can be hard sometimes, and a lot of times opens up Pandora's box, right? But it's really, really, really important for us to look at this and consider how certain generational traumas can contribute to adverse childhood events. It can really take time to build that rapport between our patients and our caregivers and ourselves to get to a place where they would feel comfortable discussing that at a clinical visit. But it's really, really, really important.
I also think we can't talk about vulnerabilities in adolescents and young adults without considering brain development. So, I could do a whole podcast on this, but I will try to make it really short and really sweet. So the brain continues to kind of refine these neural pathways throughout the brain in response to experiences well into early adulthood. So it's believed that the frontal cortex isn't fully developed until between the ages of 23 and 25. The frontal cortex and the amygdala, they're both really responsible for what we would call emotional intelligence or emotional maturity, our judgment, our goal planning, motivation, impulse control, decision-making, memory, attention span.
Trisha Williams: All the things.
Rachel Whitfield: All of the things, right? And all of the things that people joke that teens are lacking, right? And it's really because it's developing, it's changing all the time based on the experiences that they're having. So this makes adolescents and young adults uniquely vulnerable to everything that happens around them. If they're experiencing healthy thoughts, healthy interactions, receiving healthy information or relationships, familial, romantic, platonic, all of those types of relationships, they're able to develop healthy relationships, develop healthy daily behaviors and use healthy thoughts every day. But if they're experiencing unhealthy thoughts, interactions, behaviors, they're going to have a really difficult time with developing these healthy behaviors throughout their lifetime.
Trisha Williams: I'm currently raising two teenagers now as a lot of our listeners know because I feel like I talk about them a lot. But it's true, like my teenagers will say something and they're like, "Well, why can't I make my own decision?" I'm like, "Because your brain's not fully developed. Like, that's my responsibility as your parent, that's your dad's responsibility as your parent." Like, we'll help you we'll guide you kind of things. But I feel like there's so much to be addressing with our teens, you know, at every clinic visit. And I know that ACEs is one of them for certain. Are there other things that providers should be addressing when meeting with our teens during a well kid visit?
Rachel Whitfield: Absolutely. There's so many things. And oftentimes, especially when I have learners or people who are in orientation with me, I'm like, "We really have to talk about this every single visit." And they're like, "How do you ever actually get anything done?" And it just takes time, right? But as with anything with practice, you just figure out ways to make it work. Clearly, obviously I'm passionate about assessing for adverse childhood events, but I really feel like the HEADSS assessment, doing that in some capacity at every visit. So you'd do it more in depth one at a well visit, a more kind of pointed one at a more acute visit. It's really important.
So if you're not familiar with HEADSS, HEADSS is an acronym we use to obtain history in adolescent visits. And so HEADSS, the H is for home, E is for education, A is for activities, D is for drugs. The first S is for suicidality. The second S is for sexuality. And so with home, you just want to assess do they have a safe home? Do they have everything they need at home? Or do they have supportive families, good support systems around them? Or are they in a more dysfunctional home? Do they have unstable home? Do they not have enough food in their home? Do they not have a good support system surrounding them?
And then for education, you just want to check and make sure that they're on track, their educational needs are being met and even starting to explore kind of career planning and what they want to do in the future, what they're thinking about doing in the future. And if they don't know, affirming that and telling them that it is A-okay to not know what you want to do for the rest of your life at 18. It's okay to explore and get to know what you like to ensure that you're going to have that job satisfaction later in life.
Activities, so looking at their peer groups, ensuring that they have peers around them who are similar age, having similar experiences that they're doing healthy, positive activities with; assessing whether they're involved in extracurricular activities within school or outside of school; assessing if they're working outside of, you know, their school responsibilities and then again, assessing for support systems. So this is going to be more adults outside of their guardianship who are also providing them with support because, as we know, having more positive adult influences other than parents on teens has a greater impact on their life later.
And then drugs, so drug, alcohol and vape or e-cigarette use, you always want to assess for that. And not just are they doing drugs, but are people around them doing any drugs or vaping or they're drinking alcohol?
And then suicidality, that's really just the mental health assessments, assessing for depression, anxiety or suicidal thoughts, self-harm. Eating disorders is really important to talk about, especially now with COVID-19 and we'll touch on that a little bit later in our talk, I think.
And then sexuality. So I would love to see more providers consistently discussing things like gender identity. As we know, LGBTQ+ youth are more likely to experience mental health disorders due to the nature of generally just not being or not feeling accepted by the people around them at school, at home and family, social places. It's important to make sure places where this population is seeking care, they feel safe and accepted. And a very easy way to do this is to ensure that we're not misgendering the people that we're caring for. I'm a huge advocate for reproductive health things also and so ensuring that we're discussing those attributes of healthy relationships, preventing sexual coercion and exploitation, talking about trafficking and what that really looks like with teens and that it does not look like the movies where they snatch you. It looks more like building unhealthy relationships, et cetera, right? But we'll talk about that a little bit more, I think, as well later.
