The last patient presented in morning handover is Buffy, 14, who was admitted overnight with pyelonephritis. The admitting registrar couldn’t get much more than flank pain and a wee out of her overnight. Your resident rolls her eyes, quietly muttering “Not another teenager!”…
Adolescence is about change.
Consider the patient’s developmental stage.
Talk to the patient!
Establish a therapeutic relationship!
Explain your examination & give feedback.
“Minimal intervention” & public health.
Adolescent medical inpatients are often challenging for inpatient paediatric teams, perhaps because the majority of paediatric inpatients are under 12 years old, and well under 18. In fact, many children’s hospitals simply won’t admit patients past a certain age. Although some tertiary paediatric hospitals have specialised adolescent teams, the majority of adolescents admitted to hospital are under the care of general or other subspecialty teams, caring for children (or adults) of all ages. This post serves to both inform and humanise the care of a patient group with quite age-specific vulnerabilities.
So, why is there a teenager on your ward? Let’s consider the main reasons adolescents are admitted to hospital:
Chronic illness requiring investigation, management, or a complication thereof. Things like diabetes, asthma, cystic fibrosis, cancer and rheumatic conditions.
Psychiatric illness requiring stabilisation or management of complications, including eating disorders or anxiety & depression.
Injuries are the major cause of morbidity and mortality in patients 12-18.
Infections – everyone gets them!
Surgical procedures both emergent and elective.
Additionally, in hospitals with Obstetric facilities, an expectant mother may also be an adolescent.
Evidently, adolescents, like patients of any age, often require hospital care. In fact, the WHO observes that whilst over the last 50 years, mortality rates in all age groups from children to adolescents and young adults, have declined, mortality among young people (15-24 years) has decreased less than for these other age groups, overtaking childhood mortality in high income countries.
The World Health Organisation defines adolescence as ages 10-19 years of age, and ‘young people’ as 10-24 years of age. This highlights a key discrepancy between the development of biologic maturity and the attainment of perceived social maturity.
In Australia, data is aimed at those aged 12–24, accounting for 3.7 million young people (~18% of the population). Of note, about 1 in 30 adolescents is indigenous and 1 in 7 Australian 15-24 year olds were born overseas (with 74% of a non-English speaking background).
The total number of incident disability-adjusted life years (DALYs) in those aged 10–24 years was about 236 million, representing 15.5% of total DALYs for all age groups. In real terms, that means that 15.5% of all days lost to death or disability are as a result of adolescent morbidity and mortality. In Australia, the death rate for 12-24 year olds is 37/100,000 (51 for males, 23 for females). Worldwide, adolescent mortality is due to female deaths were caused by maternal conditions (15%), HIV/AIDS & tuberculosis (11%). Traffic accidents account for 14% of male and 5% of female deaths, and 12% of male deaths resulted from violence. A total of 6% of all deaths resulted from suicide.
We know that death is a very crude measure of the health of a population, these numbers are more illustrative of the point that adolescents are by no means ‘bulletproof’! So…
Adolescents live quite varied lives; asking about different aspects & activities will make caring for them and their stay easier! Think about the concrete and the abstract.
Physically, they go to school & work, play sports & music, internet & gaming, art, eat & drink, cook, other group activities like Scouts. They might describe these things as “hanging out”, or socialising. Having an awareness of prevailing trends, particularly in internet/app usage can yield surprising changes of attitude!
Adolescents often learn to drive, or try out other risky behaviours, like smoking, alcohol and testing their parents’ limits. It is during adolescence that most people make their first forays into sexual activity and relationships.
They may also have extended responsibilities, such as caring or main financial supporter for their family.
And, in our “mature eyes” we conceptualise all these activities as growing, philosophising, discovery, creativity, experimentation, questioning & survival.
Neinstein describes the tasks and stages of Adolescence;
- Achieving independence from parents
- Adopting peer codes & lifestyles
- Assigning increased importance to body image and accepting one’s body image
- Establishing sexual, ego, vocational and moral identities
Each of these tasks is achieved at various stages of adolescence. These can be divided into early middle and late, with each stage having some key themes;
Early (~10-13 years); Am I normal? The struggle for autonomy commences, comparisons are made with peers and anxieties about body shape and change begin.
Middle (~14-16 years); Who am I? and Where do I belong? The teen has new sexual drive and new cognitive powers. A strong need for privacy begins in this stage.
