Adolescent health and development

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chapter 56 Adolescent health and development

INTRODUCTION AND OVERVIEW

The essence of good adolescent healthcare consists of:

Adolescent health falls outside biological paradigms, clinical medicine and its usual classifications, and outside the classic distinctions between physical and mental health, between medical and social aspects of health, and between curative and preventive care. Adolescent healthcare is a bio-psychosocial field, one which, by its very nature, requires an integrative approach.

While young people are often considered a relatively healthy population group, current indices are poor for at least 20–30% of young people. Their health problems are mainly psychosocial and, certainly in clinical settings, likely to be overlooked. Young people are notoriously reluctant to seek services to address these social and psychological self-concerns.1,2 They are also involved in health risk behaviours earlier than in past generations. Many engage in behaviour that threatens their health and wellbeing, and there is increasing evidence that many problem behaviours in young people are interrelated. Young people with conduct disorders, for example, are also likely to engage in tobacco, alcohol and substance use, to engage in high-risk sexual behaviour and to experience academic failure.3

A note about terminology: the term young person refers to someone aged 12–25 years. The word adolescent will be used where it is more appropriate to refer specifically to the developmental processes occurring during these years.

NORMAL ADOLESCENT DEVELOPMENT

Adolescence has been described as:

Adolescence begins with the onset of puberty and ends with the acquisition of adult roles and responsibilities. It is characterised by rapid change in the following domains:5

THE EXPERIENCE OF PUBERTY

Puberty involves the most rapid and dramatic physical changes that occur during the entire lifespan outside the womb. Average duration is about 3 years and there is great variability in time of onset, velocity of change and age of completion. Height velocity and weight velocity increase and peak during the growth spurt.

The classic milestones of puberty are determined by Tanner’s sex maturity ratings. Tanner’s staging system is based on breast, genital and pubic hair changes, with Stage 1 being prepubertal and Stage 5 adult (Figs 56.1, 56.2 and 56.3).6 In girls, peak height velocity usually occurs at Stage 2–3 (around 12 years) and menarche (initiation of menstruation) at Stage 4. In boys, peak height velocity occurs at Stage 3–4 (14 years) and semenarche (initial ejaculation) at Stage 3.

The experience of puberty is to have a changing body that feels out of control. Feelings of helplessness or persecution are common and may not abate until about 12 months after the growth spurt has ended. The typical irritability, moodiness and occasional aggressiveness, sexual arousal and unpredictable behaviour of the early adolescent are largely due to hormonal changes. Puberty tends to be conceptualised as a biological event, with emotional and psychological ‘side effects’. However, puberty may also be regarded as a cultural phenomenon, with each young person’s experience being influenced by the cultural milieu in which it occurs. In many cultures, for example, an event such as menarche remains somewhat taboo, while changing body shape for girls and boys may bring high levels of anxiety in our image-driven society.

The psychosocial impact of the timing of puberty affects girls and boys differently.

For those who mature earlier than average:

For those who mature later than average:

MAJOR DEVELOPMENT SERIES MAIN CONCERNS COGNITIVE DEVELOPMENT PRACTICE POINTS

Physical, cognitive and psychological changes may be ‘out of sync’. For example, an early-developing, mature-looking girl may be psychologically immature and vulnerable.

A SNAPSHOT OF HEALTH ISSUES IN ADOLESCENCE7

Adolescent health is, ideally, understood via the dual concepts of health and wellbeing. It is estimated that approximately 75% of deaths among young people in developed countries are from preventable causes, mostly non-intentional injury. Drug-related deaths account for almost 25% of all deaths among young people, and youth suicide is another major cause of mortality. Young people are experiencing mental health problems at higher rates than older age groups and retaining their increased risk beyond youth into older age8—at any one time, up to 20% of young people will suffer from a mental disorder. Together, mental health and behavioural disorders account for more than half of all afflictions affecting adolescents. Poor nutrition is now also coming to be recognised as a significant risk factor for poor mental health in adolescents.9

In most developed countries, over one-third of young people report using marijuana in the previous 12 months, while around 70% of 16–17 year olds report that they consume alcohol. Drug and alcohol use is also of concern because it can seriously exacerbate depression and suicidal behaviour. While teenage smoking rates tend to be on the decline, tobacco use is another prime target for research, with close to 20% of 17-year-olds being established smokers.

Sexual health is another important and challenging issue. The number of notifications for chlamydia among 15–24 year olds has increased by more than 300% between 1999 (when national data have been available) and 2008. Young people, especially young women, are more likely to contract STIs and, while rates of teenage childbirth have declined in recent decades, teenage pregnancy remains a major adolescent health concern in developed nations. Restricting our focus to these biological indicators alone, however, ignores the complex, dynamic contexts in which sexuality is being experienced by young people.

In addition, an obesity epidemic is currently affecting 25% of young people, a figure rising every year, and 15–20% of young people have a chronic illness. Chronic illness can have a serious social and emotional impact on young people, who wish to see themselves as ‘normal’, and can trigger withdrawal from medical care.

THE CLINICAL CONSULTATION

In contrast to most general practice consultations, the aim of the consultation with a young person who you have not seen since they entered adolescence, or who is new to your practice, is to engage them. A relationship of trust must first be established, otherwise many potentially serious health issues can be missed and opportunities for prevention and health promotion forgone.