But I also think it's really important for providers and just adults who are in the lives of teens to really understand gender identity versus sexual orientation versus gender pronoun and gender expression. Teens really get it. And if you just ask them, they will explain it to you. As adults, we really struggle because this is such a new concept for us.
And so, you know, really over simplifying this, I think, understanding gender identity versus assigned sex. So your assigned sex, or also known as gender at birth, is a label that you're given at birth. It's based on your genitals. It's based on hormones and chromosomes, et cetera. So when someone's born, they have a vagina, assigned female at birth. Gender identity is more of who a person is on the inside. It's their internal sense of self, so it can differ from that gender assigned at birth.
Terms include, but are not limited to cisgender, so that means that your gender identity matches with your gender at birth. Transgender male or female would be someone whose gender identity does not align with their gender assigned at birth. Gender fluid or gender non-conforming and gender non-binary are all terms-- they're not used interchangeably, but I'm just going to lump them together for time's sake to say they're all terms that apply to people who don't really want to or don't really feel that they align with any specific gender label per se. They really express attributes of all genders and that's how they want to express their gender or prefer their gender to be expressed.
And then sexual orientation is more of like think of it as who you want to be with, who you're attracted to both romantically, sexually, emotionally and physically. And then pronouns are just those terms that we use to reflect one's gender identity. And so it includes, but not limited to he, she, them or none. Some people prefer not to have a gender pronoun at all and we honor that.
And then I have some honorable mentions here just really quickly, if you have extra time, because you know, we all have so much time in our clinic visits, right?
Tobie O'Brien: Sure.
Rachel Whitfield: But just talking about self-care routines, the importance of good quality sleep habits and getting good sleep; the importance of daily physical activity, getting outside, getting some sun. It doesn't have to be a Peloton workout, but just getting outside and getting a walk a few times a day. Healthy diets focusing on health, not weight. Focusing on health is so important with teens.
Trisha Williams: Yeah, so important. I mean, I feel like we could do a whole podcast just talking about gender identity and the topics that you had mentioned. So I really appreciate you just talking on that, but I think, you know, like you said, for adults, it's kind of a hard concept for-- it's a newer concept, right? I'm not going to say it's a hard concept for us to wrap our heads around. It's just a newer concept that we need to educate ourselves about to be able to help our patients. So I think that that's a good podcast for the future discussions because I really feel like that there's a lot to dive in there with.
Rachel Whitfield: I absolutely agree with that. It's not being afraid to ask, right? And that's what I hear from teens all the time. Just ask if you don't understand. And if you mis-gender someone, just apologize, "I'm so sorry," and just get it right, you know.
Trisha Williams: Yeah.
Rachel Whitfield: Definitely.
Trisha Williams: And be respectful about it, you know, and just get it, get it right. Be respectful.
Tobie O'Brien: So thank you so much for that HEADSS acronym. That is very helpful. So as we in a subspecialty clinic might be visiting with families, a lot of times I will ask the teen how's school going, tell me about your friends and that sort of thing, hit on all of those. But say I did and somebody gave me an answer that was worrisome or concerning, what would be the best action for me to take afterwards?
Rachel Whitfield: So that's a great question. I think always starting with acknowledging that what someone has shared with you could have been very hard and that they entrusted you with that answer, it's always really important, so "Thank you for telling me that. I know that must have been hard for you to share." Social work is always a great resource anytime we get kind of a positive response in the HEADSS assessment. Depending on what their responses too would depend on your level of response, right? And so if they disclose to you, "Yeah, I did smoke marijuana last week. I felt terrible. I hated it. I never want to do it again," then it's, you know, just affirming like, "It's totally normal as an adolescent to want to try these things or be curious or understand why other people do them. Sounds like you did not love it. And so in the future prior to doing those things, I think it's really important for you to have an adult identified that you talk to about that before you were to try those things and then ensuring safety, you know, making sure you were around people that you trusted, you weren't driving a car while you were under the influence," et cetera.
If they were to disclose they went to a party and smoked marijuana and they were sexually assaulted, that is a whole d ifferent level of response, right? But really just affirming them, making them feel safe and then calling in social work is really probably the best response for most situations. Does that answer your question?
Tobie O'Brien: It does. Yes, you know, we think about pediatrics, but like, really, I feel like teens, it's so different than just pediatrics because what a different lens to look through as you're talking with these kids, and they are so kids, because like you said, their brain is not developed really until they're 23, 25. And so I'm just thinking about just how much there is to like how their brain is growing and how we interact with them so differently at age 8 versus age 12 to 15 and then 18 and... Oh, it's just a lot. So I think it's so fantastic that we have people like you that are just so specialty trained in adolescents. I am thankful for that.
