For the 42 million adolescents living in the United States, health care is "highly fragmented" and "poorly coordinated," according to a new report issued by the National Research Council (NRC) and the Institute of Medicine (IOM). "We're missing opportunities to respond to critical issues of young people that may have a long-lasting impact on their health and well-being," says Linda H. Bearinger, a professor at the University of Minnesota's School of Nursing, director of the university's Center for Adolescent Nursing, and the only nurse on the 20-member IOM committee. The report, Adolescent Health Services: Missing Opportunities, which focuses on the health care needs of people ages 10 to 19, highlights five areas in which improvements are necessary: primary care coordination; disease prevention, health promotion, and behavioral health; community involvement; protection of confidentiality; and preparation of providers. It can be found at http://www.nap.edu/catalog.php?record_id=12063.

According to Bearinger, the majority of health care providers who work with adolescents believe they're ill equipped to do so. As an example, the report cited one survey of 520 nurses who worked with adolescents, more than a quarter of whom identified substantial gaps in their knowledge of such common teen health issues as depression, eating disorders, and violence. In addition, says Bearinger, nearly two thirds felt inadequate to address the needs of gay, lesbian, and bisexual adolescents or to counsel teens on pregnancy options.

Part of the problem is regulatory. "With the exception of pediatric and family medicine," she explains, "there's currently no requirement that curriculum content or accreditation, licensure, or certification exams deal with adolescent health." The NRC-IOM report calls for regulatory bodies and agencies funding training programs to address such deficiencies.

Even with adequate preparation, however, providers are hard pressed to promote comprehensive adolescent care within a system that neither fosters nor funds coordination of primary and specialty care. The NRC and IOM recommend that providers and the federal, state, and private systems that support them develop interdisciplinary adolescent health care services. In such endeavors, Bearinger suggests, nurses may be particularly well suited to provide leadership. Nurses, she says, "move seamlessly between mental, physical, and psychosocial health and are prepared to create solutions for coordinating systems."

Echoing many of the same concerns as the NRC-IOM report is the policy statement from the American Academy of Pediatrics (AAP) (http://pediatrics.aappublications.org/cgi/content/full/123/1/191), which addresses the deleterious effects of underinsurance on adolescent access to preventive, reproductive, and behavioral health care. The AAP identified the following problems: benefits are not well matched to adolescent needs; nearly 40% of adolescent health care expenditures are paid out of pocket; and within Medicaid risk-based managed care systems, capitation rates covering 13-to-18-year-olds are substantially lower than those covering younger and older patients, which effectively penalizes the physicians who see them.

Maribeth Maher