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

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

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
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

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• 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.

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

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