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Engaging with and assessing the adolescent patient

• Assessment
  • History
  • Confidentiality statement
  • Consent
  • HEADDSS screening
  • Examination
• Management
• Resources

Background

• Adolescent health care recognises the young person's growing autonomy coupled with the diminishing role of the parent in promoting health and well being.
• Not all young people are at the same stage of development in the key areas of physical, cognitive and psychosocial development, despite being similarly aged.
• Whilst adolescents are generally healthy, psychosocial issues and risk-taking behaviour figure prominently as causes of morbidity and mortality.
• Physical complaints are commonly connected to psychosocial issues.
• This group of patients rarely access routine health care, so any visit to a healthcare provider gives an opportunity to assess and explore a broad range of issues.
• Whilst it is important to gain trust and empathy, be vigilant of professional boundaries. 
• Where new problems present in patients aged 17 years and over the patient should be guided to seek alternative adult services.
  

Assessment

History:

Communication style:

• A respectful and non judgmental approach should be used. Introduce yourself and explain your role.
• Get the young person to introduce who they have come with.
• Explain that the consultation will involve some time with the parent(s) and young person and some time with the young person alone.

Confidentiality statement:

• Young people have the legal right to confidential health care unless:
  • they cannot be considered a mature minor  and/or
  • there is a significant concern of risk i.e. harm to self, threat of homicide or physical or sexual abuse.
• Be explicit with the adolescent about confidentiality requirements.
• The duty of confidentiality does not preclude encouraging and empowering young people to talk to parents about important issues.
• In the case of adolescents in DHS residential care, DHS should be notified if the patient arrives unaccompanied, however regarding confidentiality of medical care, DHS should only be given information if the young person explicitly gives permission or suggests it. If unsure of duty of care discuss with a consultant or Gatehouse.

Consent Requirements:

1. It is generally accepted that most young people over 16 are capable of giving their own informed consent. Those younger, may sometimes be considered mature minors.
   • The mature minor principle has been confirmed in Australian common law, such that minors (< 18 years) may be able to give informed consent if they have sufficient understanding and intelligence to enable full understanding of what is proposed.
   • If there is a need to determine the mature minor status of the young person discuss with a consultant.
   • Consent for Treatment and Confidentiality in Young People, Medical Practitioners Board of Victoria. September 2004 is a useful reference
2. Before talking to school or youth agencies, permission should be obtained from the young person.

Indications for psychosocial screening-include but are not limited to:

1. Chronic unexplained problems
2. Drug and alcohol presentations
3. Mental health concerns
   

HEADSSS assessment (Psychosocial Screening):

• Taking a psychosocial history is an important part of the health interview of young people as physical, emotional and social well being are closely interlinked.
• These questions will also allow exploration of the developmental stage of the young person.
• Parents, family members or other involved adults should not be present during the psychosocial assessment.
• Preface the discussion by saying that you are about to ask lots of personal questions that include drugs, sex and depressed mood and that you are asking because these behaviours may affect a person's health. 
• It can be useful to make a general statement instead of personalising questions, such as "Some young people experiment with cigarettes and alcohol. In your year at school, do people smoke/drink/use illicit drugs? What about your friends? And you?"

Examination:

• Use of a chaperone is recomended
• Consider privacy. Many young people are anxious about attending doctors for examination. The young person should be reassured that they have the final say about examination.
• Explain the reason for the particular examination and give immediate feedback on findings.
• Leave the room when the patient is changing, request removal of the minimum amount of clothing and provide a sheet or gown for the patient
• For tanner staging consider asking the young person to make a self assessment.
• Ask the young person if they have any questions about their body?
  

Management

Having taken a psychosocial history, consider adolescent health concerns in terms of risk and protective factors. Give positive feedback for the things that are going well, as positive reinforcement goes a long way toward improving self esteem and cementing a positive, trusting relationship with the young person.

For young people who engage in significant health risk behaviours express concern and then ask them if they are willing to change their lives or are interested in learning more about ways to deal with their problems. This then leads to a discussion of potential follow up and therapeutic interventions. Where possible the main focus of management should be on short term goals.

Consider opportunistic vaccination including Hepatitis B & HPV.

Follow-up

• Ensure adequate follow-up with either the patient's local doctor, with their regular paediatrician or refer them for follow-up at an adolescent clinic at the Centre for Adolescent Health (or the adolescent gynaecology clinic if appropriate).
• Adolescent substance use clinic: this clinic is on Tuesday mornings and is presently only suitable for drug and alcohol affected young people.
• Discuss with a consultant or the adolescent team regarding individual patient suitability
• The young person's mobile number should be documented if follow up might be required.

Notes & Resources

1. Referral for Counselling / Psychology services:

• The RCH emergency department has a social worker most days of the week, usually 14:00-22:00.
• The Centre for Adolescent Health has limited psychology/psychiatry and family therapy available.
• Frontyard has a part-time counsellor
• School counsellors can be a very useful resource
• GP's can refer suitable patients to psychologists for a limited number of funded sessions
• Local psychologists can be found on the internet site provided by the Australian Psychological Society http://www.psychology.org.au/ and then follow instructions for "Find a Psychologist."

2. Transition:

An RCH policy is available online at Transition of patients to adult services

3. Medicare Cards:

Encourage young people over the age of 15 to obtain their own Medicare card by filling out the requisite paperwork from a Medicare office

4. Other useful community services (not a complete list):