Adolescent Encounters Research Articles

Increasing Follow-up for Adolescents With Depressive Symptoms.

Prompt follow-up for positive depression screen results is important in providing high-quality care for adolescents. We sought to improve follow-up within 30 days for adolescents (≥12 years) with Patient Health Questionnaire-9 scores ≥10, or those with a positive question 9, from 25% to 40%. We conducted a quality improvement project at 6 primary care locations serving ∼33,300 patients (70% Black, 7.3% Hispanic, 80% Medicaid-enrolled). Our team identified key drivers and iteratively tested interventions, including contacting patients after antidepressant medication initiation, scheduling patients for follow-up during index visits, collaborating with integrated psychologists to expedite therapy for higher-risk patients, and reaching out to patients without scheduled follow-ups. Pre-intervention, 13.3% (589 of 4427) of adolescent encounters met the criteria for follow-up within 30 days, and 25.8% had a documented follow-up within 30 days. During the intervention period, 12.3% (764 of 6224) of adolescent encounters met the criteria for follow-up within 30 days, and the mean follow-up rate increased to 43.1%. By monitoring process measures, we scheduled follow-up visits for 18.9% of patients during the index encounter. Outreach to the remainder led to 32.6% of these patients completing follow-up. Our balancing measure of monitoring integrated psychology visit volumes remained stable. The application of quality improvement methods in primary care practices increased the frequency of follow-up care for high-risk adolescents after a positive depression screen.

Fighting behavior, conflict perceptions, and firearm access among U.S. adolescents in a pediatric emergency department

ObjectivePrior evidence demonstrates that both firearm access and fighting can predict future violence and injury in adolescents. We aimed to examine associations between firearm access with fighting behavior and conflict perception in a sample of adolescents in an urban emergency department (ED) setting. MethodsIn 2023, we conducted a secondary analysis of 13,610 adolescent encounters in the ED of a U.S. children's hospital from 2013 to 2020, using a universally applied, self-administered computerized behavioral health survey. We compared patient characteristics by reported firearm access and fighting behavior using chi-squared tests. Generalized estimating equations (GEE) were used to investigate associations between 1) fighting behavior and firearm access, and 2) between fighting behavior and respondent preference to and reporting of fighting incident to law enforcement after adjusting for race and ethnicity, age, and gender. ResultsApproximately one-quarter of the sample reported past year fighting. Youth who reported fighting were more likely to report firearm access (AOR = 1.66, 95%CI = [1.49–1.86]). This association strengthened among youth who perceived continued conflict after a fight (AOR = 2.05, 95%CI = [1.73–2.43]). Youth who perceived continued conflict following a fight were more likely to report (AOR = 1.97, 95%CI = [1.65–2.36]) or want to report (AOR = 2.63, 95%CI = [1.81–3.81]) the fight to law enforcement. ConclusionsThose perceiving continued conflict after a fight were more likely to report access to firearms and endorse retaliation; however, they were more likely to want to report the fight to law enforcement. These findings highlight the potential for more comprehensive ED risk assessment to reduce retaliation and reinjury for adolescents reporting fighting behavior.

Applying a Trauma-Informed Lens to Challenging Adolescent Encounters: A Faculty Development Session for Pediatricians.

Patient encounters perceived to be challenging are common and contribute to both suboptimal patient health outcomes and provider burnout. A trauma-informed care (TIC) approach to these encounters is critical, as many of the characteristics associated with challenging patient encounters can be linked to a history of trauma exposure. Our team created and delivered a 1-hour synchronous virtual session intended to bolster provider knowledge of TIC principles and their application to challenging adolescent encounters. Participants were all faculty and staff engaged in pediatric primary care at an urban academic center, including physicians, nurse practitioners, psychologists, and social workers. The content was rooted in adult learning principles and included didactic components anchored to case-based learning with facilitated group discussions and opportunities for reflection. We used paired pre- and postsession self-assessments of provider knowledge, confidence, and practice related to TIC using Likert-scale and free-text questions. Descriptive statistics and a paired t test were used to determine the impact of the session on these metrics. In 24 paired surveys, there were statistically significant increases (p ≤ .001) in participant perceived knowledge, confidence, and practice, with 100% of participants having a statistically significant improvement in one or more of these domains. There were also strongly positive Likert-scale and free-text responses regarding content relevance and delivery. We demonstrate that a brief session can create improvement in pediatric providers' perceived knowledge about the application of TIC principles to challenging adolescent encounters as well as confidence in their ability to put these into practice.

