ABIM Adolescent cheat sheet

Tanner staging: girls use breast (B1–B5) and pubic hair (PH1–PH5); boys use genital (G1–G5, testicular volume ≥4 mL marks G2) and pubic hair.

Normal puberty timing: thelarche in girls between 8 and 13 years, menarche typically 2–2.5 years after thelarche; testicular enlargement in boys between 9 and 14 years.

Precocious puberty: any secondary sexual development before age 8 in girls or age 9 in boys; evaluate with bone age, LH/FSH, and GnRH stimulation testing.

Delayed puberty: no thelarche by 13 in girls, no menses by 15, or no testicular enlargement by 14 in boys; obtain bone age and screen for chronic disease.

Peak height velocity averages about 9 cm/year in girls near age 11.5 and 10 cm/year in boys near age 13.5; growth decelerates after this peak.

Mid-parental height: boys = (father + mother + 13 cm)/2; girls = (father + mother − 13 cm)/2; target range is ±8.5 cm.

BMI percentile: <5th underweight, 5th–<85th healthy, 85th–<95th overweight, ≥95th obesity, ≥99th severe obesity.

Psychosocial: Erikson's identity versus role confusion (12–18 years); Piaget's formal operational stage begins around age 11, enabling abstract reasoning, hypothetical thinking, and heightened risk-taking with peers.

Bright Futures recommends an annual preventive visit for ages 11–21 with confidential HEADSS assessment (Home, Education, Activities, Drugs, Sexuality, Suicide/depression).

Routine adolescent vaccines: Tdap and MenACWY at 11–12 (MenACWY booster at 16), HPV series at 11–12, annual influenza; MenB at 16–18 by shared clinical decision-making.

Depression screening is recommended for all adolescents aged 12 and older; anxiety screening is recommended for ages 8–18.

Annual chlamydia and gonorrhea NAAT screening for all sexually active females aged ≤24; HIV screening at least once for ages 15–65 and risk-based syphilis testing.

Lipid screening once at ages 9–11 and again at ages 17–21; blood pressure measurement at every visit; vision and hearing screening per schedule.

Universal annual substance use screening with a validated tool (e.g., CRAFFT), paired with brief intervention and referral when positive.

Cervical cancer screening begins at age 21 regardless of sexual history; Pap testing is not indicated in younger adolescents.

Anemia, tuberculosis, and lead screening are risk-based only; routine hematocrit or tuberculin testing is not recommended for asymptomatic adolescents.

Depression screening: PHQ-2, then PHQ-9 or PHQ-A; a score ≥10 indicates moderate depression and requires suicide risk assessment and functional evaluation.

Suicide is the second leading cause of death in ages 10–24; ask directly about ideation, plan, intent, and access to lethal means, and complete a safety plan.

First-line treatment for moderate-to-severe adolescent major depression is fluoxetine or escitalopram plus CBT or interpersonal therapy; monitor for activation and suicidality.

Anxiety disorders: CBT is first-line; SSRIs (sertraline, fluoxetine, escitalopram) are first-line pharmacotherapy when therapy is insufficient.

ADHD DSM-5 criteria: ≥6 inattentive and/or hyperactive-impulsive symptoms for ≥6 months, onset before age 12, present in ≥2 settings with functional impairment; stimulants are first-line.

Monitor height, weight, blood pressure, and heart rate every visit in adolescents treated with stimulants; screen for diversion and comorbid substance use.

Bipolar I requires mania lasting ≥1 week or any duration requiring hospitalization; avoid SSRI monotherapy, and use mood stabilizers such as lithium or atypical antipsychotics.

First-episode psychosis warrants prompt antipsychotic treatment and evaluation; cannabis use is associated with earlier onset and relapse of psychotic disorders.

Long-acting reversible contraception (subdermal implant, IUD) is first-line for adolescents; typical-use failure rates are below 1% per year.

Emergency contraception: levonorgestrel 1.5 mg within 72 hours, ulipristal acetate within 120 hours, or copper IUD within 5 days (most effective).

Sexual history framework: partners, practices, protection from STIs, past STI history, and pregnancy prevention (the 5 P's).

Primary amenorrhea: no menses by age 15, or by age 13 without secondary sexual development; begin with pregnancy test, TSH, prolactin, FSH/LH, and karyotype.

Early adolescent cycles are often irregular; normal cycle length is 21–45 days in the first 1–3 gynecologic years.

HIV pre-exposure prophylaxis (tenofovir/emtricitabine) is indicated for adolescents at substantial HIV risk, with HIV testing every 3 months and adherence support.

HPV vaccination prevents cervical, anal, and oropharyngeal cancers; catch-up vaccination is recommended through age 26.

Pregnancy options counseling should be non-directive and include parenting, adoption, and abortion, with confidentiality and state consent laws clarified.

CRAFFT 2.0 screens for Car, Relax, Alone, Forget, Friends, and Trouble; a score ≥2 indicates high risk and warrants brief intervention or referral.

Alcohol is the most commonly used substance by adolescents; early initiation predicts later substance use disorder and injury.

E-cigarette use delivers nicotine and flavoring chemicals and is associated with nicotine dependence, EVALI, and later combustible tobacco use.

Cannabis exposure during adolescence is associated with impaired attention and memory, cannabis hyperemesis syndrome, and increased psychosis risk.

First-line adolescent tobacco cessation is behavioral counseling; nicotine replacement may be used off-label, and pharmacotherapy should be individualized.

Alcohol and benzodiazepine withdrawal can be life-threatening; manage with benzodiazepine-assisted protocols and inpatient monitoring when severe.

Buprenorphine is FDA-approved for opioid use disorder in patients aged 16 and older; provide naloxone to at-risk adolescents and household contacts.

