ADOLESCENT MEDICINE

ALICE ARMITAGE

APPROACH TO THE ADOLESCENT CONSULTATION

Adolescence is the transitional phase of growth and development between childhood and adulthood. An adolescent is defined by the World Health Organisation as a person between 10 and 19 years of age. There is increasing recognition of the specific problems of this age group, including trauma, mental health issues, pregnancy and sexually transmitted diseases. The rise in healthcare usage in adolescence is multifactorial; increasing survival from chronic childhood conditions, use of drugs and alcohol, and risk-taking behaviour all play a role, and advances in perinatal care and immunisation have shifted the burden of disease away from the under-fives. Understanding the unique needs of this age group is a core skill for any physician. The law relating to children and adolescents is covered in Chapter 1.13.

Adolescent History Taking

It is important to adapt the approach to the needs of the adolescent age-group. At the start of a consultation, consider the following:

* Always speak to the patient, not to their parent or carer, unless there is no alternative.

* Ask the patient if they would like to speak to alone or ask them if they would like someone to be present, such as a parent or friend.

* For any examination, offer a chaperone.

* Talk in an age-appropriate fashion. It is easy to alienate an adolescent patient by appearing patronising or by using medical jargon.

* Try to anticipate issues around consent and confidentiality.

The psychosocial history is vital to the adolescent history. Many presentations will stem from an issue like drug use, a fight with a partner or worries about sexuality. A useful aide-memoire is the HEADSS tool, shown in Table 1. In general, start with more open questions and then focus questions to the information given. A common reason for missing important issues is making assumptions; for example, thinking that all young people live at home with their parents or that all young people are heterosexual.

Asking Difficult Questions

Some of these questions can feel difficult to ask directly, and are even more difficult to answer directly. One useful tip is to use scenarios as a way into difficult questions. For example:

* "It's quite common for young people to experiment with drugs; is that something you've had experience with?"

* "Some of the work I do with young people is about choosing types of contraception and talking about sexual health; has anyone ever talked to you about this?"

This is also a good way to address more specific concerns that may have arisen during the consultation. For example:

* "Some young people I work with have told me that their parents fight a lot and sometimes it gets violent; is that something that happens in your home?"

* "One thing that can happen in a relationship is feeling pressured into acting or behaving in a certain way; sometimes people feel they don't have any choice about it. Have you ever felt like that?"

Questions need to ensure the young person will feel supported but not accused. For example, with the drug question, a young person may not admit to usage if they believe the police will immediately be called. The more comfortable the child, the more likely they are to give an honest response. When questioning, the doctor must remain aware of nonverbal language, e.g. changes in body language when talking about home (breaking eye contact, fidgeting and shorter responses).

Puberty, Growth and Development

Any consultation with an adolescent patient should include assessment of height, weight and pubertal status. This assessment is often forgotten, particularly in older teenagers transitioning to adult care. Young people with chronic health needs may have delayed growth and puberty compared with their peers. This is also a good opportunity to highlight problems such as obesity, eating disorders or neglect.

Autonomy, Consent and Confidentiality

One of the challenges of working with adolescents is managing their emerging autonomy as they move into adulthood. The ability to develop and maintain trust and rapport with patients relies on sensitive handling of these complex issues.

Remember:

* Each adolescent should be assessed on an individual basis without prejudice.

* There is no lower age limit to Gillick competence, and even younger children may be able to consent for their own medical care.

* There is no lower age limit on confidentiality but there are limits to this confidentiality, such as if there is a concern that the patient is in danger. If there is a duty to break confidentiality, tell the patient beforehand, except in rare, exceptional circumstances where this may result in significantly more harm than good.

