Adolescent medicine

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Adolescent medicine

Adolescence is the transition from childhood to adulthood. There is no clearly defined age range, but it is usually considered to be from puberty until 18 years of age. There are 7.8 million adolescents in the UK, 12–13% of the population, with increased proportions observed in ethnic minority groups.

The transition from being a child to an adult involves many biological, psychological and social changes (Table 28.1). Pubertal development is considered in Chapter 11. Difficulties may arise if the pubertal changes are early or delayed.

Table 28.1

Developmental changes of adolescence

	Biological	Psychological	Social
Early adolescence	Early puberty: Females – breast bud, pubic hair development, start of growth spurt Males – testicular enlargement, start of genital growth	Concrete thinking (Fig. 28.1a), but begin to develop moral concepts and awareness of their sexual identity	The early emotional separation from parents, start of a strong peer identification, early exploratory behaviours, e.g. may start smoking
Mid-adolescence	Females – end of growth spurt, menarche, change in body shape Males – sperm production, voice breaks, start of growth spurt Acne Blushing Need for more sleep	Abstract thinking, but still seen as ‘bulletproof’, increasing verbal dexterity, may develop a fervent ideology (religious, political)	Continuing emotional separation from parents, heterosexual peer interest, early vocational plans
Late adolescence	Males – end of puberty, continued growth in height, strength and body hair	Complex abstract thinking (Fig. 28.1b), identification of difference between law and morality, increased impulse control, further development of personal identity, further development or rejection of ideologies	Social autonomy, may develop intimate relationships, further education or employment, may begin or develop financial independence

Adapted from Adolescent development. In: Viner R, ed. 2005. ABC of Adolescence. Blackwell, Oxford.

Figure 28.1 Example showing the difference between **(a)** concrete and **(b)** abstract thinking in the management of asthma in an older child and an adolescent.

While general practitioners will see all adolescent medical problems, difficulties may arise when obtaining specialist medical care. Those less than 16 years old are generally looked after by paediatricians; over 16 years old, by either paediatricians or more often by adult physicians and surgeons. However, paediatric facilities, e.g. children’s wards, are often geared to the needs of young children rather than adolescents, whilst older adolescents may be overwhelmed by the medical conditions encountered on adult wards and the independence expected of them. Adolescent females with gynaecological problems are often cared for by gynaecologists, usually in adult facilities. Some paediatricians in the UK are now specialising in adolescent medicine in a similar way to North America and Australia.

Communicating with adolescents

The adolescent consultation differs from the paediatric consultation for young children, in that the adolescent has a greater active role in the consultation.

As well as seeing adolescents with their parents, an integral component of adolescent healthcare is offering young people the opportunity to be seen independently of their parents for at least part of the visit The principle is that the parents should not be seen alone after the adolescent has spent time with the doctor, so that the adolescent can trust that whatever confidences have been disclosed to the doctor have been kept.

Some practical points about communicating and working with adolescents are:

• Make the adolescent the central person in the consultation.

• Be yourself. When establishing rapport, it may be appropriate to engage the adolescent by talking about their interests, e.g. football, clothes or music, but do not try to be cool, false or patronising; your relationship should be as their doctor, not their friend.

• Consider the family dynamics. Is the mother or father answering for the adolescent? Does the adolescent seem to want this or resent being interrupted?

• Avoid being judgemental or lecturing. Avoid ‘You ….’ statements and use ‘I ….’ statements in preference, e.g. ‘I am concerned that you ….’. A frank and direct approach works best. Your role should be that of a knowledgeable, trusted adult from whom they can get advice if they so choose.

• An authoritarian approach is likely to result in a rebellious stance. Working things out together in a practical way has the best chance of success.

• Frame difficult questions so they are less threatening and judgemental, e.g. ‘Lots of teenagers drink alcohol, do any of your friends drink? How much do they drink in a week? Do you drink alcohol – how much do you drink compared to them?’ Likewise, when asking sensitive questions on, e.g. sexual health, always give young people warning and explain the rationale of why such questions need to be asked.

• Confidentiality is particularly important to this age group and must be respected. Explain that you will keep everything you are told confidential, unless they or somebody else is at risk of serious harm. Always assess their understanding of confidentiality and correct any misunderstanding.

