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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.
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Some tips on reassuring adolescents on confidentiality issues7,9 include:
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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)
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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.
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Who is in the room and who talks?
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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.
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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.
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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?’
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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.
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Communication and rapport with adolescents
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The single most crucial role of a GP caring for an adolescent, regardless of their presenting complaint, is to foster and develop a relationship of trust.10
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Tips for fostering engagement with adolescents3 include:
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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.
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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.
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E = Education and Employment
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A = Activities and peer relationships
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D = Drug use, cigarettes and alcohol
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S = Suicide and depression (including mood and possible psychiatric symptoms)
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Adolescents are often very sensitive about their bodies and physical appearance, especially when going through puberty. When physically examining adolescents:
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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
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Note: The new cervical screening test is not required until the age of 25.
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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:
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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.
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Developing a management plan4
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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:
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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
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MENTAL HEALTH IN ADOLESCENTS4
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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).
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Depression in adolescents3,4
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(See CHAPTER 19 for a discussion on depression.)
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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.
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Use of antidepressants in adolescents
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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.