RELATIONSHIPS, SEXUAL HEALTH AND CONTRACEPTION

Before bringing up sex and relationships, give patients an opportunity to talk alone and reassure them about confidentiality. If a young person is having sex or considering having sex, it is important to talk to them about healthy relationships, sexual health and contraception. As with drugs and alcohol, some of this may have been covered at school. Do not make assumptions based on age, culture, disability or diagnosis. If a patient is not sexually active, they may well wish to be and have questions about this. Chronic health conditions and disabilities impact on sex and relationships; therefore, doctors are potentially in a position to address these issues.

Sexual Health

Globally, young people have disproportionately high rates of sexually transmitted infections (STIs), with chlamydia, gonorrhoea, viral warts and syphilis being particularly common. The best protection is through use of condoms; these are often freely given out in health care settings and should be discussed with all young people even if on another form of contraception. Some STIs can by asymptomatic, particularly in women, so regular sexual health screening should be recommended for anyone who is sexually active. Walk-in services allow for easy, anonymous access to sexual health advice and testing. Similarly, the sending of results of STI testing by text messaging is convenient and helps preserve anonymity.

Contraception

In addition to condoms, forms of long-acting reversible contraception (LARC) are a good option for adolescent patients, and providing leaflets and counselling will allow them to choose the method that they feel is most appropriate for them. Some examples of LARCs include:

* Intrauterine device (IUD). This is also called a coil; this can stay in place for five to ten years but can be removed at any time.

* Intra-uterine system (IUS). This coil releases a small amount of progestogen locally. It can stay in place for five years.

* Contraceptive injection. This lasts for eight or twelve weeks; it delivers systemic progestogen.

* Contraceptive implant. This sits under the skin and releases a small amount of systemic progestogen. It can stay in place for up to three years.

All these forms are over 99% effective, and normal fertility returns as soon as they are removed. However, unless sex is with a regular partner and both have had recent sexual health screening, it is important to recommend additional barrier methods of contraception, like condoms. Doctors in the UK and elsewhere are legally allowed to provide contraception to females under 16 without parental consent, providing certain conditions are met (p174).

Teenage Pregnancy

Globally, over 10% of births are to girls 15 to 19-years-old. Although the majority of these are in low and middle-income countries, both the UK and the USA continue to have high rates of teenage pregnancy. This remains a significant cause of morbidity and mortality in this age-group, particularly in younger adolescents (13 to 15-years-old) who experience higher rates of pregnancy complications and pre-term births.

Risk factors for teenage pregnancy include:

* Low socioeconomic status.

* Low level of educational attainment.

* Having been a baby of a teenage parent.

Any young person who becomes pregnant should be offered counselling covering abortion and adoption to allow them to make an informed choice. Remember that for some young people, particularly in certain ethnic groups, having a baby as a teenager can be a positive choice.

An important part of antenatal care for younger patients is a focus on health promotion, including reducing drug and alcohol intake and optimising nutritional status. It is important to involve social care and consider the needs of both the mother and the unborn child.

MENTAL HEALTH

Half of all mental illnesses begin before 14-years-old, and 75% begin before 24-years-old. Young people suspected or known to have mental health problems should be formally assessed by a child and adolescent mental health service (CAMHS). CAMHS teams involve a range of professionals including psychiatrists, psychologists, family therapists, social workers, counsellors and nurses. Some common mental health problems are discussed below.

Depression

The three core symptoms of depression are low mood, low energy levels and loss of interest in activities that were previously pleasurable (anhedonia). Other symptoms are shown in Table 2.

Approximately five percent of teenagers suffer from depression at some point. Most young people will go through periods of feeling "down" or anxious. However, depression is longer lasting and interferes with the patient's ability to function.

In addition to the symptoms listed above, depression in adolescents may present with symptoms such as:

* Extreme sensitivity to criticism.

* Irritability and anger.

* Worsening performance at school.

* Unexplained aches and pains.

In young people, the signs of depression may be: taking drugs, going missing or getting involved in fights. A presentation of depression can be secondary to another problem; examples in adolescence are bullying, undisclosed sexual assault or maltreatment.