• Bear in mind proxy presentations, e.g. abdominal pain, when the real reason is anxiety about the possibility of pregnancy, or sexually transmitted infection or the result of recreational drug use.

• A full adolescent psychosocial history is useful to engage the young person, to assess the level of risk as well as provide information which will aid the formulation of effective interventions. The HEADS acronym may be helpful in this regard (Table 28.2), although questions must always be tailored to stage of development and the right of the young person to not answer should be respected.

Table 28.2

HEADS acronym for psychosocial history taking in adolescents

H	Home life	Relationships, social support, household chores
E	Education	School, exams, work experience, career, university, financial issues
A	Activities	Exercise, sport, other leisure activities
A	Activities	Social relationships, friends, peers, who can they rely on?
D	Driving	Aged 16 if has high rate mobility component of the Disability Living Allowance (DLA)
	Drugs	Drug use, cigarettes, alcohol. How much? How often?
	Diet	Weight, caffeine (diet drinks), binges/vomits
S	Sex	Concerns, periods, contraception (and in relation to medication)
	Sleep	How much? Hard to get to sleep? Wake often?
	Suicide/affect	Early waking? Depression, self-harm, body image

• Communicate and explain concepts appropriate to their cognitive development. For young adolescents, use concrete examples (‘here and now’) rather than abstract concepts (‘if … then’) .

• History-taking should avoid making the assumption of heterosexuality with questions about romantic and sexual partners asked in a gender neutral way.

• If they need to have a physical examination, consider their privacy and personal integrity – Who do they want present? As with any age, young people have the right to a chaperone but it should not be assumed the young person will want this to be their parent. Also, find out if they would prefer a doctor of the same sex, if this is an option.

Summary

Talking and listening with young people

• Always give them the opportunity to be seen independently of their parents

• Explain and assure confidentiality

• Psychosocial screening is useful to:

– Engage young people

– Assess risk

– Assist formulation of interventions.

Consent and confidentiality

Consent

In the UK, young people can give consent if they are sufficiently informed and either over 16 years old or under 16 years and competent to make decisions for themselves. Conflict rarely arises about a treatment, as usually the adolescent, their parents and doctors agree that it is necessary. Handling of disagreement over consent is considered in Chapter 5.

Confidentiality

Confidentiality is regarded by adolescents as of crucial importance in their medical care. They want to know that information they have disclosed to their doctor is not revealed to others, whether parents, school or police, without their permission. In most circumstances, their confidentiality should be kept unless there is a risk of serious harm, either to themselves from physical or sexual abuse or from suicidal thoughts or to others from homicidal intent. Difficulties relating to confidentiality for adolescents are usually about contraception, abortion, sexually transmitted infections, substance abuse or mental health. It is usually desirable for the parents to be informed and involved in the management of these situations and the adolescent should be encouraged to tell them or allow the doctor to do so. However, if the young person is competent to make these decisions for himself/herself, the courts have supported medical management of these situations without parental knowledge or consent.

Range of health problems

Adolescence is considered a healthy stage of life compared with early childhood or old age. In spite of this, the majority of young people will consult their general practitioner more than once in a year and 13% of adolescents report a chronic illness. The range of health problems affecting adolescents include:

• Common acute illnesses: respiratory disorders, skin conditions, musculoskeletal problems including sports injuries and somatic complaints. Acute serious illness has become rare, with mortality predominantly from trauma

• Chronic illness and disability: e.g. asthma, epilepsy, diabetes, cerebral palsy, juvenile idiopathic arthritis, sickle cell disease. The prevalence of some of the common chronic disorders in adolescence is shown in Table 28.3. There is also a range of uncommon disorders with serious chronic morbidity such as malignant disease and connective tissue disorders. In addition, children with many congenital disorders which often used to be fatal in childhood now survive into adolescence or adult life, e.g. cystic fibrosis, Duchenne muscular dystrophy, complex congenital heart disease, metabolic disorders, etc.

Table 28.3

Prevalence of some chronic illnesses per 1000 adolescents (12–18 years old)

Disease	Prevalence per 1000 adolescents
Musculoskeletal conditions	41
Skin conditions	32
Significant mental health problems	120
Diabetes
Type 1	2
Type 2	1–2
Respiratory conditions	150
Asthma	100
Cystic fibrosis	0.1
Epilepsy	4
Hearing problems	18
Cerebral palsy	1.5

• High prevalence of somatic symptoms: fatigue, headaches, backache, etc.

