University of Michigan
Department of Pediatrics
Evidence-Based Pediatrics Web Site

Question

• Is counseling done by a primary care physician effective at reducing or preventing adolescents' risky behaviors?

Clinical Bottom Lines

1. For those behavioral interventions studied, repeated intensive programs of counseling that are reinforced over time are more likely to change behaviors than brief interventions during well-child care.1
2. Only 2 of the 20 screening tests recommended during well-child exams are supported by evidence from clinical trials.
3. Implementation of any recommendation may cause harm or displacement of other beneficial activities; therefore these recommendations should be based on the strongest evidence.

Summary of Key Evidence

1. Recommendations that were common to 2 or more of the organizations were included (AAP, Bright Futures, USPSTF, GAPS, AAFP, CTF, ICSI.1
2. Only high-quality systematic reviews and randomized controlled trials were included and the search for the articles was detailed and exhaustive.
3. Population: Healthy children between birth and 18 to 21 yrs of age.
4. Outcomes included primary and secondary prevention of disease, improvements in overall and well-being of children, and increases in healthy behaviors.
5. Behavioral counseling: the strongest evidence is for injury prevention, STD's, physical activity, and breastfeeding; there are no studies of office-based counseling to prevent smoking or drug use in adolescents; one trial studying alcohol prevention by PCP's showed an increase in drinking among children in the intervention.
6. Screening: of all the tests recommended, trials have only been conducted for chlamydia screening and ambylopia screening.
7. Prophylaxis: strong evidence for immunizations, folate to prevent neural tube defects, and iron supplemention to prevent anemia; trials have not been conducted for fluoride treatment and newborn ocular prophylaxis.

Additional Comments

• USPSTF, CTF, and AAFP recommendations are based on systematic reviews of the evidence; GAPS and ICSI state that the evidence was reviewed but the content of the reviews was not discussed; currently, AAP and Bright Futures recommendations are based on expert consensus.
• In 2006, Bright Futures will be publishing evidence based guidelines for well-child care.
• The lack of evidence does not mean well-child care recommendations lack effectiveness. It means we need significantly more research to be done in this field so we can focus on interventions that will benefit our patients.
  

Citation

1. Moyer VA, Butler M. Gaps in the evidence for well-child care: A challenge to our profession. Pediatrics 2004;114:1511-21.

CAT Author: Aarti Raheja, MD

CAT Appraisers: Ken Pituch, MD

Date appraised: May 18, 2005