Moment of youth

Pediatricians find opportunity in caring for at-risk teens

One person in Jessica Villeda’s life gives straight-up answers to her questions. He makes her laugh when she feels down. If she needs advice, he’ll offer it. When she describes the void he filled in her life, that of an adult who was really paying attention, she says, “It was like I found a friend.”

“When Jessica first came to the Teen Van in 2008, we talked about her goals,” says Seth Ammerman, MD, clinical professor of pediatrics at the Stanford School of Medicine. “She had some good goals: finishing school, working in health care.

I pointed out that those were really cool things, things that she could accomplish.”

But Villeda, who was 16 at the time of that conversation, was too preoccupied to think much about a career. She had thyroid problems, symptoms of depression and no way to pay for a doctor’s visit. Ammerman directs the Mobile Adolescent Health Services Program, a mobile health clinic known to its patients as the Teen Van. It’s a service of Lucile Packard Children’s Hospital Stanford and provides free health care for about 400 at-risk teens and young adults per year. Villeda went because she needed a doctor.

Ammerman’s approach to patients like Villeda — simultaneously low-key, friendly and sincere — is intended to help struggling teens reshape their lives. Instead of being overwhelmed by patients’ problems, which range from poverty and uninvolved families to homelessness and trouble with the law, doctors like Ammerman see their interactions with at-risk youth as an opportunity to form a uniquely powerful type of doctor-patient relationship.

So, when he first meets them, Ammerman does far more than pinpoint patients’ chief medical complaints. He asks them to name their strengths. To articulate their goals. Then he says, “What do you want to work on first?”

“They’ve never heard of this,” Ammerman says. “They’ve only heard how they screwed up.”

Just kids

Kids who’ve screwed up are Arash Anoshiravani’s specialty. Anoshiravani, MD, medical director of the Santa Clara County Juvenile Custody Institutions and clinical assistant professor of pediatrics at the School of Medicine, began working with incarcerated teens during a medical-school rotation in Los Angeles County. He was hesitant to go; the world of lawbreaking teenagers seemed remote from his own Southern California upbringing, where he earned good grades and competed on the water polo and swim teams at a Catholic all-boys high school before attending Stanford and Harvard.

But when he got to juvenile hall, his view of young inmates shifted.

“I was struck by how normal they were,” he says. “These kids, had they been plopped into a different life or a different family, could easily have done what I was doing instead of being locked up.”

Anoshiravani’s instinct for social justice was spurred by hearing his patients’ accounts of the violence and chaos they endured in their homes and neighborhoods. Although he saw many disadvantages to putting young people in jail, he became convinced that doctors could play a uniquely helpful role inside the justice system.

“When they’re in detention, these kids are sober or becoming sober, and all those peer influences — gangs, friends, their drug dealer, intimate partners who pressure them to do things that are not good for them — are not there,” Anoshiravani says. Unlike most adults working in juvenile halls, doctors have no disciplinary responsibilities. While police, lawyers and probation officers are trying to collect evidence to prosecute young inmates, physicians aren’t trying to get them in trouble. Doctors can encourage teens to reflect on what they want from their lives. “It’s a huge opportunity,” Anoshiravani says.

It isn’t always easy. One 15-year-old gang member, charged with assault with a deadly weapon, showed such hostility during a hospital visit that Anoshiravani began to question his own safety.

“He was a big kid, probably 6 feet tall and muscular, and visibly angry,” Anoshiravani recalls. “His fists were clenched. He had hurt people multiple times, and now he was talking about how he wanted to kill members of a rival gang.”

Anoshiravani took a step back from the patient and said, “Hey, let’s talk about something else. Three years from now, what do you want your life to look like?”

The boy wasn’t sure.

“OK, how about this? When you were 4 or 5, what did you want to be when you grew up?”

“I wanted to be a firefighter.”

“Why?” said Anoshiravani.

“Because I wanted to help people and save lives,” said the patient.

“But … now you just want to kill people,” Anoshiravani said. “What happened?”

The patient was silent. Tears welled in his eyes. “When I was 7, I was walking from my house to school alone,” he said. “Four or five big kids, 13-year-olds from the opposite gang, came to beat me up. From that time on, all I’ve wanted to do is hurt them back.”

“That just blew me away,” Anoshiravani says.

Few doctors who work with adults would consider it part of their jobs to ask What did you want to be when you were 5? Why a firefighter?

“For an adult, they’re maybe cheesy questions, but for an adolescent, these are the questions,” Anoshiravani says. “Is their life what they wanted or not? And the reality is that these are the questions that matter when it comes to their health. Their health problems are almost invariably related to behavior, and their behaviors are related to how they perceive themselves and their lives.”

Paying attention

It’s hard to know how frequently doctors have a lasting impact on high-risk teens’ futures. There is no research tracking long-term outcomes of such doctor-patient relationships; adolescent medicine researchers, including Ammerman and Anoshiravani, focus instead on their patients’ considerable unmet health needs. (Among their projects are a paper by Ammerman describing patients’ misconceptions about the “morning after” pill and another by Anoshiravani showing that incarcerated teens have much higher rates of mental illness than those outside the justice system.)

So, instead of a “meta” view that could be afforded by research, physicians can only rely on to their own individual experiences with patients like Jessica Villeda.

“In some ways she’s a typical patient because she had so many things going on,” Ammerman says. He had first treated Villeda as a preteen at a San Francisco clinic, the Mission Neighborhood Health Center, but got to know her better when he recommended she visit the Teen Van after her family lost their health insurance. When Villeda showed up at the Teen Van, she needed blood tests to monitor her thyroid function, evaluation and treatment for menstrual irregularity, allergy treatment and advice on healthy weight loss. And there was the most challenging problem: She screened positive for moderate-to-severe depression.