Late (~17-21+), Where am I going? The adolescent achieves independence from parents, develops self responsibility and their own values.
It is a dynamic period of rapid change, from five points of view; Psychological, Physical, Emotional, Social and Cognitive. Adolescence is a biologically universal phenomenon, however the concept of ‘adolescence’ is defined differently in different cultures. It’s not a continuous process, and for some, it is traumatic.
What about the teenager in front of you! They’re not talking and a bit surly & quiet. Here are some Adolescent Consult, History & Examination Tips.
A well established framework is the HEADSSS Assessment;
Home & Environment
Education, Employment, Eating Habits
Introduce yourself to the adolescent, then the parents. The young person is your patient! The most important part of this consult is establishing and maintaing a therapeutic relationship with the patient. If you achieve nothing, learn nothing, convince them of nothing, at least get them to come back!!
Also, remember that the physical maturity is not an accurate measure of psychological, cognitive, social or emotional maturity. Make observations about each and tailor your consult accordingly.
Aim to talk to the teenager without parents, particularly in clinic. Explain early and why. Phrase the statement as if it’s already been decided. “Today we’ll have a chat all together, then I’ll sake you to step out so I can talk with Buffy, by herself. Then I’ll invite you back in and we can finish the consult.”
Talk about confidentiality early. (More detail below)
Ask the patient;
- Who made the appointment? (At this point, if the adolescent says “Me”, things should become easier!)
- Why? (This is the opportunity for the parents to give their concerns, and can open up discussion for the patent’s responses)
- What are your concerns?
If the patient is talking, shut up and listen!
Ask indirect questions, non-judgemental questions. Give examples as appropriate; starters such as “Some people your age…” or “Do you have classmates who…”
Don’t make assumptions about heterosexuality or the absence of bisexuality. Additionally, patients who have homosexual sex may not identify as “gay” or “lesbian”.
Always have a chaperone for the physical exam, irrespective of age or gender. This is policy in some Paediatric Hospitals, and refusal by either patient or clinician to have a chaperone has had medico-legal consequences.
Explain your physical exam & give immediate feedback. Simple things such as ‘I’m listening to your heart, it has normal sounds’, and so on can help reassure when things are normal. No one likes being poked, prodded and stared at; be personable and professional.
The most significant barrier identified by young people is fear about confidentiality and trust. This includes concerns about the doctor disclosing information to their parents, lack of privacy in the waiting room and reception staff not protecting their confidentiality.
You need to reinforce confidentiality at the outset of consult, including situations where confidentiality would be breached? Self-harm, homicide, abuse. The RACP has a prescriptive policy on this, referenced below.
Public health issues are often at the forefront of an adolescent’s mind during your consult. This is an ideal time for minimal interventions for both encouraging positive behaviours and cautioning against more risky ones. Topics pertinent to you patient may include;
- School safety
- Driving safety
- Sexual health
- Recreational & illicit drugs
- Access to healthcare
A final note on this is to “be real”; by which I mean, if you’re talking to a 16 year old girl who’s using marijuana and hallucinogens on a daily basis, and isn’t keen to change her habits, provide the next level of counselling, in addition to warning about the risks of drug use/risky sexual behaviours, as appropriate. For example;
“If you are going to keep getting wasted, think about with who and where you are. You’re in quite a vulnerable position when you’re ‘off your head’/intoxicated, and it’s smart to take some steps to protect yourself. Is there someone who’s there that you can trust? Tell me about a back up plan if you find yourself in trouble?”
I believe this is a more responsible, realistic approach than potentially alienating or isolating the patient, and adds an extra dimension to their care, applicable in situations from reckless driving, alcohol usage and so on. Remember, establish a therapeutic relationship – get them to come back!
BMJ Series; “ABC of Adolescence”. Viner, R., Patton, G., Michaud, PA., Sawyer, S., Macfarlane, A. ~2005. www.bmj.com
EuTEACH –European Training in Effective Adolescent Care and Health., EPLF & UNIL, Lausanne, Switzerland June 2010.
Goldenring & Rosen, “Getting into adolescent heads: An essential update” 2004. Contemporary Pediatrics 21-1; pp64-90
Neinstein, L et al. Handbook of Adolescent Health Care, 5e. Wolters Kluwer 2008. United States.