Approaching the Adolescent

Published on 10/06/2015 by admin

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chapter 17 Approaching the Adolescent

Alexa L. Bagnell

It’s my life

It’s now or never

’Cause I ain’t gonna live forever

I just wanna live while I’m alive.

IT’S MY LIFE

BON JOVI

Adolescence is a time of many changes: physical, emotional, social, and cognitive. Each time they look in the mirror, adolescents see someone different. For most teenagers, these are exciting years, filled with new activities and responsibilities, and most enjoy the experience. They experiment, take more risks, engage in romantic relationships, and begin to display autonomy and independence from their parents, spending progressively more time with their peers. For some, this evolution can lead to difficulties. Many report significant stress and pressure. Therefore, learning to manage stress becomes a very important life skill. For any teen, the goal should be to develop into a physically and psychologically healthy young adult, who takes charge of his or her own health care.

Interviewing adolescents calls for a different approach from that used for younger children and their parents. To begin taking responsibility for their own health, adolescents need to meet privately with their doctor (without the presence of their parents or caregivers) to discuss personal health issues. This is an important sign of respect for the adolescent’s individuality and for the confidentiality of the doctor-patient relationship. (See Key Point, page 260.)

Brain Development

The frontal lobe, required for decision making, planning, emotion, and impulse control, is poorly developed in children and youth. Between ages 12 and 24 years, the brain’s synaptic system undergoes significant pruning of neural connections in the frontal lobes. The predominant theory of brain development in teens is “Use it or lose it.” Their experiences during this time determine which connections remain and which die off by adulthood.

Risk taking is a normal element of teen development. Teens are exposed to many more risk-taking models and opportunities than in the past (e.g., Internet, substances, media). This vulnerable stage of brain development, coupled with underdeveloped powers of decision making and impulse control, leads to a higher risk of poorer health outcomes in adolescents.

Puberty

Boys generally experience puberty between ages 10 and 17 years, girls between ages 9 and 14 years. The wide individual variation in the time of the onset and completion of the physical changes of puberty can cause angst for teens who undergo early or late puberty compared with their peers. Early puberty is sometimes advantageous to boys in terms of confidence and physical abilities; however, it can be disadvantageous for both sexes when they are uncomfortable with the changes in their bodies and with being noticeably different from their peers. Early puberty has also been associated with a tendency to join older peer groups and with exposure to higher risk behaviors, such as earlier sexual experiences or experimentation with substance use to “fit in.” Late puberty can also pose challenges with peer relationships and the development of self-confidence.

Body image becomes more significant in puberty and, for some youth, this can lead to unhealthy behaviors, including changes in physical activity and poor eating habits. Screening for health risk behaviors and education concerning good nutrition and regular activity is important for teen health. Puberty is also the stage in which teen sleep patterns begin to change. Youth become “night owls,” often staying up late; this is thought to be related to a change in timing of melatonin release in the brain during puberty. The difficulty for teens is that school starting times generally remain the same, so they often get less sleep during the week and try to catch up on the weekend. Teens should get 9 to 10 hours of sleep per night and, ideally, should stay on the same sleep schedule throughout weekdays and weekends. Good sleep hygiene is an important topic to discuss with teens and their parents because sleep deprivation can affect school, social relationships, physical health, and mental health.

Teen Health

For most adolescents, the teen years are a period of relatively good health, with low morbidity and mortality rates. Yearly check-ups should still be encouraged because it provides you with the opportunity to promote healthy choices and to take steps toward the prevention of illnesses and accidents, including the opportunity to identify at-risk youth. Accidents, suicide, and homicide are the three leading causes of death, accounting for about 75% of deaths in this age group. Whenever you see an adolescent for any problem, you have a golden opportunity to do a brief risk screen and provide appropriate health promotion education. The top two reasons for adolescent visits to teen health centers are for concerns about sexual health and mental health.

Mental illness

Major psychiatric illnesses often begin in adolescence, but many teens do not receive the help they need. About one in five teens will suffer from a psychiatric illness during adolescence. Major depression, schizophrenia, bipolar disorder, social anxiety disorder, panic disorder, eating disorders, and addictions all have their peaks of onset during the teen years. Suicide is the second leading cause of death in this age group in Canada (third in the United States) and is often related to underlying mental illness, such as depression. Stigma continues to be a problem for youth seeking help for psychiatric disorder. Fear, blame and misunderstanding contribute to stigma around mental illness. Many teens do not realize they need help or that effective treatment is available.

