Special Brand of Medicine for the In-Between Age : Youth: A surge in teen health problems has prompted some doctors to focus on the needs of adolescents. They try to treat the whole patient: mind, body--and lifestyle.

Dr. Irving N. Klitsner vividly remembers the first time he realized that teen-agers deserve their own place in the health-care system.

In 1954, the pediatrician had just set up a new office full of colorful, toddler-size plastic chairs and toys. But a 14-year-old girl saw the room as less than tasteful.

“I’m not going to that baby clinic!” she yelped to her mother, returning to the parking lot and locking herself in the car.

“The mother was embarrassed and tried to apologize. But I said, ‘No, she’s right. We should be much more sensitive to the needs of teen-agers.’ ” Klitsner recalls.

Today, the kind, grandfatherly figure is very much in tune with the medical needs of San Fernando Valley youths, about 5,000 of whom visit Kaiser’s Teen & Young Adult Health Center each year.

“They demand that you take a personal interest in them. That’s what I like,” he says, sitting in his office at the Kaiser Permanente medical building in Granada Hills.

Klitsner is among the pioneers in adolescent medicine who believe that most medical professionals overlook teen-agers’ unique health needs. As a result, he says, teen health problems have grown significantly:

“Traditionally you deal with the biological aspects of disease as a doctor. But when we looked at what is killing our kids, ages 12 to 22, you see that it is accidents, homicides, suicides. It’s related to behavior. It’s related to lifestyle.

“By the time they get to a certain age, they don’t come (to the doctor) that often for problems and they are out there struggling. They basically fall through the cracks. It’s the one age group where the death rate has been rising in the past 20 years.”

Recent studies point to the explosion of adolescent health problems. A recent federal report found that about one in five adolescents has at least one serious health problem and that many face stiff barriers in trying to get basic health care. The report found that poor and minority youths are at highest risk, but noted that white, middle-class teens also lacked services and support.

Adolescent health concerns go well beyond physical disease, according to the report:

* About 1 million teen-agers become pregnant every year.

* American youths are having sexual intercourse at younger ages; 53% of women ages 15 to 19 are sexually active.

* Diagnosable mental disorders such as anxiety, depression and schizophrenia are experienced by 18% to 22% of adolescents.

* At least 5,000 Americans ages 15 to 24 commit suicide every year.

* More than one-third of the nation’s teens drink alcohol weekly and nearly half a million are binge drinkers whose weekly consumption averages 15 drinks.

These figures represent increases over previous surveys and, in short, rebut the 1960s view that the teen-age years are robust and healthy, experts say.

Anita Sarad wasn’t certain what to expect when she walked into the Kaiser Permanente Adolescent Health Center a few years ago. But, within minutes of her appointment, the doctor made it clear what he expected from her.

“He asked me some things that I wouldn’t necessarily have brought up,” she says, including questions regarding her health habits and lifestyle. “That threw me off-guard completely. I told my friends later what he asked me and they said, ‘Did you tell him?’ ”

Anita, now 19, says she appreciates the candid and confidential atmosphere she shares with her doctor.

Stacy, also a regular Kaiser patient, says teen clinics offer a big improvement over visits to the pediatrician: “My pediatrician would always talk to my parents. But, it’s like, I’m the patient. Talk to me!”

Building an atmosphere of trust is an underpinning of adolescent medicine, says Dr. Lawrence Neinstein, associate director of the Division of Adolescent Medicine at Childrens Hospital of Los Angeles. Among the first such facilities in the country to open a comprehensive adolescent health unit, Childrens is now a primary teaching center for the subspecialty.

“These kids are really happy to have someone they can talk to, particularly if they understand why we are asking these questions,” Neinstein says. “I think many people are afraid to talk to teen-agers. They think they’re difficult, in general.”

But persuading skeptical teen-agers to talk about their health and lifestyle in an atmosphere of trust is, initially, not easy, Klitsner says. It requires special training that only about half of all medical schools now provide. Some pediatricians, internists and other physicians receive no special training in adolescent health, he says.

A study by Kaiser and Childrens Hospital researchers found that many physicians say they lack training in one or more areas considered fundamental in adolescent health care, such as drug abuse, eating disorders or depression.

For example, Klitsner says, a teen-ager who complains of a headache could have a sinus problem, a brain tumor or vision problems. Or that teen-ager could be depressed, pregnant or abusing drugs; all can produce a headache as a symptom.

To discover problems related to behavior, all teen-agers attending the Childrens Hospital Teenage Health Center and the Kaiser teen clinics undergo a “psychosocial” interview about their lifestyles along with the traditional medical history and examination.

“The psychosocial interview reminds us of these other things we need to look for,” Klitsner says.

Once, says Neinstein, a 16-year-old girl was referred to Childrens teen center because of chest pain. She had already seen numerous specialists who found nothing wrong with her. After a psychosocial interview, doctors discovered that she had a parent who abused alcohol and that the teen-ager abused drugs.