• Mental health problems including suicide and deliberate self-harm

• Eating disorders and weight problems

• Those associated with health-risk behaviours, such as smoking, drinking, drug abuse and sexual health, contraception and teenage pregnancy.

Mortality

The dramatic improvement in the mortality of young children seen since the 1960s has not been matched in adolescents, who now have a higher mortality rate than that of 1–4-year-olds (Fig. 28.2). Although deaths in adolescents from communicable diseases have declined markedly, this has not been matched by mortality from road traffic accidents, other injuries and suicide, and these now predominate (Fig. 28.3). Alcohol is thought to be a contributing factor in one-third of these deaths.

Figure 28.3 Causes of death, 15–19 years of age, in England and Wales, 2008. (*Source*: ONS, 2010.)

Impact of chronic conditions

Chronic illness may disrupt biological, psychological and social development. In addition, these developmental changes may affect the control and management of the disorder (Table 28.4). The impact of chronic illness on children, young people and their families is considered in Chapter 23.

Table 28.4

Some of the ways in which chronic illness and development interact with each other

	Effect of chronic illness on development	Effect of development on chronic illness
Biological	Delayed puberty Short stature Reduced bone mass accretion Malnutrition secondary to inadequate intake due to increased caloric requirement of disease or anorexia Localised growth abnormalities in inflammatory joint disease, e.g. premature fusion of epiphyses	Pubertal hormones may impact on disease, e.g. growth hormone worsens diabetes and increases insulin requirements; females with cystic fibrosis may have deterioration in lung function; corticosteroid toxicity worse in peripubertal phase Increased caloric requirement may worsen disease control or result in undernutrition – may need dietary supplements or overnight feeding with nasogastric tube or gastrostomy Growth may cause scoliosis
Psychological	Regression to less mature behaviour Adopt sick role Impaired development of sense of attractive/sexual self Parental stress, depression, financial problems in providing care; siblings may suffer	Deny that their health may suffer from their actions Poor adherence and disease control Reject medics like parents
Social	Reduced independence when should be separating Failure of peer relationships Social isolation – unable to participate in sports or social events School absence and decline in school performance, may lower self-esteem Vocational failure	Risk behaviour may adversely affect disease, e.g. smoking and asthma or cystic fibrosis, alcohol and diabetic control, sleep deprivation and epilepsy Chaotic eating habits lead to malnutrition or obesity

Adherence

Poor adherence is a problem for many people, including adolescents as they are beginning to take over management of their illness, wish to avoid parental supervision and may give the management of their illness a lower priority than social and recreational activities. They may not believe that taking the medication really matters, especially if it is preventative or of long-term rather than short-term benefit.

Peer relationships and self-image are very important when considering adherence. For example, it may be more important for an adolescent with diabetes to lunch promptly, so he can sit with his friends rather than go to the school nurse first for his insulin injection. Side-effects are also important, particularly those that affect well-being or appearance. They may assess risk differently from adults, so that the risk of not being one of their crowd because of having to adhere to a certain treatment may appear to be more important than the risks attached to not taking any medication.

Adherence may be influenced by lack of knowledge and/or poor recall of previous disease education. The disorder may have presented when the child was much younger, so that the original consultation will have taken place primarily between the doctor and parents. If this communication has not been updated with increasing age, the adolescent’s knowledge may be poor, with little understanding about his/her illness, what medications he/she is taking and why. As the responsibility for management moves to the young person, information needs to be provided about medications and treatment appropriate for his/her development. Other ways to maximise adherence are summarised in Table 28.5.