Sexually Transmitted Infection Diagnoses at Children's Hospitals During COVID-19.

COVID-19 mitigation strategies resulted in changes in health care access and utilization, which could negatively impact adolescents at risk for sexually transmitted infections (STIs). We evaluated changes in STI diagnoses during adolescent visits at children's hospitals during COVID-19. We conducted a retrospective cohort study using the Pediatric Health Information System database comparing adolescent (11-18 years) hospital visits with an STI diagnosis by International Classification of Diseases, 10th revision, code during COVID-19 (2020) to pre-COVID-19 (2017-2019). Data were divided into spring (March 15-May 31), summer (June 1-August 31), and fall (September 1-December 31). Median weekly visits and patient characteristics were compared using median regression. Of 2 747 135 adolescent encounters, there were 10 941 encounters with an STI diagnosis from 44 children's hospitals in 2020. There was a decrease in overall median weekly visits for STIs in spring during COVID-19 (n = -18.6%, P = .001) and an increase in overall visits in summer (11%, P = .002) during COVID-19. There were significant increases in inpatient median weekly visits for STIs in summer (30%, P = .001) and fall (27%, P = .003) during COVID-19. We found increases in Neisseria gonorrhoeae (50%, P < .001) and other STI diagnoses (defined as other or unspecified STI by International Classification of Diseases, 10th revision, code; 38%, P = .040) in fall COVID-19 (2020), and a decrease in pelvic inflammatory disease (-28%, P = .032) in spring COVID-19 (2020). We found increases in median weekly adolescent inpatient visits with an STI diagnosis in summer and fall COVID-19 (2020). These findings were likely partially driven by changes in behaviors or health care access. Further work is needed to improve STI care and thus potentially improve related health outcomes.

Turning HEADSS: Utilizing Coached Role-Play to Increase Student Self-Efficacy with Adolescent Interviewing Skills.

Adolescent patients make up a significant number of the primary care population, yet medical training specific to adolescents is inadequate and challenging. 2 Medical trainees report feeling less competent caring for adolescents compared to caring for infants and children. 3 Framed after an adolescent HEADSS (Home, Education/employment, peer group Activities, Drugs, Sexuality and Suicide/depression) interview role-play activity for pediatric clerkship students, 1,2 this study sought to investigate the impact that facilitated role-play would have on physician assistant (PA) students' self-perceived knowledge, skills, and comfort in interviewing adolescents. A coached role-play focused on skills used during a HEADSS interview was used to demonstrate the communication skills inherently important to adolescent encounters. Pre- and postintervention surveys were administered. Data from 2 sequential cohorts (n = 88) showed statistically significant improvement in pre- versus postsession self-perception of knowledge ( p ≤ 0.0001) and skills ( p ≤ 0.0001), but not in comfort ( p = 0.1610). Teaching PA students how best to engage with adolescents can be done effectively via coached role-play.

Perceived barriers to the provision of adolescent confidential care in a tertiary care setting.

Adolescents are more likely to seek care and disclose sensitive health information if confidentiality is assured. Little is known regarding the provision of confidential care to adolescents in the hospital setting. We sought to understand confidentiality practices and barriers for adolescents cared for in a tertiary hospital setting. This was a cross-sectional survey of all Emergency Department (ED), hospitalist, and resident physicians at a tertiary paediatric hospital from May/2019 to July/2019. Participants were asked multiple choice questions regarding practices, comfort, and barriers to confidential care. Response rate was 91% (n = 72/79; 26 ED, 14 hospitalists, 32 residents). Overall, 47% of respondents doubted that confidential care was being consistently provided to adolescents. Fifty-eight per cent of attendings and 31% of residents reported usually/always offering confidential care. Factors most reported to influence the provision of confidential care were chief complaint (75%), time of visit (45%), and patient age (25%). Barriers to the quantity or quality of confidential care were identified by 89%, most commonly including time constraints (21%), perceived parental resistance (26%), lack of private space (26%), and the belief that confidentiality is not necessary for all adolescent encounters (34%). Forty per cent of respondents reported breaching confidentially and discussing sensitive topics with adolescents in front of family members. Overall, only 45% felt they had received adequate training on how best to deliver confidential care, and 75% reported a desire for additional training. Results suggest inadequate provision of confidential care in a tertiary teaching hospital, with several potentially modifiable barriers.