Rachel Whitfield: Yeah. Thank you. What you're saying is spot on. It's absolutely correct.
Trisha Williams: It's definitely a challenge all in itself, you know, and with the ever changing world that we are living in right now, can we share or can we talk a little bit about what you see as the biggest hurdles for our teens, you know, now in 2022, after we've been through two years of a pandemic with COVID-19? I feel like in my own home, we have challenges, but if you're not raising teens, I don't know if you're abreast as to what is going on with our teenage population. So can you share a little bit about what you see as the biggest health hurdles for our kiddos or teenagers? They're not kiddos, they're teens.
Rachel Whitfield: No, absolutely. I think historically, if you would have asked me this pre-COVID-19, I really would have focused on-- you know, I think we all know this, but the number one cause of death for those age 10 to 24 is going to be unintentional injury. So that includes traffic accidents, which would be even considered under cycling accidents or ATV accidents, et cetera, and then drowning falls under that unintentional injury. And then kind of close second or runners up would be violence, mental health, substance abuse, communicable diseases or infections, and then chronic diseases. But COVID-19 has really exposed glaring deficiencies in our ability to care for adolescents and young adults, specifically in the areas of mental health, substance abuse and sexual and reproductive health. And so, it's still really important to keep them that unintentional injuries are the number one cause of death for adolescents and young adults. And so always doing kind of that safety planning with them, "Wear your seatbelt," "Don't drink and drive," "Wear a helmet when you ride your bike," et cetera.
The mental health substance abuse and reproductive health concerns really have come to the forefront since COVID-19. And so I think first and foremost, living through a pandemic during this formative time of life really is something that we all have to remember. I just this week had a patient come in a young lady who we had seen before, and we hadn't seen her since pre-pandemic and she was just, you know, going along in adolescence, doing great in school, and she was a whole different kid. And I really couldn't get out of her, kind of like, "Did something happened? Have you experienced something?" And as I was thinking about it, I was like, "She experienced the whole pandemic." That's what happened. That's what led us to this. And so it was really glaring that I think, as adults, we're kind of like, "Well, it's a pandemic, but we did this or we did that. But for adults. It's a pandemic and that's a statement in itself. I hope that makes sense.
Trisha Williams: It does. And I'm wondering, like, you know, in the beginning of this podcast, we talked about ACEs, is going through the pandemic going to be an ACE for every single one of these teenage people? And how are we going to address that? Because every single person has gone through this and they're all gonna have their different responses. So is this going to be an ACE or should it be considered an ACE for everybody?
Rachel Whitfield: So absolutely, I think that this kind of leads right into my mental health piece of talking about what COVID has done to change what we're focusing on with adolescents and young adults. Suicide is the second leading cause of death for adolescents and young adults. And the rates of suicide has steadily increased since 1999. OPA reports that approximately 49% of adolescents have had a mental health diagnosis in their lifetime. All of these diagnosis have increased since COVID-19 emerged. So 32% of youth ages 13 to 18 have been diagnosed with an anxiety disorder, 13% of youths ages 12 through 17 have been diagnosed with depression, and 3% of youth ages 13 to 18 have been diagnosed with an eating disorder.
COVID-19 has exacerbated the feelings of isolation. It's decreased availability of our mental health care, which which was already insufficient prior to the pandemic. And so our healthcare systems are already lacking the infrastructure and the availability of mental health providers and services and preventative services to prevent anxiety and depression and eating disorders in youth. But COVID-19 has made the ability for youth and their caregivers to seek care worse and it has multiplied the demand for mental health care.
You know, and then that kind of leads right into substance use. One of our worries as adolescent health care providers is if we do have an undiagnosed mental health disorder, and I'm going to just kind of bring in ADHD for this, because it's a huge concern with kids that have undiagnosed ADHD that they're going to self-medicate. And we'd find a lot of youth who report using marijuana regularly. They have an underlying anxiety disorder and they're self-medicating with marijuana. And if we are not seeing them in clinic and able to address this early on, they're going to start medicating, which can lead to bigger problems later.
Thinking about marijuana, for instance, 7% of eighth graders and 30% of high school seniors report using marijuana within the last year. Marijuana has effects on your brain development, learning, and memory, all the parts of the brain that's developing at that time. And it's linked with development and mental health disorders into adulthood. We don't know if, you know, the use of marijuana is causative or, if again, they're self-medicating because a lot of times they don't have access to healthcare to receive that diagnosis prior to their use. And then the legalization of marijuana in recent years has caused a lot of mixed messaging for adolescents and young adults around the safety of its use. And so while actually the research does show that it is much safer if one delays use of marijuana into their late 20s, early 30s, it still has its health consequences, don't get me wrong. But it is detrimental when you're using it through adolescence and young adulthood regularly. It is detrimental to the brain, And so I think that because there's so much positivity around marijuana use for adults, teens perceive it as safe for themselves, which is not accurate.
