Chapter 97: Adolescent health

Adolescence is the transitional period of development between relatively dependent childhood and relatively independent adulthood. The time of onset and duration varies from one person to another but it is generally considered to occur between the ages of 10 and 19 years.¹ It is a critical period of transition in the human lifespan, marked by rapid growth and physical and mental changes second only to infancy.

While biological changes drive this transition, the duration and characteristics of adolescence can vary depending on cultural and socioeconomic settings. Adolescence has also altered over the past century, occurring earlier and being influenced by societal changes such as later marriage, increased urbanisation, global communication, information technology, social networking and changing sexual attitudes and behaviours.^1,2

Adolescent patients require special understanding and caring from their family doctor. They can present very challenging and sometimes confronting issues. A profound increase in mental health issues (particularly mood disorders)³ in adolescents has exacerbated the frequency of challenging adolescent consultations in general practice. Another common difficulty is establishing rapport and trust with adolescents, who may be trying to break away from the adult world to establish their own sense of adult self, so it can be vitally important to address confidentiality issues. Actively raising and clarifying confidentiality parameters and doing so at the beginning of the consultation can greatly assist the interaction with an adolescent patient.

In recent times, reference is made to the young person in the context of health policies. Young people are defined as those between the ages of 12 and 24 years and youths as those between 15 and 24 years.² Some 18% of the population are young people, and they tend to have a low rate of GP visits; if they do visit, it is usually for physical reasons, despite the fact that the largest health burden for adolescents is actually mental health issues.

Early adolescence (10–14 years): ‘Am I normal?’

This stage is dominated by adjustment to physical and psychosexual changes and by the beginnings of psychological independence from parents. Girls generally advance through this stage more rapidly than boys.

Middle adolescence (14–17 years): ‘Who am I?’

Middle adolescence is a time when boys have caught up physically and psychologically with girls, so that peer group sexual attractions and relationships are common preoccupations at this stage. It is a phase of peer group alliances, clothes, music, jargon and food and drink. The average age for first sexual intercourse for both sexes is 16 years. It is a stage where intellectual knowledge and cognitive processes become quite sophisticated. Experimentation and risk-taking behaviour is a feature, and confidentiality issues are often important.

Late adolescence (17–19 years): ‘Where am I going?’

This is the stage of reaching maturity and leads to more self-confidence with relationships and successful rapport with parents. Thought is more abstract and reality-based. Relationships may become more intimate, moral value systems are more established, and vocational and educational goals become more central.

• Psychological health problems with high rates of first onset in adolescence include depression, self-harm, anxiety disorders, behavioural disorders (e.g. ADHD, conduct disorders) and eating disorders. More than 80% of mental illness starts under the age of 25

• Other areas of concern: substance abuse, schizophrenia and drug-related psychosis

• Eating disorders, including obesity, fast food, bulimia nervosa and anorexia nervosa (refer to CHAPTERS 78 and 79)

• Injuries, including sporting injuries, motor vehicle accidents and interpersonal violence

• Risk-taking behaviour, including drug abuse

• Sexual adjustment, including unsafe sexual practices and teenage pregnancy

• Chronic illness and disability, including survivors of inherited disorders

• Asthma, which is a leading cause of hospital admissions for both sexes in the 10–14 years age group

• Overexposure to sunlight

• Acne, which can be very distressing for adolescents. Severe acne can increase the risk of suicide⁵

The following are myths that some practitioners feel apply to the adolescent:

• different from adults in needs

• ‘superficial’ thinkers

• represent a ‘quick’ consultation

• shun personal questions

• resent invasion of space

It is important to treat adolescents as normal human beings.

As a rule, parents and physicians should not exclude children and adolescents from decision making without persuasive reasons. Across Australia, common law states that 18 years of age is the age of consent. It also states that consent may be given under 18 years, but that the nature of the medical intervention and the ability of the young person to fully understand need to be taken into consideration. A concept that can be applied to this is the Gillick test, which prescribes that the parental right to determine their child’s treatment terminates once an adolescent under the age of 16 is capable of fully understanding the medical treatment proposed. Two questions that GPs may be confronted with are:

• When can a young person under 18 years of age consent to medical treatment?

• When can parents or guardians consent to medical treatment for young people under 18 years of age?

