For your patients who have been risk takers, especially if they have had trouble with drugs or alcohol in high school, it will be important to speak with them about the likelihood that a risky pattern of substance use in high school will grow into a more serious problem in the less-supervised college setting. While this may sound to them like the exciting chance to have easier access and fewer restrictions or punishments, you have the opportunity to complicate their thinking about what this will actually mean. In all likelihood, their use will grow into a problem of abuse or dependence and could easily threaten their ability to succeed at college, landing them back in a far more restrictive setting. It may be valuable to talk with your patients about how they would know if their drug or alcohol use was becoming a problem. When would they say they have reached a limit they are concerned about? Would they be willing to see a therapist or psychiatrist about their substance use before leaving for college to make thoughtful plans for how to manage it? If they are willing, it may be protective to invite their parents into this conversation so that there is a better chance that they may discuss this with their parents outside of your office and once they are on campus.
Mental health
The prevalence of depressive and anxiety symptoms in the college years is very high, likely because of a combination of external stressors, loss of external supports, and continued rapid physical and neurologic development. For adolescents who have not experienced any mental health problems, it can be protective to have a conversation with them about the real risks of developing a mental health problem while they are at school and the value and efficacy of early treatment. You might tell them that while some anxiety and sadness are to be expected during a challenging transition, experiencing intense anxiety or sadness that is sustained (2 weeks or more) and that interferes with their functioning should prompt them to seek help from the student health services. They should be on the lookout for sustained disruptions in their sleep and loss of appetite and energy (the classic neurovegetative symptoms), and of course, any emerging hopelessness or suicidal preoccupation also should prompt them to turn to student health services for evaluation and support.
For your patients who have a history of psychiatric problems and treatment, it is critical – even if they are in remission – that you review with them when they should turn to the campus student health services for evaluation. What symptoms have indicated a worsening problem or relapse for them in the past? What might be the earliest signs of deterioration? If they are in active treatment, you should ensure that the treatment provider has built a transition plan for their treatment to continue on campus. Helping these patients to be smart about their self-care, just as you would if they were responsible for continuing treatment of their diabetes away from the supports of home, can be a powerful preventative intervention.
Sexuality
In all likelihood, you have already had a conversation about sex, even a brief one, with your adolescent patients by the time they are packing for college. But this is a key time to revisit the subject with them. You can begin an open-ended discussion about the fact that the years in college are commonly a time when adolescents start having sex (if they have not already done so). As such, it is important for them to learn about birth control and protection against sexually transmitted infections. This is normally a developmental stage in which sex becomes a more fully integrated part of their emerging identity and their healthy adult life. They may find that they develop a fuller awareness of whom they are attracted to and what they enjoy, and it is commonly a time of some experimentation or exploration. It is very meaningful for your young patients to hear about this nonjudgmentally from their pediatrician. This discussion should include some prevention, in the form of talk about the risks of sexual assault on campus. Help your patients, both male and female, to consider how new independence and access to alcohol can be a dangerous mix with the intense social scene on college campuses. Many situations in which they will be socializing with strangers will involve alcohol, even drugs. Would they have sex with someone if they or their partner were intoxicated? How would they know if the person they were connecting with was actually very intoxicated? How might they think about protecting a friend who seemed to be very intoxicated and at risk for sexual exploitation or assault? If they think they are witnessing a sexual assault or a risky situation, what could they do? If they are considering sex with someone, is it because they are attracted to and interested in that person, or are they feeling pressured, anxious, or bullied? Remind them that while exploration is healthy and should be fun, it also is wise to go slowly when something is new, and to be especially cautious when substance use is involved. They can protect themselves and their friends from the trauma of assault or of being accused of assaulting someone who could not meaningfully consent to sex with some thoughtful anticipation and planning. They took great care to arrange to get into college, and they can take equally great care with their own health and well-being.