INTRODUCTION AND OVERVIEW

The essence of good adolescent healthcare consists of:

Adolescent health falls outside biological paradigms, clinical medicine and its usual classifications, and outside the classic distinctions between physical and mental health, between medical and social aspects of health, and between curative and preventive care. Adolescent healthcare is a bio-psychosocial field, one which, by its very nature, requires an integrative approach.

While young people are often considered a relatively healthy population group, current indices are poor for at least 20–30% of young people. Their health problems are mainly psychosocial and, certainly in clinical settings, likely to be overlooked. Young people are notoriously reluctant to seek services to address these social and psychological self-concerns.¹,² They are also involved in health risk behaviours earlier than in past generations. Many engage in behaviour that threatens their health and wellbeing, and there is increasing evidence that many problem behaviours in young people are interrelated. Young people with conduct disorders, for example, are also likely to engage in tobacco, alcohol and substance use, to engage in high-risk sexual behaviour and to experience academic failure.³

A note about terminology: the term young person refers to someone aged 12–25 years. The word adolescent will be used where it is more appropriate to refer specifically to the developmental processes occurring during these years.

NORMAL ADOLESCENT DEVELOPMENT

Adolescence has been described as:

Adolescence begins with the onset of puberty and ends with the acquisition of adult roles and responsibilities. It is characterised by rapid change in the following domains:⁵

THE EXPERIENCE OF PUBERTY

Puberty involves the most rapid and dramatic physical changes that occur during the entire lifespan outside the womb. Average duration is about 3 years and there is great variability in time of onset, velocity of change and age of completion. Height velocity and weight velocity increase and peak during the growth spurt.

The classic milestones of puberty are determined by Tanner’s sex maturity ratings. Tanner’s staging system is based on breast, genital and pubic hair changes, with Stage 1 being prepubertal and Stage 5 adult (Figs 56.1, 56.2 and 56.3).⁶ In girls, peak height velocity usually occurs at Stage 2–3 (around 12 years) and menarche (initiation of menstruation) at Stage 4. In boys, peak height velocity occurs at Stage 3–4 (14 years) and semenarche (initial ejaculation) at Stage 3.

FIGURE 56.1 Tanner stages of pubic hair development in girls

FIGURE 56.2 Tanner stages of breast development in girls

FIGURE 56.3 Tanner stages of pubertal development in boys

The experience of puberty is to have a changing body that feels out of control. Feelings of helplessness or persecution are common and may not abate until about 12 months after the growth spurt has ended. The typical irritability, moodiness and occasional aggressiveness, sexual arousal and unpredictable behaviour of the early adolescent are largely due to hormonal changes. Puberty tends to be conceptualised as a biological event, with emotional and psychological ‘side effects’. However, puberty may also be regarded as a cultural phenomenon, with each young person’s experience being influenced by the cultural milieu in which it occurs. In many cultures, for example, an event such as menarche remains somewhat taboo, while changing body shape for girls and boys may bring high levels of anxiety in our image-driven society.

The psychosocial impact of the timing of puberty affects girls and boys differently.

For those who mature earlier than average:

• boys seem to benefit—more relaxed, independent, self-confident and physically attractive

• girls seem to be disadvantaged—seen as less popular, appear withdrawn, less positive body image, lack confidence

• both are more likely to engage in more adult behaviours, although they tend to be physically rather than cognitively ready, associating with older peers.

For those who mature later than average:

• boys seem to be disadvantaged—less well liked and viewed as anxious, overly talkative and attention seeking

• girls seem to benefit—regarded by peers and adults as physically attractive, lively, sociable and leaders at school.

MAJOR DEVELOPMENT SERIES

MAIN CONCERNS

COGNITIVE DEVELOPMENT

PRACTICE POINTS

Physical, cognitive and psychological changes may be ‘out of sync’. For example, an early-developing, mature-looking girl may be psychologically immature and vulnerable.