A method to advance adolescent sexual health research: Automated algorithm finds sexual history documentation.

Background:We aimed to develop and validate a rule-based Natural Language Processing (NLP) algorithm to detect sexual history documentation and its five key components [partners, practices, past history of sexually transmitted infections (STIs), protection from STIs, and prevention of pregnancy] among adolescent encounters in the pediatric emergency and inpatient settings.MethodsWe iteratively designed a NLP algorithm using pediatric emergency department (ED) provider notes from adolescent ED visits with specific abdominal or genitourinary (GU) chief complaints. The algorithm is composed of regular expressions identifying commonly used phrases in sexual history documentation. We validated this algorithm with inpatient admission notes for adolescents. We calculated the sensitivity, specificity, negative predictive value, positive predictive value, and F1 score of the tool in each environment using manual chart review as the gold standard.ResultsIn the ED test cohort with abdominal or GU complaints, 97/179 (54%) provider notes had a sexual history documented, and the NLP algorithm correctly classified each note. In the inpatient validation cohort, 97/321 (30%) admission notes included a sexual history, and the NLP algorithm had 100% sensitivity and 98.2% specificity. The algorithm demonstrated >97% sensitivity and specificity in both settings for detection of elements of a high quality sexual history including protection used and contraception. Type of sexual practice and STI testing offered were also detected with >97% sensitivity and specificity in the ED test cohort with slightly lower performance in the inpatient validation cohort.ConclusionThis NLP algorithm automatically detects the presence of sexual history documentation and its key components in ED and inpatient settings.

Adolescent Sexual and Reproductive Health Counselling in Relation to Female Genital Cutting: Swedish Professionals\u2019 Approach to Menstrual Pain as an Empirical Example

In Sweden, as well as in an international context, professionals are urged to acquire knowledge about possible health effects of female genital cutting (FGC) in order to tackle prevention and care in relation to the practice. While professionals are guided by policies and interventions focusing on medical effects of FGC, some scholars have cautioned that many popular beliefs about health risks rest on inconclusive evidence. The way professionals understand and respond to health information about FGC has in this context largely been left unexamined. This article aims to provide a qualitative exploration of how professionals in Sweden approach adolescent sexual and reproductive healthcare encounters in relation to acquired knowledge about FGC, using menstrual pain as an empirical example. The analysis shows that there was a tendency in counselling to differentiate young migrant women’s menstrual complaints from ordinary menstrual pain, with professionals understanding pain complaints either in terms of FGC or as culturally influenced. The study shows how professionals navigated their various sources of knowledge where FGC awareness worked as a lens through which young women’s health complaints were understood. Biomedical knowledge and culture-specific expectations and assumptions regarding menstrual pain also informed counselling. Finally, the article discusses how FGC awareness about health risks was used constructively as a tool to establish rapport and take a history on both menstrual pain and FGC. The analysis also recognises potential pitfalls of the approaches used, if not based in well-informed policies and interventions in the first place.

A Clinic-Based Quality Improvement Initiative to Increase Screening for Gonorrhea and Chlamydia in Adolescents

BackgroundUniversal screening is a strategy for addressing the limitations of risk-based screening for gonorrhea and chlamydia (GC/CT). This quality improvement (QI) initiative aimed to improve GC/CT screening by implementing universal annual screening for all adolescents ≥ 13 years old. MethodsAt an academic pediatric resident continuity clinic, an interdisciplinary team designed and conducted multiple Plan-Do-Study-Act (PDSA) cycles over one year. The primary aim, and process measure, was to increase the percentage of encounters with screening for GC/CT in the 12 months prior to the encounter to 80%. The secondary outcome measure was rate of detection of GC or CT infection. Further, pulse checks of provider/staff knowledge and adherence were conducted. The balancing measure was denied insurance claims. ResultsThe mean screening rate of 29.2% increased during the project implementation to 65.1% with several bundles of PDSA cycles. There were no cases of gonorrhea detected in the baseline period or implementation period. The case rate of chlamydia was similar during both periods (from 9.7 per 1,000 adolescent encounters to 10.8 per 1,000 adolescent encounters, p = 0.74). There was similarly high provider/staff knowledge about (p = 0.35) and adherence to (p = 0.06) the screening protocol at 6 and 12 months of implementation. There was no increase in percentage of denied insurance claims. ConclusionThis QI initiative doubled rates of GC/CT screening with no statistically significant increase in number of cases.