Table 28.5

Ways to maximise adherence

Assess the size of the problem and be non-judgemental	Ask: ‘Most people have trouble taking their medication. When was the last time you forgot?’
Take time to explore practicalities	Try to put yourself in the adolescent’s shoes and think through the detail of their regimen with them. Make regimen as simple as possible. Don’t forget practical issues – poor adherence may be as simple as not having anywhere private at school to take the treatment
Explore beliefs	May harbour strange or incorrect beliefs about medications, e.g. falsely attribute a side-effect and therefore refuse to take the medication
Use daily routines to ‘anchor’ adherence	Find daily activities to anchor taking the medication, e.g. brushing teeth, or ‘with breakfast and dinner’ instead of ‘twice a day’. Find the least chaotic time of day: may be morning or evening! Let the suggestions come from the adolescent
Motivation	Negotiate short-term treatment goals. Search for factors that motivate the young person
Involve and contract	Plan the regimen with the adolescent. Some may respond to a written contract that both sides agree to stick to
Written instructions	Most of what is said has been shown to be forgotten once they leave the room!
Take time to explain	Check level of knowledge on each occasion
Solution-focused approach	Find out what has been going well and why. Use this information, e.g. ‘How have you managed to remain out of hospital for 3 weeks this month?’

The implications of their condition on the rest of their health needs to be considered. This may include sexual health, future vocational development, including the need for disclosure and their rights under the Disability Discrimination Act. Similarly, the implications of other health-risk behaviours such as substance use, tattoos and piercing may need to be discussed.

Transition to adult services

The young person with a chronic condition must eventually leave paediatric and adolescent services for adult services. This often involves changing from a treatment model based around close contact between the adolescent and healthcare professionals (unlimited telephone advice from clinical nurse specialists, possibly home visits, frequent appointments) and involvement with parents and other family members, to one where they are likely to be seen infrequently in a busy adult clinic where parental involvement may be minimal or discouraged.

Young people and their parents need both information about the transfer process and time to prepare. Transitional care encompasses this preparation which, by definition, addresses the medical, psychosocial and educational/vocational needs as a young person moves from child- to adult-centred services. Parents are often concerned that the adult team will not address their teenager’s healthcare needs. It is helpful if an identified healthcare professional, often a nurse specialist, is responsible for coordinating transition arrangements.

Whereas transitional care starts in early adolescence, some flexibility in age of transfer is desirable, so that it can occur when the young person is developmentally ready and has the necessary maturity to cope with adult services.

Transfer may be via an adolescent or young adult service with clinics run by both adolescent and adult teams together. Such bridging arrangements have many advantages, but require a sufficient number of patients and medical staff able and willing to provide this service. These clinics are usually for specialist conditions, e.g. diabetes, juvenile idiopathic arthritis, cystic fibrosis or congenital heart disease. Alternatively, transfer may be successfully accomplished if there is good communication between teams, although it usually involves a radical change in ethos for the adolescent and family. The general practitioner may be a source of continuity between changing specialty practitioners.

Summary

Chronic conditions during adolescence

• Chronic illness and/or disability may disrupt adolescent development

• Consideration should be made of the impact of the chronic condition on the rest of health (including sexual and reproductive health) as well as education and leisure

• Transitional care aims to address medical, psychosocial and educational/vocational issues as young people move from child- to adult-centred services.

Fatigue, headache and other somatic symptoms

Fatigue, headache, abdominal pain, backache and dizziness are common in adolescence. International surveys of adolescents in Europe reveal that two-thirds report morning fatigue more than once a week, 25% have a headache and 15% stomach ache, backache or sleep problems more than once a week. In many, these symptoms appear to be a feature of adolescence, although organic disease must be excluded by history, examination and, occasionally, investigation. For a minority, they may be a physical manifestation of psychological problems, and are precipitated by or maintained by factors such as bullying or parental discord.

Occasionally, the symptoms are so severe and persistent that they considerably affect quality of life, with impairment of school attendance, academic results and peer relationships. This may be from chronic fatigue syndrome or chronic idiopathic pain syndromes. Further investigation and assessment will be required and multidisciplinary rehabilitation and cognitive behavioural therapy within the family may be beneficial. The management of somatic symptoms and chronic fatigue syndrome are considered further in Chapter 23.

Mental health problems

The prevalence of mental health problems in adolescents is estimated to be about 11%. The main problems are listed in Table 28.6.

Table 28.6

Main mental health problems and disorders in adolescents

Problem or disorder	Prevalence (%)
Depression	3–5
Anxiety	4–6
Attention deficit hyperactivity disorder	2–4
Eating disorders	1–2
Conduct disorder	4–6
Substance misuse disorder	2–3