When considering these questions, a competency assessment of the adolescent should be undertaken that includes considering:

• age

• level of independence

• level of schooling

• maturity

• ability to express own wishes

In NSW and South Australia, additional laws allow for those aged 14 years (NSW) and 16 years (SA) and over to consent to their own treatment. GPs in these states should familiarise themselves with these laws in situations where consent is problematic.

A large ongoing survey by Mission Australia⁶ on 15–19-year-olds shows that these adolescents most value:

• friendships

• family relationships

• school and study satisfaction

• physical and mental health

The top issues of personal concern include:

• coping with stress (increasing from 19% to 38% from 2009 to 2013)

• school or study problems (37%)

• body image (31%)

Some 20% were also extremely or very concerned about family conflict.

The internet is the number one source of information for young people, 20% of whom spend >20 hours a week on social network sites.

There can be many barriers to adolescents accessing general practice. This is especially so for those marginalised by factors such as homelessness or risk of homelessness, involvement in the juvenile justice system, disability, same-sex attraction, or being from an Indigenous, non-English-speaking or refugee background. Barriers include:⁷

• knowledge of services

• concerns about confidentiality

• availability of services, particularly in regional, rural and remote areas

• cost

• poor previous experiences

• location of services

• complicated systems and referral processes

Because of these significant barriers, improving adolescents’ access to health services in general, and specifically to general practice, is essential. While youth-specific services such as the national headspace initiative <www.headspace.org.au> have gained momentum in recent years, general practice remains the cornerstone of primary health care for young people.⁶ The characteristics of a youth-friendly practice have been defined⁷ as having:

• accessibility to young people (e.g. visual appearance, online services, registering for Medicare)

• youth participation in the practice (e.g. involving adolescents in policy development, employing adolescent/young person staff)

• collaboration and partnerships (e.g. with housing or mental health services)

• professional development in youth service provision

• evaluation by the practice of services provided to young people

• evidence-based approaches to the health of adolescents

• sustainability of these approaches

Teenagers want to be asked about sexual health, mental health and substance use, even if they present to their GP for other reasons, according to Tasmanian research. They also want non-judgmental doctors who ‘avoid medical jargon, listen, assure them about confidentiality and respect their views and choices’.⁸

A video for GPs and young people about being and implementing a youth-friendly practice is available through NSW Kids and Families <www.kidsfamilies.health.nsw.gov.au/current-work/youth-health-and-wellbeing/>. It includes issues such as adolescents accessing Medicare and the all-important issue of confidentiality.

Confidentiality

Confidentiality is a major issue when seeing adolescent patients, especially those who are new to the practice or who have had negative experiences with authority previously (e.g. involvement in community services or the juvenile justice system) or in cases where other members of a family (particularly the parents) are also your patients. The whole concept of adolescents struggling to establish an identity separate from their carers is tied up in the burgeoning relationship with the GP, and the rules of medical confidentiality, well known to most adults, are often a mystery to young people.

Some tips on reassuring adolescents on confidentiality issues^7,9 include:

• having a practice confidentiality policy visible for all patients to see (e.g. online, in waiting room, in practice information leaflets/orientation pack)

• talking about or defining what medical confidentiality means (and the boundaries or exceptions to this—see TABLE 97.1) up front, i.e. before the first consult starts, especially if you suspect the patient may be worried about such issues

• reinforcing these principles when sensitive issues arise through the evolving GP–patient relationship (e.g. contraceptive or other sexual health issues, mental health issues)

Cost

One of the major barriers to adolescents accessing primary care is cost. They are often unaware of how Medicare operates and how to access a card. Adolescents can acquire their own Medicare card from the age of 15. Having application forms available in the surgery (you need photo identification) can help. Young people should be made aware that they do not need to have the card on them to see the doctor. Medicare doesn’t reveal to anyone (including parents) who has used the card, provided they are over the age of 14.

Who is in the room and who talks?

An adolescent may present alone or accompanied by others, including, often, a parent. The parent may take a dominating role, doing the talking for the adolescent. Teasing out the two roles (that of the adolescent and that of the parent) as two separate entities can be a challenge, and needs to be done sensitively. The objective of the GP should be to establish rapport and a patient–doctor relationship with the adolescent him or herself, while not threatening the role of the parent.