Home drug testing has high false-positive rates and should not replace validated screening, brief intervention, and referral to treatment.

Anorexia nervosa (DSM-5): restriction leading to significantly low weight, fear of weight gain, and body image disturbance; amenorrhea is no longer required.

Bulimia nervosa: recurrent binge eating with compensatory behaviors at least once weekly for 3 months; weight is typically normal or above normal.

Binge eating disorder: recurrent binges without compensatory behaviors, with marked distress; treat with CBT and consider SSRIs.

ARFID (avoidant/restrictive food intake disorder) involves inadequate intake without body image disturbance, often with sensory sensitivity or fear of aversive consequences.

Medical instability in eating disorders: bradycardia (heart rate <50), orthostatic hypotension, hypothermia, dehydration, or electrolyte abnormalities warrant hospitalization.

Refeeding syndrome causes hypophosphatemia, hypokalemia, and hypomagnesemia; start nutrition at a low caloric rate, give thiamine, and monitor electrolytes closely.

Family-based treatment (Maudsley) is first-line psychotherapy for adolescent anorexia nervosa; CBT and fluoxetine are first-line for bulimia nervosa.

Pediatric obesity: BMI ≥95th percentile; screen for hypertension, dyslipidemia, impaired glucose tolerance, fatty liver, and mental health comorbidity.

Intensive behavioral therapy is first-line for adolescent obesity; pharmacotherapy (semaglutide, liraglutide, metformin) and bariatric surgery are considered for severe obesity.

Health care transition planning should begin at ages 12–14 and culminate in a written transition plan and adult-care transfer by age 18–21.

Readiness assessment tools such as the TRAQ identify gaps in self-management, medication knowledge, insurance, and appointment independence.

Supported decision-making, power of attorney, and limited guardianship are less restrictive alternatives to full guardianship for youth without decision-making capacity.

Adherence interventions: simplify regimens, use reminders and pill organizers, address cost and insurance barriers, and involve caregivers without removing adolescent autonomy.

School supports: a 504 plan provides accommodations; an IEP provides specialized instruction and requires evaluation under IDEA criteria.

Reproductive health counseling is essential in chronic illness; review teratogenic medications (e.g., methotrexate, valproate, isotretinoin) and contraception.

Transition planning should include insurance continuation, medication refills, durable equipment, and identification of an adult primary care clinician.

Palliative care provides symptom management and goals-of-care discussions alongside curative treatment and is appropriate at any disease stage.

Preparticipation physical evaluation: personal and family history of syncope, chest pain, palpitations, sudden death, or exertional symptoms is the highest-yield screening component.

Common causes of sudden cardiac death in young athletes: hypertrophic cardiomyopathy, congenital coronary anomalies, and channelopathies (long QT, Brugada).

Concussion: remove from play immediately; return to learn precedes return to sport, and progression occurs in 24-hour steps from light aerobic activity to full contact.

Exertional heat stroke is a medical emergency; cool first (ice immersion) and transport second, targeting core temperature <39°C.

Overuse injuries (Osgood-Schlatter, Sever disease, patellofemoral pain) are managed with load modification, relative rest, and progressive return rather than complete immobilization.

Female athlete triad / RED-S: low energy availability, menstrual dysfunction, and low bone mineral density; screen for stress fractures, amenorrhea, and disordered eating.

Infectious mononucleosis: avoid contact sports for about 4 weeks because of splenic rupture risk, or until splenomegaly resolves on examination or ultrasound.

Anabolic-androgenic steroid use causes acne, gynecomastia, hypertension, dyslipidemia, and mood changes; screen athletes privately and non-judgmentally.

Infectious mononucleosis (EBV): fever, exudative pharyngitis, posterior cervical adenopathy, and fatigue; avoid contact sports for about 4 weeks because of splenomegaly.

Group A streptococcal pharyngitis: confirm with rapid antigen test or culture; treat with penicillin or amoxicillin for 10 days to prevent acute rheumatic fever.

Acne: topical retinoid for comedonal acne; add benzoyl peroxide with or without a topical antibiotic for inflammatory lesions; avoid topical antibiotic monotherapy.

Atopic dermatitis: emollients plus topical corticosteroids; topical calcineurin inhibitors for sensitive areas; dupilumab for moderate-to-severe refractory disease.

Tinea capitis requires oral therapy (griseofulvin or terbinafine); topical azoles are adequate for tinea corporis and pedis.

Molluscum contagiosum is self-limited in immunocompetent adolescents; cantharidin or cryotherapy can be considered for bothersome lesions.

Asthma: stepwise therapy with as-needed short-acting beta-agonist plus inhaled corticosteroid; single maintenance and reliever therapy (SMART) improves adherence.

Anaphylaxis: intramuscular epinephrine 0.01 mg/kg (maximum 0.5 mg) into the anterolateral thigh, repeated every 5–15 minutes as needed, plus supportive care.

Explain confidentiality and its limits at the start of every adolescent visit: suspected abuse or neglect, suicidality or homicidality, and statutory rape reporting obligations.

Minor consent laws vary by state; many allow minors to consent independently to STI testing and treatment, contraception, mental health care, and substance use treatment.

Mandated reporting requires reporting on reasonable suspicion, not proof; clinicians are generally immune from liability for good-faith reports.

HIPAA generally treats parents as personal representatives of minors, but state law and adolescent-specific confidentiality protections may override parental access.

Insurance explanation-of-benefits statements can breach confidentiality; discuss billing privacy and offer confidential payment options before services.

Emancipated minors (via marriage, military service, or court order) can consent to most medical care independently.

The mature minor doctrine permits some minors to consent to certain care based on demonstrated maturity; scope varies by state and by service.

Telehealth with adolescents requires private space, verified identity, state licensure compliance, and clear emergency protocols.