Traditionally, doctors “rule out” physical causes of problems. But, Neinstein says, “our approach is to also rule in that the teen might have psychosocial stress.”

Teen-agers with more traditional medical problems, such as diabetes or high blood pressure, also require more time-consuming and sensitive handling than adults, Klitsner says: “They resent their health problem because they have all these other problems growing up to deal with.”

Nevertheless, 30 years after the adolescent health concept was suggested, specialists still try to convince others in the health-care field that teen-agers deserve special clinics and doctors.

“A lot of doctors think this should be social work,” Klitsner says.

Only a few comprehensive teen health centers, such as the one at Childrens, can be found nationwide; Kaiser is the first health maintenance organization to open several teen clinics.

Teen-agers who think they are pregnant, have a sexually transmitted disease or want help for a drug habit are usually lonely and frightened, experts say.

“Some parents say ‘I don’t care what you do, I don’t want to know about it.’ But the kids have to tell someone. They usually go tell a friend and get misinformation,” Klitsner says.

Or they spend after-school job money to go to clinics where they are unlikely to receive counseling or follow-up care.

Albert, 18, a Kaiser patient, recalls a friend who thought he had a sexually transmitted disease. Not knowing where to turn, the youth scraped together $40 for a blood test at a clinic.

“It’s more comfortable here (at the teen center) because you’re talking with someone with a background in teen health,” says Albert. “It’s easier and you’re getting the right information.”

Of course, someone pays those office bills--mom and dad. And the issue of how much mom and dad need to know about their teen-ager’s visit to the doctor is a sticky one. Adolescent health specialists have tried to work out rules regarding confidentiality that respect and please all family members, yet keep the teen-ager’s health a priority.

“When I think about one of the key factors in our approach to adolescent health, it’s the area of confidentiality,” Neinstein says. “We try to reassure our teens when we’re getting into sensitive areas--drugs, sex--that the things we talk about with them are going to remain private.”

There are exceptions. Both Neinstein and Klitsner say that parents are informed when a youth is a danger to himself or others. And physicians are required by law to inform authorities about any physical or sexual abuse.

Doctors encourage teen-agers to share their health concerns and problems with their parents, but the teen-agers are treated like adults, whenever possible.

The system doesn’t always work, Klitsner says: “We sometimes lose them as patients. We lose their trust.”

Likewise, sometimes parents become angry. Under California law, minors can agree to medical care for substance abuse, sexually transmitted disease or pregnancy without parental consent. (Consent laws regarding minors vary widely from state to state.)

“When a teen is pregnant, under California law, she has the right to keep it confidential,” Neinstein says. “We try to discuss with the teen who they can talk to about this.”

Usually, he persuades the teen-ager to tell her parents, or he suggests that the girl and her parents meet with him and he breaks the news.

“About half the time, that works,” he says. “About half the time it doesn’t. Some parents have become quite upset that we couldn’t tell them if the teen had a pregnancy test or if she is pregnant.”

Not all teen problems relate to sex and drugs.

“It’s not just a sex clinic,” says Klitsner, with a smile.

Teen clinics, such as Childrens’, are a resource for people with various problems: from obesity to asthma to acne. Patients do not need a doctor’s referral, and Medicare and most major insurance plans are accepted, Neinstein says.

A major goal of adolescent health care is to help the patient learn to prevent health problems later.

“One of our objectives is to say it’s time you take care of your health,” Klitsner says. “Sometimes, this is our last crack at these kids.”

Neinstein says he doesn’t foresee adolescent health clinics popping up on every corner. But, he says, “one of the key roles for adolescent medicine is these special units, say at a Kaiser or at a university center, where we’re going to teach pediatricians or internists or family practitioners so that they can ask questions and feel comfortable dealing with teens.”

Another way to reach teens is through health clinics at schools. Childrens has operated a pioneering health clinic for two years at Los Angeles High School.

“I think it has been very successful in getting teens in who would not have had access to health care,” Neinstein says.

Still, in an era of shrinking health-care dollars, a major question remains whether such programs are cost-effective. Klitsner says Kaiser is researching whether focusing now on teen-agers’ health pays off later.

“Hopefully,” says Klitsner, “we’ll find out we’re doing some good.”

What the Doctors Think

One of the arguments for the development of adolescent health programs and clinics is that many physicians aren’t particularly comfortable around teen patients.

Researchers asked a group of Southern California physicians likely to see adolescents whether they like working with teens. Specialty: Percent who like working with teens Pediatrics: 31.1% Internal medicine: 34.1% Obstetrics-gynecology: 50.6% Family practice: 61.2% Adolescent specialty: 100%

Source: Dr. Irving N. Klitsner, Kaiser Permanente Adolescent Health Center.