Universal Pediatric Suicide Risk Screening in a Health Care System: 90,000 Patient Encounters.

Suicidal behavior is increasing among US youths. Contact with the health care system is common in the months before suicide. To assess the characteristics of suicide risk among youths presenting for health care, universal screening results from a large hospital system were analyzed. A retrospective analysis of the Ask Suicide-Screening Questions tool administered to patients aged 10-17 years in a hospital system including an emergency department, inpatient medical units, and primary care clinics was conducted. Demographic and clinical data from 3 years of encounters were analyzed. The sample consisted of 91,580 pediatric encounters, predominantly white Hispanic and women, with one third speaking Spanish. Across health care settings, 2.9% of encounters produced positive suicide risk screens, with the highest rate in the emergency department (8.5%). Acute positive screens, indicating imminent risk for suicidal behavior, accounted for 0.3% of all encounters. Approximately one-fourth (27.6%) of encounters for psychiatric presenting problems screened positive compared with 2.3% for nonpsychiatric encounters. Higher rates of positive screens were present among encounters for psychiatric presenting problems across all settings. Positive screens were less common among preteen (1.8%) than adolescent (3.1%) encounters (χ2=65.50, P < 0.001). Universal screening detected suicide risk in approximately 3% of pediatric health care encounters. Screening identified risk in encounters among preteen and adolescent patients, with a higher prevalence of positive screens in encounters for youths presenting with psychiatric problems and for emergency department visits. Acute positive screens were rare, occurring in less than half of 1 percent of encounters.

90 Perceived Barriers to the Provision of Adolescent Confidential Care in the Tertiary Care Setting

Abstract Background A cornerstone of quality adolescent health care is assuring confidential time for adolescent patients. Adolescents are more likely to seek care and disclose sensitive health information if confidentiality is assured. Several national societies endorse the need for confidential care at all health-related encounters with adolescents. Many adolescents have infrequent contact with the medical system other than unscheduled urgent care in pediatric hospitals. Little is known regarding the effectiveness and feasibility of providing confidential care to adolescents in a tertiary pediatric hospital setting. Objectives We hypothesized that significant variation exists in the frequency and quality of confidential care delivery for adolescents. This study sought to characterize clinician comfort with confidentiality provision as well as identification of potential predicators and barriers to providing confidential care for adolescents in a tertiary, pediatric hospital setting. Design/Methods We undertook a cross-sectional survey among Emergency Department (ED), Hospitalist and Resident physicians at an urban, academic pediatric center. Data was collected using a standardized, self-administered electronic questionnaire. Survey participants responded to multiple-choice questions to characterize their comfort and self-identified barriers to providing confidential care to adolescents. Results Response rate was 91% (n=72/79; 26 ED, 14 Hospitalists, 32 Residents). A majority of respondents were female (69%), under the age of 50 (60%) and within their first 10 years of practice (51%). Forty-seven percent of respondents reported being somewhat/very doubtful that confidential care was being consistently provided to adolescents. Eighty-nine percent of respondents identified barriers to the quantity or quality of confidential care provided. Factors most commonly reported to influence physician decision to provide confidential care were diagnosis (75%), time of visit (45%), and patient age (25%). Among attending physicians 60% reported that they usually/always provide confidential care to adolescents, and 83% ensure that their trainees offer confidential care; whereas only 31% of trainees reported usually/always providing confidential care themselves (p=0.01). Limits of confidentiality were more likely to be explained to adolescent patients compared to their parents (83% vs. 33%; p&amp;lt;0.001). The most common reasons identified limiting the provision of confidential care were insufficient time (21%), perceived parental resistance (26%), lack of private space (26%) and the belief that it is not necessary for all adolescent encounters (34%). Forty percent of respondents reported discussing sensitive topics with adolescents in front of family members. Among both attending physicians and trainees, only 45% felt they had received adequate training on how best to deliver confidential care and similarly, 75% in both groups reported a desire for additional training. Conclusion Survey results suggest inadequate provision of confidential care in an academic pediatric hospital, with several potentially modifiable barriers. Confidentiality-specific education likely represents an important intervention to optimize physician comfort and improve the delivery of appropriate confidential care for adolescents.