NEURODEVELOPMENT

Our understanding of adolescent risk taking has been greatly enhanced by recent findings from neuroscience—research using magnetic resonance imaging (MRI) on the brains of children at 2-year intervals. While some areas of the human brain are mature by the end of childhood, the prefrontal cortex—responsible for impulse control and strategic planning—continues to mature through the teenage years and beyond. This makes sense of adolescence as ‘a time of heightened opportunity’ (teenagers are more amenable to change), but also ‘a time of heightened risk’. During this period, self-focused thinking is developmentally common, and in some cases may present in ways often described as a narcissistic teenager, particularly when combined with heightened emotional reactivity and risk-seeking behaviour.

A SNAPSHOT OF HEALTH ISSUES IN ADOLESCENCE⁷

Adolescent health is, ideally, understood via the dual concepts of health and wellbeing. It is estimated that approximately 75% of deaths among young people in developed countries are from preventable causes, mostly non-intentional injury. Drug-related deaths account for almost 25% of all deaths among young people, and youth suicide is another major cause of mortality. Young people are experiencing mental health problems at higher rates than older age groups and retaining their increased risk beyond youth into older age⁸—at any one time, up to 20% of young people will suffer from a mental disorder. Together, mental health and behavioural disorders account for more than half of all afflictions affecting adolescents. Poor nutrition is now also coming to be recognised as a significant risk factor for poor mental health in adolescents.⁹

In most developed countries, over one-third of young people report using marijuana in the previous 12 months, while around 70% of 16–17 year olds report that they consume alcohol. Drug and alcohol use is also of concern because it can seriously exacerbate depression and suicidal behaviour. While teenage smoking rates tend to be on the decline, tobacco use is another prime target for research, with close to 20% of 17-year-olds being established smokers.

Sexual health is another important and challenging issue. The number of notifications for chlamydia among 15–24 year olds has increased by more than 300% between 1999 (when national data have been available) and 2008. Young people, especially young women, are more likely to contract STIs and, while rates of teenage childbirth have declined in recent decades, teenage pregnancy remains a major adolescent health concern in developed nations. Restricting our focus to these biological indicators alone, however, ignores the complex, dynamic contexts in which sexuality is being experienced by young people.

In addition, an obesity epidemic is currently affecting 25% of young people, a figure rising every year, and 15–20% of young people have a chronic illness. Chronic illness can have a serious social and emotional impact on young people, who wish to see themselves as ‘normal’, and can trigger withdrawal from medical care.

THE CLINICAL CONSULTATION

In contrast to most general practice consultations, the aim of the consultation with a young person who you have not seen since they entered adolescence, or who is new to your practice, is to engage them. A relationship of trust must first be established, otherwise many potentially serious health issues can be missed and opportunities for prevention and health promotion forgone.

Adolescent patients have neither the naivety of the child nor the awareness or experience of the adult. However, it probably takes about three seconds for a young person to ‘suss out’ the kind of encounter it is going to be. Young people have a sixth sense about it and can read the clues: how the doctor greets them, whether or not they are given a chance to talk for themselves, how questions are put and how the physical examination is conducted.

Many healthcare professionals feel ill-equipped to deal with young people in their practices, particularly in relation to sexuality and substance use.² Young people want to address health behaviours with their doctor but often feel too embarrassed to initiate discussion in these sensitive areas. And while parents also want clinicians to discuss a broad range of health issues with their adolescent children, many fail to do so.

Education/employment

Eating/exercise

Activities

Prior to proceeding to the ‘Drugs’ and subsequent domains, it is useful to reiterate the confidentiality statement, and to ask permission to ask sensitive questions: ‘I am about to ask you some personal questions about drugs, sex and how you feel in general. You don’t have to answer them if you don’t wish to. I ask these as part of a health assessment with all young people. Is it OK if I proceed?’

