2.3 Anticipatory Guidance: Preschool Through Young Adult

From the third birthday through young adulthood, Bright Futures visits are usually annual, with extra visits when school, mental health, injury, or social risk demands them. Anticipatory guidance still occupies a planned part of the visit, but the content shifts: helmets and firearms, school readiness, media, sports, puberty, driving, substances, confidentiality, and transition. Domain I.A on the CPNP-PC outline is explicit — birth through young adulthood, in collaboration with patients and caregivers. An 18- or 21-year-old in your panel is still your patient.

Use the current AAP periodicity schedule for screening ages (depression annually from 12 years, HIV once in later adolescence, cervical cancer screening starting at 21, lipids at recommended ages). Do not freeze a number that the committee may have updated; know the principle and look up the current table.

Preschool (About 3–5 Years)

Injury prevention remains the leading cause of death in this age, so AG is still safety-first.

• Helmets for bicycles, scooters, skateboards, and snow sports, every ride, modeled by adults.
• Stranger and abduction counseling that is concrete (who may pick up from preschool, what to do if separated in a store) without terrorizing the child.
• Firearms. The safest home for a child is one without a gun. If a firearm is present, it should be stored locked and unloaded, with ammunition locked separately. Ask at well visits: "Is there an unlocked gun where your child plays — including grandparents' homes?" This is Bright Futures safety counseling, not a political debate.
• School readiness is more than knowing letters. Watch language, the ability to follow two- and three-step directions, sustained attention for circle time, play with peers, and emotional regulation. Academic red flags (no phrases, unintelligible speech to strangers, no pretend play) convert AG into developmental evaluation.
• Toileting. Most children achieve daytime continence between 2 and 4 years. Night dryness lags. Do not set a kindergarten deadline that produces punishment. Constipation and encopresis are medical problems, not moral failures.
• Oral health. Pea-sized fluoride toothpaste once the child can spit (often around age 3); a smear before that. Fluoride varnish in primary care. A dental home if one was not established at 12 months.
• Passenger safety. Stay in a forward-facing harness seat until the child reaches that seat's height or weight limit, then a belt-positioning booster. Back seat of the vehicle.
• Water, sun, and poison counseling continues: touch supervision around water, shade and sunscreen, medicines locked, Poison Help 1-800-222-1222.
• Media. Consistent limits, no screens in the bedroom, and co-viewing of high-quality content. Use current AAP family media plan principles rather than arguing a single historic minute-count if the family needs a feasible start.

Clinic vignette. A 4-year-old is here for preschool forms. Growth and shots are up to date. When you ask about guns, the father says a loaded hunting rifle leans in a closet at the grandparents' farm where the child spends weekends. School-readiness paperwork does not close the visit. Firearm storage is today's priority AG, and you document the counseling and a follow-up plan.

School Age (About 6–12 Years)

• Bullying. Ask directly about friends, lunchtime, online messages, and school avoidance. Somatic complaints (stomachache Monday mornings) are surveillance data.
• Media and sleep. A family media plan, device curfew, and no phones in the bedroom protect sleep. School-age children generally need 9–12 hours of sleep in 24 hours (AAP/AASM age-band).
• Sports physical versus well visit. A preparticipation physical evaluation (PPE) is a focused clearance exam. It does not replace a comprehensive Bright Futures visit (surveillance, validated screens when due, full AG, immunizations, SDOH). Conversely, a well visit can incorporate PPE elements so the family is not billed for two incomplete encounters in your mind. On the exam, signing a sports form after listening to the heart in the hallway is not health supervision.
• Bicycles and boosters. Helmet every ride. Belt-positioning booster until the vehicle seat belt fits, typically when the child reaches about 4 feet 9 inches, often between 8 and 12 years. All children younger than 13 years should ride in the rear seat.
• Mental health check-ins. Mood, anhedonia, irritability, declining grades, and family conflict. Formal depression screening is universal in adolescence; school-age children still need surveillance and a validated tool when concern appears (for example, a Pediatric Symptom Checklist in many practices).
• Activity and nutrition. Daily physical activity (AAP/CDC principle of about 60 minutes for school-age youth) and a dietary pattern built on regular meals, not as a weight-shaming lecture.
• Substances. Start the conversation before first use. Name vaping, cannabis, alcohol, and unused prescription medicines in the home.