Adolescent patients have neither the naivety of the child nor the awareness or experience of the adult. However, it probably takes about three seconds for a young person to ‘suss out’ the kind of encounter it is going to be. Young people have a sixth sense about it and can read the clues: how the doctor greets them, whether or not they are given a chance to talk for themselves, how questions are put and how the physical examination is conducted.

Many healthcare professionals feel ill-equipped to deal with young people in their practices, particularly in relation to sexuality and substance use.2 Young people want to address health behaviours with their doctor but often feel too embarrassed to initiate discussion in these sensitive areas. And while parents also want clinicians to discuss a broad range of health issues with their adolescent children, many fail to do so.

COMMUNICATION SKILLS WITH YOUNG PEOPLE

Communication skills are essential in general practice. A summary of communication skills that are particularly pertinent to the consultation with a young person is given here.

Education/employment Eating/exercise   Activities Prior to proceeding to the ‘Drugs’ and subsequent domains, it is useful to reiterate the confidentiality statement, and to ask permission to ask sensitive questions: ‘I am about to ask you some personal questions about drugs, sex and how you feel in general. You don’t have to answer them if you don’t wish to. I ask these as part of a health assessment with all young people. Is it OK if I proceed?’ Drugs and alcohol Explore motivation to change behaviour if risky Sexuality Avoid heterosexist language or assumptions:

Explore feelings around becoming sexual if appropriate Suicide/depression Identify protective factors such as those suggested previously Safety from injury and violence  

LEGAL ISSUES

The ambiguous legal status of young people aged under 18 years creates unique challenges in the health consultation. Each country, state and territory has its own statutory laws regarding the age at which an individual under 18 years of age can consent to medical treatment, and in relation to child protection and mandatory reporting requirements, both of which have an impact on clinical care.

Even within countries, different state jurisdictions may allow for different legal rights and obligations in relation to medical consultations and mandatory notification by healthcare professionals about issues such as ‘children at risk of harm’ or the reporting of notifiable diseases. Confidentiality is also a legal requirement in many countries.

Common law allows for the recognition of the ‘mature minor’ in many countries, a legal concept that arose in the United Kingdom in the 1980s in Gillick vs West Norfolk A.H.A. [1984] 1 QB581. This process requires a clinical judgment about the young person’s ‘intelligence and understanding, to enable full understanding of what is proposed’; this is sometimes referred to the ‘Gillick test’.14

Full understanding must include understanding of:

Making a competency assessment will include consideration of the young person’s age, level of independence, level of schooling, maturity and ability to express their own wishes.

Note that the doctor’s assessment of these factors could be influenced by cultural differences between the doctor and the young person. A cognitively mature adolescent may come across as socially or emotionally immature, because of different cultural expectations about their role in the family/society (for example, they may seem less independent), or differences in the way they communicate their thoughts or wishes. If in doubt, seek advice from a colleague or an appropriate agency.

If you are unsure whether a minor is competent, seek the opinion of a colleague, or obtain the consent of the minor’s parents/guardians.

REFERENCES

1 Kang M, Sanci LA. Primary healthcare for young people in Australia. Int J Adolesc Med Health. 2007;9(3):229-234.

2 Booth M, Bernard D, Quine S, et al. Access to healthcare among Australian adolescents: young people’s perspectives and their socioeconomic distribution. J Adolesc Health. 2004;34:97-103.

3 Ary D. Development of adolescent problem behaviour. J Abnorm Child Psychol. 1999;27(2):141-150.

4 Ingersoll GM. Adolescents. 2nd edn. Englewood Cliffs, NJ: Prentice-Hall, 1989.

5 Bennett DL, Kang M. Adolescence. In: Oates K, Currow K, Hu W, editors. Child health: a practical manual for general practice. Sydney: MacLennan & Petty, 2001. Ch 12

6 Bennett DL, Kang M, Leu-Marshall E. Adolescent health. Check program of self-assessment. Melbourne: Royal Australian College of General Practitioners, 2006.

7 Australian Institute of Health and Welfare. Young Australians: their health and wellbeing. AIHW Cat. No. PHE 87. Canberra: AIHW, 2007.

8 Eckersley RM. The health and well-being of young Australians: present patterns, future challenges. Int J Adolesc Med Health. 2007;9(3):217-227.

9 Jacka FN, Kremer PJ, Leslie ER, et al. Associations between diet quality and depressed mood in adolescents: results from the Australian Healthy Neighbourhoods Study. Aust NZ J Psychiatry. 2010;44(5):435-442.

10 Bennett DL, Chown P, Kang M. Cultural diversity in adolescent healthcare. Med J Aust. 2005;183(8):436-438.

11 Goldenring JM, Rosen DS. Getting into adolescent heads: an essential update. Contemp Pediatr. 2004;21:64.

12 Royal Australian College of General Practitioners. Guidelines for preventive activities in general practice. 7th edn. Melbourne, Australia: RACGP, 2009.

13 Reidpath D, Allotey P. Multicultural issues in general practice. Curr Ther. 1999/2000;40(12):35-37.

14 Bird S. Children and adolescents: who can give consent? Aust Fam Physician. 2007;36(3):165-166.