Trisha Williams: Because they don't think about their brain development the way that we do.
Rachel Whitfield: Exactly. And they look like adults.
Trisha Williams: Oh, right. They do
Rachel Whitfield: I mean, we have 14-year-old kids who look like they're 20, which is normal, right? That's physical development. So then people start to treat them like adults and they are really still children learning and developing, absolutely.
Trisha Williams: Yeah, correct. I mean, I feel like we just hit the tip of the iceberg with our conversations today and I feel like we can, you know, spend hours talking about each specific topic. I really appreciate your knowledge set and the information that you are able to share with us today. I'm going to switch to kind of a little brighter side of things and, you know, what do you see in our teens today that gives you hope for the next generation?
Rachel Whitfield: Oh, my goodness. My favorite topic. And I get a little worked up when I talk about this, because teens are so resilient and that we use that term a lot. But when we all look back, I think, and say, "Man, I would never go back to eighth grade." I don't know many people who are like, "I loved middle school," you know.
Tobie O'Brien: Sure.
Rachel Whitfield: Most of us don't look back and think, "I would have to get back to eighth grade." And to do that in a world where there's the internet-- we didn't even talk about the internet, right?
Trisha Williams: No.
Tobie O'Brien: We didn't even talk about the internet.
Trisha Williams: That's like a two-hour podcast, right?
Rachel Whitfield: Yes.
Tobie O'Brien: I see mini series ahead of us for this.
Rachel Whitfield: Yeah. Right? I mean, we didn't even touch on the effects of internet and texting and sexting and all of these other pieces.
Trisha Williams: Social media.
Rachel Whitfield: Yes. That we did not have to endure growing up, right? And I didn't get my first cell phone until college and it was a flip phone. There were no pictures on it, you know? And so I think that it's really important to understand that we can relate to the teen experience, we can relate to kind of the coming of yourself and navigating who you are and what kind of person you want to be as you get older and what you want to do. Teens are doing such a fantastic job of growing up really fast in unprecedented times and making the best of it and focusing on self-care and really standing up for themselves and their needs, and that is so inspiring to me.
And I think that teens are also doing a great job of recognizing those ACEs and calling out things in their families or in ways that their parents were raised to say, "That's not healthy and I'm not going to do that moving forward. I'm going to stop that here." And I just see so much hope for the future. It can look very bleak sometimes day to day to day in our clinics or watching the news or being on social media, but then when you really sit down and start talking to adolescents and young adults, you realize, "Wow, these kids get it. They get it." And they are going to make some really, really great changes and they are so compassionate for the experiences of other people, which also really gives me hope. They're really aware of what everyone else is experiencing. I have a 13-year-old daughter who is in seventh grade. And writing statistics, as I was preparing for today really was like, "Oh my gosh, we're entering into the thick of it here."
Trisha Williams: Into the thick of it, for sure. I would have to say that I am inspired by their courage. I mean, they are just so courageous and, you know, I have a 17 and a 15-year-old and their friends and their ability to articulate their needs and their ability to, you know, even get up and give class presentations in front of 50 some students and classmates, I was never able to be that courageous at this age, so their courage, for sure.
Rachel Whitfield: Yeah, absolutely. And they really are still accepting, which we do deal with bullying and all of that too still, especially with the internet, but I just listened to my daughter and her friends talk and I'm like, "Well, what do you think about that?" And they're like, "You know..." I think they can take into account experiences that people have and that's what shaped them into who they are. And they're like, "You know, I wouldn't do that,, but that's what they do and I just want to show them better" kind of situation. I'm like, "Yes. Yeah."
Trisha Williams: Yup.
Tobie O'Brien: Well, Rachel, thank you so much for chatting with us today. And like we've said, we really would love to have you back again. There's so much more that we could talk about. We left in each episode with a question that we ask all of our guests. So the question is, what is the best overall piece of advice you have read or heard lately?
Rachel Whitfield: Okay. I haven't heard it lately. I mean, it's not new for me, but I think it's a great reminder, and it's Black History Month. So I'm going to go with Frederick Douglass' quote, "It's easier to build strong children than to repair broken men."
Tobie O'Brien: Hmm. Yeah.
Trisha Williams: That gave me the chills right now. That is beautiful. Beautiful. I love that so much. So thank you so much, Rachel, for sharing your knowledge, your wonderful piece of advice, and just spending your morning with us here on our podcast. And listeners, thanks so much for tuning in today.
Rachel Whitfield: Thank you so much.
Tobie O'Brien: If you guys have a topic you want to hear more about or interested in being a guest, please email us at either tdobrien@cmh.edu or tWilliams@cmh.edu. Thanks again, Rachel. And thank you to our guests for tuning in today.