Effectiveness of a Quality Improvement Intervention to Improve Rates of Routine Chlamydia Trachomatis Screening in Female Adolescents Seeking Primary Preventive Care.

To determine the impact of a multicomponent quality improvement (QI) intervention on Chlamydia trachomatis screening for young women in primary care. Observational cohort analysis. Urban primary care site providing adolescent primary and confidential sexual health care. Female adolescents aged 15-19years. From December 2016 to April 2018, we designed and implemented a multiphase QI intervention. The final intervention, beginning March 2017, consisted of the following at all adolescent well visits: (1) dual registration for well and confidential sexual health encounters; (2) urine collection during the rooming process; and (3) electronic health record-based prompts for chlamydia screening. Annual chlamydia screening rates before and after the intervention, with a goal of achieving a relative increase of 10%. There were 1550 well adolescent encounters from December 2016 to April 2018. The preimplementation chlamydia screening rate among 15- to 19-year-old female adolescents was 312/757 (41.2%) (95% confidence interval, 20.9%-61.5%). Postintervention, this increased to 397/793 (50.0%) (95% confidence interval, 28.6%-71.5%; P<.001). The clinic chlamydia test positivity rate remained stable, at 10.7% and 11.1% in the pre- and postintervention periods, respectively. There was no significant change in median visit length in the pre- (79.2minutes; interquartile range, 59.5-103.3) and postintervention periods (80.4minutes; interquartile range, 61.7-102.8; P=.63). This practice-based QI intervention resulted in a statistically significant 21% relative increase in annual Chlamydia trachomatis screening rates among female adolescents, without lengthening median visit time.

Sexually Transmitted Infection Testing in Adolescents: Current Practices in the Hospital Setting

PurposeAdolescents are disproportionately affected by sexually transmitted infections (STIs), and evidence supports expanding sexual health services to the hospital setting. Because STI testing practices in the hospital setting are poorly understood, we sought to describe current STI testing practices among adolescents seen in children's hospitals. MethodsWe performed a retrospective analysis of adolescents (14–18 years old) from 45 children's hospitals in 2015–2016, excluding visits with a billing code for sexual abuse/assault. We calculated rates of STI testing and investigated differences in STI testing by patient and hospital characteristics using generalized linear mixed modeling. ResultsOf the 541,714 adolescent encounters, 59,158 (10.9%) underwent STI testing. After adjusting for demographic characteristics, those with an STI test were more likely to be female (adjusted odds ratio [aOR] 1.61; 95% confidence interval [CI] 1.58–1.64), of non-Hispanic black race/ethnicity (aOR 1.20; 95% CI 1.17–1.23), or from the lowest median household income quartile (aOR 1.21; 95% CI 1.17–1.24). There was substantial inter-hospital variation in adjusted rates of STI testing (3%–24%), but strong correlation was observed between STI testing rates in the ED and inpatient settings within individual hospitals (adjusted R2 .99). ConclusionsOnly one in ten adolescents seen in children's hospitals underwent STI testing with wide variation in testing patterns across hospitals. There are critical opportunities to increase adolescent STI testing in this setting. Our findings highlight potential disparities in STI testing rates and patterns that warrant further exploration from the patient, provider, and health system perspective.

Con lo sguardo di un adolescente: riflessioni sull’incontro terapeutico in chiave costruttivista

The reflections presented in this paper originate from the question: what happens when an adolescent encounters constructivism by way of their psychotherapist? The author decided to approach adolescence initially as a category whose criteria of inclusion are often shared by adolescents and adults. The constructivist view then allowed for a framing of adolescents as actors in a domain of experience of which adults are part. What came to light was a dilemma: how can an adolescent, with whom the adult plays an educational role, choose freely for themselves? Bannister &amp; Fransella’s (1981) concept of the self invented and shaped person superordinated this dilemma. Drawing inspiration from the educational guidelines Ernst von Glasersfeld (1989) offers, the author has outlined some working suggestions for psychotherapy with adolescents, thus understood as a place to learn and have new experiences.

