Clinical Practice Guidelines

Engaging with and assessing the adolescent patient

  • See also

    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.
    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?"
    Home: including who, where, recent moves, relationships, violence.
    Education & Employment: including where, attendance, year, performance, relationships, supports, recent moves, bullying, disciplinary actions, future plans, and work details
    Eating: including weight (heaviest, lightest, recent changes), dieting, exercise and menstrual history.
    Activities: outside of school, including sport, organised groups, clubs, parties, TV/ computer use
    Drugs and Alcohol: including cigarettes, alcohol and illicit drug use by friends, family and the patient. Enquire into patterns & frequency of use & about any regrets from using these substances.
    Also ask about how use is financed and about negative consequences.
    Sexuality: including close relationships, sexual experiences, number of partners (total and in the last 3 months), gender of sexual partners (don't assume sexual preferences), uncomfortable situations/ sexual abuse, risk of pregnancy and previous pregnancies (relevant to males as well as females), contraception, condoms and STIs.
    Suicide, Depression & Self-harm: Presence and frequency feeling down or sad as well as current feelings eg. "How do you feel in yourself at the moment on a scale of 1 to 10?" Actions when down, supports. Self-harm- thoughts and actions. Suicide risk- thoughts, attempts, plans, means and hopes for future.
    Safety from injury &Violence:

    including serious injuries, use of safety gear for sports and seatbelts for cars, riding with an intoxicated driver and exposure to violence at school and in neighbourhood.
    For high risk youths ask about carrying or use of weapons and other criminal behaviours/ incarceration of youth or family/ friends.


    Examination:

    • Use of a chaperone is recommended
    • 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):

     Community Services

    Contact details

    Child & Adolescent Mental Health Services (CAMHS):
    • RCH covers Western and North Western metropolitan region of CAMHS.
    • State government mental health services in Victoria are region-based.
    • To correctly identify CAMHS region and regional contact details: http://www.health.vic.gov.au/mentalhealth/services/index.htm
    • Northern & Western metropolitan region is the exception with children 0-15 yrs managed by CAMHS and 15-24 year olds managed by Orygen Youth Health
    • Business hours: RCH Mental Health Service Intake provides initial triage, referral, case management first appointment and an information service. 9-5 weekdays.
    • After-hours: Nurse-on-call (triage/ advise) or closest emergency department (crisis)

    Urgent referrals from RCH ED to Psychiatry Consultation and Liason:

    • Monday to Friday, 9-5pm: Speed dial 84444, OR 
    • After hours Psych CL Nurse (when available in ED), ext 4786 or page 4488 OR
    • After hours, call Switch & ask for RCH Psychiatry Registrar on call

    Less-urgent/ intake/ external referrals:

    • RCH Mental Health service Intake: Ph 1800 445 511 (under 15 years)  OR
    • Orygen Youth Health(15-24 years): Ph 1800 888 320,  YAT Paging Service: 9483 4556

    Young People's Health Service (FRONT YARD) 

    • Free service, that focuses on the needs of the homeless or disadvantaged.
    • Confidential Youth Services (Accommodation, Centrelink, Counseling, Dental Health Services, Legal Service, self employment, Victorian Ombudsman)
    • 'Reconnect' (Personal support and family mediation)
    • Computer access

    Monday to Friday 12pm to 5 pm. No appointment required, for people aged 12-22 years.

    19 King Street (near Flinders Street)
    MELBOURNE CBD
    Phone: 9611 2411, 1800 800 531

    http://www.frontyard.org/

     Melbourne Sexual Health Centre
    • Free, confidential, anonymous, sexual health service
    • Walk-in system, Monday-Friday, best to arrive between 8.40 and 13:10 in the morning
    • Fact sheets for patients and National Management Guidelines for STIs available at http://www.mshc.org.au/
     

    580 Swanston street, Carlton VIC 3053.
    Ph: 93470244, free call 1800 032 017

    http://www.mshc.org.au

    Action (Youth) Centre - (Family Planning Victoria)
    • Free service for those under 18.
    • Information about STI treatment and testing, safer sex, contraception, HIV/AIDS, hepatitis, pregnancy advise, any other sexual health issue, support groups for those with gender identity issues.
    Appointments 9am -12pm, then drop in till 5pm Monday to Friday

    Level 1, 94 Elizabeth Street
    MELBOURNE 3000 
    Ph: (03) 9654 4766, 1800 013 952

    Eating Disorders Foundation of Victoria
    • Support, information, community education and advocacy for people with eating disorders and their families in Victoria.

    1513 High Street, Glen Iris Vic 3146

    Ph: 9885 0318, (non-metro) 1300 550 236

     YSAS (Youth Support and Advocacy Service)  
    • Outreach teams are based at eight sites across Melbourne and regional Victoria for young people experiencing significant problems with alcohol and/or drug use.
    • Service for young people between the ages of 12 - 21
     

    14-18 Brunswick St, Fitzroy 3065

    Ph: (03) 9415 8860, YSASline 1800 014 446

    http://www.ysas.org.au

     Youth Beyond Blue
    • Contains  fact sheets for young people on anxiety, depression, being bullied, dealing with stress etc.
     www.ybblue.com.au/
    Infoxchange Service Seeker
    • To find more Local community support services eg local doctor, dentist,
      counselling services, drug and alcohol services
    www.vic.serviceseeker.com.au

    Reachout  

    • Australian website funded under the national Suicide prevention strategy.
    • Information for young people, carers & professionals
    • Also a mapping to your local services site
    www.reachout.com.au
     24 hour telephone help lines:

    Kids Help Line  (Free call service for those under 18 years)

    Lifeline: Counseling, support and Referral    

    Suicide HelpLine

     

     

    1800 551 800

    131114

    1300 651 251