Most parents will be aware of and sensitive to this, and may even encourage the adolescent to talk for themselves or offer to leave the consulting room. An offer like this should be taken up, with a view to bringing the parent back into the room after a private conversation with the adolescent. It should be made clear exactly what the adolescent will and will not allow to be revealed to the parent (once he or she returns) during the private conversation.

Asking a parent to leave (if no offer is made) may surprise an anxious or overbearing parent, and should be negotiated carefully. Normalising this early in the consultation, as your usual approach, can help.⁴ ‘Normally when seeing a young patient like your son/daughter, I like to see them by themselves at some stage in the consultation and then get the parent back in afterwards. Is that okay by you?’

If a parent does not want to leave the room, or continues to talk for or over the top of the adolescent, a more forthright approach may be warranted, though this is unusual. It will be difficult to foster a patient–doctor relationship with the adolescent in such circumstances.

Communication and rapport with adolescents

Tips for fostering engagement with adolescents³ include:

• Treat the young person as responsible and capable of contributing to decision making.

• Take a curious, non-intrusive and respectful stance.

• Be open and honest as much as possible.

• Clarify what the young person wants from you.

• Establish agreed goals or explain clearly why you cannot help.

• Be honestly interested in what the young person has to say.

• Be yourself, don’t fake it.

• Use metaphor and humour (where appropriate) to build rapport.

• Use language that is clear and easily understood and avoid jargon; overuse of slang is probably worse than not using it at all.

• Warn the young person if you are going to ask questions about topics that may be difficult (e.g. sexual matters).

• Avoid getting into a controlling, authoritarian position.

• Remember that engagement may wax and wane.

HEEADSSS is a guide (not a script or tick list) that can be useful for a GP when conducting a psychosocial assessment of an adolescent. It is a framework designed to progress from the (usually) less sensitive to more sensitive areas of potential concern in an adolescent. It does not have to be covered all in one consultation, and the areas that are covered may be tailored to the individual patient and his or her circumstances. A shortcut on clinical software may prompt the GP to use HEEADSSS. It has recently been expanded to reflect the major causes of adolescent morbidity and mortality.

H = Home

E = Education and Employment

E = Eating and Exercise

A = Activities and peer relationships

D = Drug use, cigarettes and alcohol

S = Sexuality

S = Suicide and depression (including mood and possible psychiatric symptoms)

S = Safety

Physical examination

Adolescents are often very sensitive about their bodies and physical appearance, especially when going through puberty. When physically examining adolescents:

• carefully explain what you are going to do before you do it

• obtain consent for examining adolescents

• consider offering a chaperone for examining breasts or genitals, especially a male doctor and female adolescent patient

• gender and cultural differences and norms should be considered prior to physical examination

Note: The new cervical screening test is not required until the age of 25.

Risk behaviours

Risk behaviours are common in adolescents and should be actively but sensitively screened for. The HEEADSSS model can be employed to do this screening. If there are risk behaviours:

• Assess how high the risk is (e.g. multiple risk behaviours? is it escalating? aware of the risk and potential consequences?).

• What are possible protective factors (e.g. support from family, school, positive peer relationships or culture)?

• Focus on strengths and abilities the adolescent may have.

• Build motivation and reinforce capacity to change.

• Actively promote behaviour change by using guided decision making.

• Provide appropriate information and education on the risk behaviour and potential consequences.

• If high-risk behaviours are identified, referral to appropriate services (e.g. drug and alcohol, psychologists) while the GP maintains a case management role.

Developing a management plan⁴

Informing an adolescent of your assessment and actively involving him or her in the development of your management plan will help improve trust and compliance. It is also useful to:

• identify risk behaviours—provide relevant information and education

• set realistic treatment goals appropriate to your adolescent patient

• where appropriate, discuss how much he or she wants parents to be informed and involved

• guide parents in how to best support their adolescent child and best respond to risk-taking behaviours

• Up to 25% of adolescents suffer from a mental health and/or substance abuse problem.

• Mental health in adolescents is worsening.

• Many chronic mental health issues have their onset in adolescence.

• Anxiety and depression are the leading mental health problems in adolescents (17% of the male disease burden and 32% of the female).

• Behavioural disorders are also common (8% of 12–17-year-olds have ADHD, and 3% have conduct disorders) as are eating disorders.

• There is a marked increase in risk factors and risk-taking behaviours for mental health in adolescence (e.g. substance abuse, peer conflicts).