‘I’d like to see your identity cards please’ – Negotiating authority in police–adolescent encounters: Findings from a mixed-method study of proactive police practices towards adolescents in two German cities

Next to exclusionary and discriminatory practices in other live domains, tense police–adolescent relations and the treatment of ethnic minority adolescents by the police are discussed as the foremost trigger for urban riots across Europe. Discretionary identity checks and ‘stop and search’ practices are particularly contentious. Situated in a country that has not experienced urban riots by marginalized and ethnic minority young people yet, our study investigates the impact of police behaviour, in particular stop and search practices, on the quality of interactions between police and young people in Germany. The study is based on extensive participant observation of police patrols, in-depth interviews with police officers and a large-scale standardized youth survey. Qualitative and quantitative evidence unequivocally suggest the absence of discriminatory practices by the police based on the ethnic background of adolescents and an overall positive character of police–adolescent relations. However, transparency – explaining the reasons for police actions – and adhering to formal rules cannot be said to be the primary attributes of the proactive control actions we observed. Rather, informal adaption strategies seemed to prevail. These findings shed new light on the question of how police authority is negotiated on the streets and contribute to the search for causes of violent protests against the police.

Missed opportunities for pregnancy prevention among insured adolescents.

Birth to a teenaged mother is associated with adverse health and social outcomes. Adolescents at risk for pregnancy may not receive needed reproductive health services at primary care visits. To review services provided at outpatient visits in the year prior to pregnancy among adolescents in a US Midwestern integrated health care delivery system. Retrospective medical record review of continuously insured adolescents aged 15 to 19 years experiencing pregnancy in a nonprofit Minnesota health care organization. Primary care visits in the year prior to pregnancy. Adolescents experiencing a pregnancy with stable insurance coverage had an estimated average of 2.7 primary care visits in the 12 months prior to becoming pregnant. Medical record review revealed that 57% did not have documentation of sexual activity and 47% did not have documentation of reproductive health counseling. These rates varied by health care professional type and visit type. Only 35% had contraception prescribed within 12 months of becoming pregnant and only 1 had a long-acting contraceptive prescribed. Our data highlight the need for primary care professionals to review health behaviors and pregnancy risk at all adolescent encounters.

Paediatricians should do more to address male adolescent sexual health.

Paediatricians should do more to address male adolescent sexual health.

Two Truths and a Lie: In re John Z. and Other Stories at the Juncture of Teen Sex and the Law

Laws governing adolescent sexuality are incoherent and chaotically enforced, and legal scholarship on the subject neither addresses nor remedies adolescents’ vulnerability in sexual encounters. To posit a meaningful relationship between the criminal law and adolescent sexual encounters, one must examine what we know about adolescent sexuality from both the academic literature and the adults who control the criminal justice response to such interactions. This article presents an in-depth study of In re John Z., a 2003 rape prosecution involving two seventeen-year-olds. Using this case, I explore the implications of the prosecution by interviewing a variety of experts and analyzing the contemporary literature on sexual norms among youth. I also relate a series of interviews conducted with the major players in the prosecution. Examining this case from a variety of perspectives permits a deeper understanding of how the law regulates adolescent sexual encounters and why it fails.

Reviews: When Death Walks in: For Teenagers Facing Grief, Adolescent Encounters with Death, Bereavement, and Coping, No Child Should Grieve Alone: A Guide for Parents, Caregivers &amp; Professionals, Kids Can Cope: An Activity Book from Children for Children Who are Living with Change and Loss, Zach and His Dog: A Story of Bonding, Love, and Loss for Children and Adults

Reviews: When Death Walks in: For Teenagers Facing Grief, Adolescent Encounters with Death, Bereavement, and Coping, No Child Should Grieve Alone: A Guide for Parents, Caregivers &amp; Professionals, Kids Can Cope: An Activity Book from Children for Children Who are Living with Change and Loss, Zach and His Dog: A Story of Bonding, Love, and Loss for Children and Adults

The Jungle Out There: Nick Adams Takes to the Road

"The Battler" and "The Light of the World" can be viewed as contributions to hobo-tramp literature. Evoking the work in this vein of Jack London, W. H. Davies, Josiah Flynt, and Glenn H. Mullin, these hard-edged stories delineate late adolescent encounters—out-in-the-real-world experiences—that stand in stark contrast to those invented by Fitzgerald in This Side of Paradise , a defining work of what Updike calls "collegiate romanticism," as well as those presented in Owen Johnson's high-jinks romps— The Prodigious Hickey (1908), The Varmint (1910), and The Tennessee Shad (1911)—the Lawrenceville prep-school stories so avidly read at the time.