Clinic vignette. An 11-year-old arrives with a sports form and a parent who says, "Just the physical — we did a well visit when she was 8." You complete sports-clearance elements and a full well visit: confidential time as developmentally appropriate, vision and other due screens per current periodicity, mental health check-in, booster-seat and helmet AG, and immunizations due now. You do not sign the form in lieu of three missed years of health supervision.

Early Adolescence (About 11–14 Years)

Confidential time with the adolescent is standard. Explain to the caregiver and the teen, together, that you will spend part of the visit privately, what will stay confidential, and what cannot.

HEADSSS (often taught as HEEADSSS) structures the psychosocial history:

Puberty counseling is AG: Tanner staging as assessment, then hygiene, gynecomastia, menarche, wet dreams, and what is typical versus what needs workup (for example, lack of thelarche by 13 years, or menarche 3 years after thelarche without a period — confirm current endocrine cutoffs rather than inventing them). Normalize asking; do not assume heterosexual activity or cisgender identity.

Vaping is the dominant nicotine exposure in many U.S. teens; ask specifically, not "Do you smoke?" Consent and healthy relationships belong in the same slot as STI prevention. Graduated driver licensing, never driving with alcohol or cannabis, and no phones in hand are injury-prevention AG with a high death toll. Adolescents generally need 8–10 hours of sleep; early school start times plus devices make this a counseling target, not a personality flaw.

HPV vaccination is routinely recommended at 11–12 years and may start at 9; meningococcal conjugate is routinely given at 11–12 years with a booster at 16. PNCB tests the principle of on-time and catch-up prevention, not memorization of every product interval — if the teen is in your office at 14 with zero HPV doses, start catch-up rather than waiting for a "better" birthday.

Older Adolescence and Young Adulthood (About 15–21 Years)

• Transition. Even healthy youth need a plan for an adult clinician, records, and how to refill a prescription. Youth with special health care needs need an explicit transition process (Got Transition's six core elements are a useful principle: tracking, transition policy, readiness, planning, transfer, and completion).
• Reproductive health. Contraception, STI screening and prevention, pregnancy options counseling, and HIV prevention including PrEP when indicated. Offer confidential sensitive services within your state's minor-consent laws. Do not invent a specific state's statute on the exam; know the principle: many jurisdictions allow minors to consent to STI, contraception, and pregnancy-related care, and you must know the law where you practice.
• Substance use. Brief, non-lecturing screening and intervention (SBIRT-style). Driving risk is part of the same conversation.
• Depression and suicide. Universal depression screening in adolescence (PHQ-9 or PHQ-A). Ask specifically about suicidal ideation, plan, timing, and lethal means, especially firearms. A positive screen is not AG.
• College, work, and military. Catch-up HPV and meningococcal vaccination as indicated, measles-mumps-rubella and tetanus-diphtheria-acellular pertussis status, dorm outbreak counseling, and who can access records after age 18 (HIPAA: the young adult, not the parent, unless the patient authorizes).

Confidentiality limits you must teach without hedging: suicidal ideation, homicidal ideation, and abuse are not secrets you keep from the people needed to keep the patient safe. Some STI and pregnancy disclosures vary by state law and by whether the situation also involves abuse (for example, a 13-year-old with a 22-year-old partner). The exam tests the principle of offering minor consent for sensitive services and the duty to break confidentiality for imminent harm — not a memorized state code.

Clinic vignette. A 16-year-old asks you not to tell a parent about vaping. Later in HEADSSS the teen describes a plan to die tonight and access to an unlocked firearm. Vaping can remain in the confidential lane that your state and professional standards allow. A suicide plan with lethal means cannot. You keep the patient safe, involve needed adults, and address the firearm — that is still Domain I.A collaboration with patients and caregivers, not a betrayal of "the teen's rights."

Clinic vignette. An 18-year-old leaving for college has never started HPV vaccine and thinks pediatric care "ended at 18." You remain in role through young adulthood: catch-up immunization as a principle, reproductive and mental health AG, a transition plan, and a scheduled well visit — not a handshake and a form.