Youth should be screened at each visit with routine mental health questions. This can include a brief discussion about the importance of seeking help if symptoms develop, particularly in those who have a family history of mental illness. (See Key Point, page 262, for screening questions.)

Sexual health

Despite plenty of current discussion of sexual health, many youth still lack clear and concise information on which to base their decision making. Many seek information from friends, at school, or from the Internet. Youth may be diffident about approaching their parents and concerned with how they will react. They may also worry that if they ask their doctor, their parents will find out. Almost all youth will be thinking about this issue, and many are already engaged in sexual activity without having accurate health information. Physicians are a trusted source of such information, and every visit provides the opportunity to ask the key questions and provide facts. (See Key Point, page 262, for screening questions.)

Accidents

Accidents are the leading cause of death in adolescents. Most are caused by motor vehicle collisions. Many of these are preventable by the responsible use of motor vehicles (following speed limits, not driving when impaired); safety measures (seat belts, not using cell phones or texting while driving); and understanding the risks of substance use prior to or while driving. Increased risk of motor vehicle accidents has also been documented in adolescents with attention deficit/hyperactivity disorder (ADHD) and teens with insufficient sleep and fatigue, a common problem among teenagers. (See Key Point, page 261, for screening questions.)

Starting the Interview

Interviewing adolescents can be one of the most satisfying experiences of clinical pediatrics, providing that you follow a few clear guidelines. To begin, setting the stage for interviewing an adolescent is important. For previous patients now entering adolescence, let them (and their parents) know that at future visits you will start to spend some time with them on their own. For new adolescent patients, or for those who return to your office as teenagers after a lapse of several years, you can inform the youth and the parents that you will be spending part of the time with the teen alone. This is an important step in teaching adolescents to manage their own health care.

What if the parent refuses to leave the room? In some cases, a parent may refuse to leave the room, not allowing the teen to be interviewed alone. It will not benefit rapport or trust to push a parent out of the room unwillingly. There could be many reasons for this behavior. The best approach is to review the basic interview structure for future visits and explain that it is important for the adolescent to begin to develop autonomy in taking care of his or her own health. Addressing any issues the parent may have can also help increase their comfort with separating from their teenaged child. At the end of the interview, spend a few minutes asking the parent about their concerns. This may help facilitate seeing the teen alone at the next visit.

What if teens tell you something they do not want their parents to know? Confidentiality is vitally important. Concern about confidentiality of information can lead teens to avoid seeking appropriate medical care or not informing their physician about important health-related behaviors. If possible, at the start of the interview, point out that some issues may come up that will be kept confidential from parents. However, explain to them that if there are any concerns regarding the safety of the teen or the safety of others, confidentiality will not be maintained.

A general statement such as, “Everything we talk about in here is confidential, which means I keep it private and do not share it with other people (such as your parents or teacher) except those involved in your health care treatment team. There are some limits to this confidentiality. If I have any concern of risk of harm to you or someone else, I would let you know that I would need to break confidentiality, and then I would have to tell your parents and others if needed, to make sure you are safe.” Having both the adolescent and parents hear this at the beginning is important and helpful. Discussing this at the end of the interview can result in parents grilling the teen later about issues that they may not be sharing with them.

Working with the family and particularly the parents, while respecting confidentiality of the youth, is one of the challenges in taking care of this age group. As in any interview, the most important issue is building trust and rapport.

Key Point

Confidentiality is a crucial part of the treatment of adolescents. It should be discussed with the teen and parents at the beginning of the interview.

Building trust and rapport

Adolescents are looking for the same thing as patients of all other ages in that initial contact: they want to be listened to, including during all subsequent visits. They want to know that you are genuinely interested in learning about them and in finding out who they are. Put down your pen, sit down, and have a brief conversation. This is particularly important at the start of every initial interview. Take a few minutes to develop rapport. For example, identify one of the teen’s particular interests, and ask questions about it. This might involve music, sports, drama, books, movies, computers, television, or video games. Faking your interest will not work because the youth will see right through it. If you have never heard of whatever they are talking about, be honest, with statements such as, “Wow, I have never heard of that—tell me how that works.” This admission may make you look far from “cool,” but honesty and genuine interest carry great value in the teen-doctor relationship.

The information you learn can help reconnect with the teen at subsequent visits, so make a brief note of those interests to remind yourself at the next visit.

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