Management of depression in adolescent therapy involves initially identifying possible precipitants (e.g. bullying) and addressing them where possible. Cognitive behavioural psychotherapies are used more commonly than with adults. However, in moderate to severe depression, doctors may choose to prescribe medication, e.g. a selective serotonin reuptake inhibitor (SSRI). Fluoxetine is the preferred choice in adolescents, although it may be associated with an increased risk of suicide. Both approaches can be used simultaneously.

Self-harm

Common forms of self-harm in adolescence include:

* Cutting the arms or legs with a sharp object.

* Taking an overdose of medications (commonly paracetamol).

* Alcohol or illicit drug intoxication.

Self-harm is linked with attempted suicide, but this is not always the case. Depression is a common comorbidity.

In assessing and managing these children, perform a risk assessment and explore the intent of suicide. Then explore the circumstances leading to the self-harm episode. Bear in mind that even those who self-harm frequently may have different reasons for each episode. Young people who present to hospital with acute self-harm will need to be formally assessed by the mental health team and will have a clear follow-up plan in place on discharge.

Suicide Risk

Any patient with depression or presenting following self-harm should have their suicide risk assessed. Never be afraid to ask directly about suicide. Questions to ask include:

* Have you ever tried to hurt yourself?

* Have you had thoughts about wanting to kill yourself?

* Have you ever tried to kill yourself?

* Have you ever made plans to kill yourself (for example, collecting tablets or writing a note)?

Any concerns about patient safety need to be escalated following child protection procedures, ideally with an assessment by someone trained in child and adolescent mental health.

Psychosis

The definition of psychosis is when a person "loses touch with reality" and may be characterised by:

* Hallucinations. When a person sees, hears or otherwise perceives things that are not present; for example, hearing voices.

* Delusions. When a person holds a belief that is untrue despite logical evidence to the contrary; for example, believing that their parent is trying to kill them.

Psychosis is a symptom of several conditions, including schizophrenia, bipolar disorder, autoimmune disease and meningoencephalitis. Schizophrenia has a prevalence of 1% in middle to late adolescence. Many more people will have at least one psychotic episode in their lives and the first episode of psychosis commonly occurs in adolescence or in the early 20s.

Psychosis is an extremely distressing experience for patients and their families. Despite antipsychotic medications, psychotic illness such as schizophrenia continues to have a poor prognosis, with multiple relapses and high rates of suicide.

Drug and Alcohol Abuse

Many young people experiment with drugs and alcohol and, for some, this can become an addiction.

Warning signs include:

* Change in behaviour.

* Hanging out with a new group of friends.

* Deterioration in academic performance.

* Getting involved in fights or shoplifting.

Beyond the direct health effects of drugs and alcohol, these substances can isolate young people from their friends and family and increase risk-taking behaviour. These problems can be easily missed, as young people will often try to hide drug and alcohol use.

Medically Unexplained Symptoms

Adolescent patients may present with symptoms such as pain, tiredness or dizziness, for which, despite investigations, no medical cause is evident. This is also called "somatisation disorder". These symptoms are more common in women, patients with depression, those who have recently had a significant medical problem or those who have experienced a bereavement. This is a difficult diagnosis to make as it is a diagnosis of exclusion, making these patients very challenging to manage. Rarely, the patient or their carer may be knowingly fabricating symptoms (this is known as factitious or fabricated illness). If the motivation is a reward for feigning or exaggerating illness, such as financial benefit or attention, this is specifically known as malingering. However, the majority are not "faking it", and if they feel judged or disbelieved, their condition is likely to worsen rather than improve.

The best approach is for a single consultant to coordinate the patient's care, working closely with the primary care physician and offering psychological support.

Management of Mental Health Problems in Adolescence

As with adults with mental health problems, adolescent patients can be managed in an inpatient or outpatient setting depending on their diagnosis and needs. In younger patients, the focus is more on treating the family unit (e.g. through family therapy), and medication is used less frequently. The two broad categories are talking therapies and medication.