These findings, from a Stanford University School of Medicine study, come more than a decade after the American Medical Association issued clear recommendations for yearly health counseling targeting teen smoking, unintended pregnancy and other preventable woes.

The results, published in the May issue of the Journal of Adolescent Health, come from the first national review of trends in an array of teen health counseling services. The study focused on outpatients aged 13-18.

"When we look at the services these adolescents are receiving, we simply find they are not receiving many services that are strongly recommended," said co-author Randall Stafford, MD, PhD, associate professor of medicine at the Stanford Prevention Research Center.

Among the significant findings were:

Teens were most likely to be counseled on diet and exercise: About one-quarter of all checkups included these health-promoting discussions.

Skin cancer was least likely to come up: About 3 percent of teens' checkup visits mentioned the dangers of sun worship.

About 5 percent of all checkups included counseling related to HIV and other sexually transmitted diseases. The rate for family planning discussions was about 8 percent.

The study also found the most common reason for teen girls' medical visits was prenatal care, and the most common diagnosis was pregnancy. "That's really alarming," especially in light of the low counseling rates for sexual behaviors, said lead author Jun Ma, MD, RD, PhD, research associate at the Stanford Prevention Research Center.

Ma and Stafford, along with statistician Yun Wang, examined health services teens received during almost 337 million outpatient visits between 1993 and 2000, as reported in two national databases from the National Center for Health Statistics. One dataset reported health-care services provided by office-based physicians; the other documented visits to hospital outpatient departments.

Ma said the teen counseling rates are much lower than the research team expected, based on the clear guidelines for regular preventive counseling. "We know adolescence is a key transition stage," she said.

"Research is clear that adolescents are at risk for adopting health-compromising behaviors." At the same time, research shows teens tend to trust doctors' advice. So physician visits offer a valuable opportunity to nudge adolescents towards healthy behaviors.

In 1992, the AMA called for a shift from teen crisis intervention to problem prevention, and it issued specific guidelines for clinical practice. It recommended, for example, that teens receive yearly guidance on diet and exercise, sexual behaviors, substance abuse, and injury reduction. To help implement the guidelines, it issued questionnaires for clinicians to use with teens: "Do you eat fruits and vegetables every day?" "Have you ever used marijuana?"

Still, the Stanford researchers consistently found gaps between expert recommendations and medical practice. "The gaps are huge," Ma said. "And the improvements over time are at best modest."

In the first four years after the AMA recommendations, 1993 to 1996, teens showing up for a health exam left with no counseling about half the time. For 1997 to 2000, about six in ten adolescent medical checkups were completed with no counseling. The average checkup lasted about 16 minutes.

The researchers also looked at teens' illness-related visits, to see who went to the doctor and why. While girls went most often for pregnancy and prenatal care, boys' medical visits were most commonly due to sore throat or the need for a general exam.

Teens don't visit doctors often compared with other age groups. Adolescents made almost 47 million outpatient visits in 2000 - 1.9 visits per capita, the lowest of any age group. Boys and ethnic minorities went least often. In contrast, infants had 8.5 visits per capita; children, 2.4 visits, and adults age 65 and over, 6.1 visits.

The researchers said the low teen visit rates translate into few opportunities for counseling. So while checkup visits are usually the best for giving advice, doctors may need to look for "teachable moments" during illness-related visits as well.

Ma said that system-related factors likely have a greater influence on counseling rates than do physician-related factors. Therefore, she explained, it's important for policy makers and insurers-not just doctors-to know about failures in delivering preventive counseling to adolescents. "What it would take to close the gaps is substantial," Ma said. "But it's not insurmountable, and proven interventions exist to facilitate the process."

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