‘Even if I didn’t want to tell them what was going on, they knew if there was something going on with me. And even if I didn’t have any illness, I could go and talk to them and get everything out.’

“If you try to get the patient to change everything all at once, it’s overwhelming and never works,” Ammerman says. He asks patients to prioritize, then gradually address each problem. It takes a lot of time — Ammerman spends an hour on each appointment instead of the 10 to 15 minutes typical in other health-care settings, and patients often return over months or years — as well as a team of people. The van has a driver/registrar, a medical assistant, a social worker, a registered dietitian and a nurse practitioner, as well as partnerships with many Bay Area community organizations that serve at-risk youth, including schools, social-service agencies and homeless shelters. The van’s primary sponsors are the Lucile Packard Foundation for Children’s Health and the Children’s Health Fund. Samsung, along with Caroline and Fabian Pease and the Westly Foundation, funded a new mobile clinic, which went live in October.

Helping young patients also requires a light touch. Fortunately, Ammerman has no difficulty tapping his sophomoric side; one recent afternoon in the Teen Van, he looked up from his computer to solemnly announce to a patient that “splinter-free toilet paper was invented in Green Bay, Wisconsin, in the early 20th century.”

“There has gotta be some lightheartedness so that patients can get a feel for you, too,” Ammerman says. “You have to show that you’re interested in them not just for their problems, but that all of what makes them up is important.”

For Villeda, receiving counseling with the van’s social worker, Patty Sotominder, as well as an antidepressant prescription and checkups with Ammerman for her medical problems, gradually shifted her sense of flatness and isolation.

“When I was depressed, I would basically be on my own planet,” she says. “I would not feel social; it would just be me in my own enclosure.” Her emotional reactions were so blunted that she remembers feeling like “a body with an empty soul.”

At home, Villeda, the oldest of seven siblings of a single mother, had difficulty getting the emotional support she needed. Her mom was stretched thin by being the sole provider for their family, and the two sometimes clashed. “My mom got upset when she found out that I was using birth control,” Villeda says. “It was for my own good, but she didn’t understand.” Villeda found it easier to confide in the people at the Teen Van, who always had time to pay attention. “Even if I didn’t want to tell them what was going on, they knew if there was something going on with me,” Villeda says. “And even if I didn’t have any illness, I could go and talk to them and get everything out.”

Ammerman kept reassuring her that he saw progress, remarking that Villeda was remembering to take her thyroid medications, was gradually losing weight, had brighter moods. “When you’re living it day to day, people around you may notice that you seem better before you do,” he says. “I kept the focus on the small but positive changes she was making, small steps that would ultimately make a big difference.”

An open door

Anoshiravani’s relationships with teens can have a double-edged quality because the kids he gets to know best are those who are incarcerated for long periods or repeatedly arrested.

“For a lot of these kids who come back over and over, we are their medical home. They think of us as their clinic, which is sad,” he says. But those kids do trust him. He can ask tough questions such as, “What are you gonna do when you get out if your friends offer you drugs? In the past, the easiest choice was to use; are you ready to say no this time?”

Sometimes the patient is willing to trust him quickly, possibly even at the medical checkup required for every new juvenile inmate. Anoshiravani’s favorite example was a 17-year-old girl who had landed in juvenile hall after years of cycling through foster homes.

“She was really alone in the system and didn’t feel like she had anyone in her life who cared about her,” he says. As they talked, he asked, What do you want to be when you’re grown up?

“I want to be a nurse or a pediatrician,” the patient said.

“You know, it’s interesting,” Anoshiravani replied, “Dr. Klein, who held my job for more than 30 years before he retired, told me that there were 13 Stanford medical students who rotated through our clinic and told him that they had been in juvenile hall as teenagers. So it’s not impossible. Your dream could happen.”

“Do you have any medical books I could borrow?” the patient asked.

Anoshiravani walked her down the hall to his office, where she chose a book on the sociology of health. A few days later, it was returned along with a tiny book review she’d written on a Post-it note. She asked for another book. She’d stop by every so often when she got stuck in her reading to ask what something meant.

On the other side

Villeda, too, had health-care aspirations. She started investigating certified nursing assistant programs, and Ammerman encouraged her to apply.

Partway through her training, she was caring for an elderly woman with worryingly high blood pressure. She called Ammerman. “I gave her some advice about the best way to recheck the patient’s blood pressure and told her that if it was still high, she really needed to call the patient’s own doctor,” he says. She’s since asked him other medical questions, too, often about concepts she’s learning. “I think it’s a cool thing that she feels comfortable to call and ask,” Ammerman says. In 2015, Villeda completed her CNA training and passed a state-level certification exam. Now 24, she reports she’s happily married to her high-school sweetheart. Her depression and medical issues are under control, and she knows she can go back to the Teen Van, which serves patients up to age 26, if she has any questions.

At work, Villeda provides assisted-living support for seniors, helping them with daily tasks such as bathing and dressing. Some of her elderly patients remind Villeda of the time when her own motivation was at its lowest ebb. “It’s something I used to see in myself, needing help to get up and do a lot of things when I was depressed,” she says.

Does she think of her work as “paying it forward”? “Yes.”

Epilogue

By the time Anoshiravani’s patient who wanted to become a pediatrician turned 18 and aged out of juvenile hall, she’d borrowed five of his books. “The last one was the clinical anatomy book all of us used in med school,” Anoshiravani said. “It’s an 800-page book with a lot of medical words.”

When the patient was leaving, she asked if she could keep it. Anoshiravani said yes.

He tried to contact her to be interviewed for this story, but couldn’t reach her. He hopes she’s doing OK. He doesn’t know.

Erin Digitale is the pediatrics science writer for the medical school’s Office of Communication & Public Affairs. Email her at digitale@stanford.edu.

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