• Mental health issues in adolescents can present differently from in adults, with mood swings, poor school performance or attendance, irritability, anger, substance abuse, somatic complaints, risk-taking behaviours or conflict with peers or family being more common.

• Adolescents are generally ill informed about mental health (<25% seek help).

Depression in adolescents^3,4

(See CHAPTER 19 for a discussion on depression.)

• Up to 24% of adolescents will have suffered an episode of major depression by the age of 18.

• Depression can be more masked by the patient and harder to detect in adolescents, so requires more active screening.

• Psychosocial development may be compromised by depression in adolescence.

• Effective engagement and developing a trusting therapeutic alliance are critical in managing depressed adolescents.

• Using the HEEADSSS tool can help in assessment.

• Comorbidity with other mental health issues (anxiety disorders, behavioural disorders, eating disorders, substance abuse) is common.

• It helps to encourage protective factors such as positive peer relationships, support from schools or families, regular sleep patterns and pleasurable activity scheduling.

• Counselling and psychological treatments are first line in the treatment of adolescents with depression.

• Using mental health Medicare item numbers may help improve access to services.

Use of antidepressants in adolescents

In major depression in adolescents, treatment with fluoxetine can be considered. There appears to be an age-related mechanism linking SSRI treatment with an increased risk of suicidal thinking, with adolescents being at greatest increased risk. Because of this, if pharmacological therapy is warranted, it should be prescribed by a practitioner who is very familiar with the range of adverse effects and able to monitor the young person appropriately. Close monitoring for suicidality is especially important in the first 4 weeks. If there are concerns regarding severe symptoms or risk of suicide, referral to a psychiatrist who treats adolescents is recommended.

• Hospital rates for suicide attempts are 3 times higher in females, but suicide deaths are 3 times higher in males (males use more lethal means).

• More than half of all adolescents who try to kill themselves will have visited a GP within the previous month (i.e. GPs can play a very important preventive role, see TABLE 97.2).

Risk factors

• Previous suicide attempt/self-harm

• History of previous attempts in family/friends

• Concrete suicide plan

• Underlying mental disorders—e.g. depression, anxiety, substance abuse

• Comorbid conditions—e.g. eating disorder, conduct disorder

• Recent stressful life events (e.g. relationship breakdown, humiliation, school problem, conflict with peers)

• Ongoing family problems

• Victim of bullying

• Lesbian, gay, bisexual, transexual (LGBT) orientation

• Cultural conflicts or concerns

Management

• Fully explore the adolescent’s thoughts, plans and actions. Assess his or her level of risk.

• Do not agree to secrecy.

• Confidentiality is over-ridden if there is serious or imminent danger of suicide. Gently explain this to the adolescent while trying to maintain and protect a therapeutic alliance.

• Contact and mobilise family and social supports.

• Get help from peers or other health providers where possible. Mental health services such as crisis teams may need to be involved.

• If possible, remove or limit access to means of self-harm (e.g. medications).

• Consider (in conjunction with other therapeutic approaches) a ‘no-suicide contract’. Usually verbal, this is an agreement for the adolescent to commit to you that he or she will not act on any suicidal thoughts until you next see them. This should be done for only a short (<1 week) period.

In a similar fashion to depression, anxiety disorders in adolescents are common, hard to detect and heavily reliant on the GP having a trusting relationship with the adolescent; they also have psychological therapies as the first-line treatment. See CHAPTER 81 for further discussion on anxiety disorders.

Anorexia nervosa and bulimia nervosa arise usually in the early to mid-teens (see CHAPTER 79). There are many sub-syndromal variations that threaten to develop into a serious state but these can settle, especially with early identification and counselling.

Adolescent violence towards parents is defined as ‘any act of a child that creates fear in, and is intended to hurt parents’. It usually refers to behaviours by adolescents between 12 and 18 years of age.

Victoria Police has reported a 40% plus increase over the past six years in family violence incident reports where the perpetrator was under the age of 18 (Victoria Police 2012). This is repeated in other states. (Violence toward parents, Parent Easy Guide 17, Department for Health and Ageing, South Australia)

Types of adolescent violence include physical, psychological/emotional, financial and sexual behaviours.

Help guidelines include:

• Emergency lifeline 13 11 14

• Parent line 13 22 89

• Kids helpline 1800 551 800

• Relationships Australia 1300 364 277.