Drugs and alcohol

Explore motivation to change behaviour if risky

Sexuality

Avoid heterosexist language or assumptions:

Explore feelings around becoming sexual if appropriate

Suicide/depression

Identify protective factors such as those suggested previously

Safety from injury and violence

PHYSICAL EXAMINATION

In contrast to the physical examination of an older or younger patient, young people are more likely to be extremely self-conscious about their changing bodies. All young people should have their weight, height and BMI recorded and skin checked for acne and moles. Blood pressure measurement is recommended for those aged 18 years or over. Other elements of the physical examination will be dictated by the presenting symptoms or concerns.

WRAPPING UP THE CONSULTATION

Closure of a consultation can be a critical part of the engagement process. The goal is to have the young person leave your practice feeling confident about returning if the need arises. Given the likely mismatch between standard consultation times and the time required to develop a relationship of trust, a thorough history may not have been taken, all ‘agendas’ may not have been explored and all health issues may not yet have been identified. Furthermore, if the presentation was relatively simple (e.g. acute viral illness), wrapping up can include extending the invitation for a further consultation to conduct a more comprehensive assessment and discuss preventive healthcare.

ENGAGING THE FAMILY

Engaging the family and gaining the trust of parents is critical in treating young people. In many cultures, participation in healthcare is a family responsibility rather than an individual responsibility.¹³

LEGAL ISSUES

The ambiguous legal status of young people aged under 18 years creates unique challenges in the health consultation. Each country, state and territory has its own statutory laws regarding the age at which an individual under 18 years of age can consent to medical treatment, and in relation to child protection and mandatory reporting requirements, both of which have an impact on clinical care.

Even within countries, different state jurisdictions may allow for different legal rights and obligations in relation to medical consultations and mandatory notification by healthcare professionals about issues such as ‘children at risk of harm’ or the reporting of notifiable diseases. Confidentiality is also a legal requirement in many countries.

Common law allows for the recognition of the ‘mature minor’ in many countries, a legal concept that arose in the United Kingdom in the 1980s in Gillick vs West Norfolk A.H.A. [1984] 1 QB581. This process requires a clinical judgment about the young person’s ‘intelligence and understanding, to enable full understanding of what is proposed’; this is sometimes referred to the ‘Gillick test’.¹⁴

Full understanding must include understanding of:

Making a competency assessment will include consideration of the young person’s age, level of independence, level of schooling, maturity and ability to express their own wishes.

Note that the doctor’s assessment of these factors could be influenced by cultural differences between the doctor and the young person. A cognitively mature adolescent may come across as socially or emotionally immature, because of different cultural expectations about their role in the family/society (for example, they may seem less independent), or differences in the way they communicate their thoughts or wishes. If in doubt, seek advice from a colleague or an appropriate agency.

If you are unsure whether a minor is competent, seek the opinion of a colleague, or obtain the consent of the minor’s parents/guardians.

CONCLUSION

The entire range of adolescent health problems likely to be seen in general practice is beyond the scope of this chapter. Certain conditions and presentations can be expected: acne and other typical adolescent skin disorders; common menstrual disorders (such as dysmenorrhoea) and sexual health problems including sexually transmitted infections; obesity and eating disorders (anorexia nervosa and bulimia); anxiety, depression and other mental health problems; substance abuse and other health risk behaviours; chronic conditions such as asthma and diabetes, together with challenges related to compliance and transition care. Aspects of these diverse issues and problems are to be found elsewhere in this book as well as in chapters and books dealing specifically with adolescent health and medical care.

Each young person presenting within a general practice setting is hopeful of engaging in a relationship of trust with a caring and insightful adult healthcare professional. By taking a developmental perspective, being sensitive to family and cultural context, and having the skills to elicit a ‘psychosocial snapshot’ (using the HEEADSSS screen), little of importance will be missed. And, while not all relevant health-related information for that young person can be addressed in a single encounter, the offer of follow-up sends a positive and protective message.