Engaging with and assessing the adolescent patient

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  • See also

    Adolescent Gynaecology- lower abdominal pain
    Adolescent gynaecology- menorrhagia
    Sexually Transmitted Infections (STIs)
    Anorexia nervosa
    Management of Eating Disorders in the Emergency Department
    Mental State Exam

    Key Points

    1. Adolescence is a transitional phase of growth and development between childhood and adulthood.
    2. Adolescents have the legal right to confidential health care.
    3. Adolescents less than 18 years old may be considered ‘mature minors’, capable of giving informed consent.
    4. The HEEADSSS interview for psychosocial screening is an important component of adolescent assessments.

    Background

    What is adolescence?

    • Historically spanning from ages 12 to 18 years, approximating the phase between pubertal onset and legal ‘independence’, and generally corresponding with attendance at high school.
    • More recently the term has expanded to include young adulthood, up to 25 years of age.

    Adolescent health care considerations

    • Increased risk-taking behaviours and psychosocial issues, contributing to morbidity and mortality.   
    • Rarely access routine health care, so any contact should be an opportunity for preventative health care.
    • Some health services manage those aged > 16 years through adult services or on adult inpatient wards.
    • Planning for transition to appropriate adult services should start well before age 18.  

    Assessment

    An adolescent consultation should include time with the adolescent and gaurdian/s together, as well as dedicated time with the adolescent alone.

    Confidentiality and consent

    • Be explicit about confidentiality requirements and obtain permission prior to contacting other relevant professionals, such as school or youth agencies.
    • Adolescents have the legal right to confidential health care unless:
      • they cannot be considered a mature minor and/or
      • there is significant concern regarding risk (i.e. harm to self or others, physical or sexual abuse).
    • Mature minors can give informed consent if they have sufficient understanding and intelligence to enable full comprehension of what is proposed [as per Australian common law - Gillick competency
      • Most adolescents aged 16 to 18 are presumed to be mature minors (legislation differs by State).
      • Younger adolescents may sometimes be considered mature minors and be capable of providing informed consent depending on the nature of the proposed intervention. Interventions include history, physical examination, procedures and treatments.
    • Adolescents involved with child protection services require special consideration with respect to confidentially and consent. The relevant State-based service may be able to assist when consent cannot be obtained in the usual way.

    Psychosocial interview

    The HEEADSSS interview is a useful screening tool, that can also aide engagement. It is best completed with the adolescent alone.

    • Parents should be asked if they have any concerns prior to leaving the room and again at the close of the interview.
    • Preface the interview by discussing confidentiality and explaining that you are about to ask lots of personal questions about the adolescent’s life, interests and behaviours, as these may be affecting their health and wellbeing.
    • Try to use open-ended, non-judgemental questions that avoid assumptions.
    • General statements instead of personalising questions can be less intrusive (e.g. "some young people experiment with cigarettes, alcohol or drugs. In your year, do people smoke/drink/use illicit drugs? What about your friends? And you?")
    • The HEEADSS framework is designed to progress from important but less threatening questions to those considered highly personal.
    • It is often not possible to cover every aspect of the interview in a single encounter. You may focus on the most releavent areas for your patient or population.
    • You may choose to end the psychosocial interview by asking the adolescent who they can trust and confide in if they have problems. 

    The HEEADSSS psychosocial interview for adolescents

    Home: who, where, recent changes (moves or new people), relationships, stress or violence, smartphone or computer use (in home vs. room)
    Education & Employment: where, year, attendance, performance, relationships and bullying, supports, recent moves, disciplinary actions, future plans, work details
    Eating and Exercise: weight and body shape (and relationship to these), recent changes, eating habits and dieting, exercise and menstrual history
    Activities: extra-curricular activities for fun: sport, organised groups, clubs, parties, TV/ computer use (how much screen time and what for)
    Drugs and Alcohol: cigarettes, alcohol and illicit drug use by friends, family and patient. Frequency, intensity, patterns of use, payment for, regrets and negative consequences
    Sexuality and Gender: gender identity, romantic relationships, sexuality and sexual experiences, uncomfortable situations/sexual abuse, previous pregnancies and risk of pregnancy, contraception and STIs
    Suicide, Depression  & Self-harm: presence and frequency of feeling stressed, sad, down, ‘bored’, trouble sleeping, online bullying, current feelings (e.g. on scale of 1 to 10). thoughts or actions of self-harm/ hurting others, suicide risk: thoughts, attempts, plans, means and hopes for future
    Safety: serious injuries, online safety (e.g. meeting people from online), riding with intoxicated driver, exposure to violence (school and community), if high risk - carrying weapons, criminal behaviours, justice system

    ** HEEADSSS screen may be adapted for local use.

    Examination:

    General considerations for physical examination of an adolescent patient:

    • Use of a chaperone is recommended.
    • Ensure privacy.
    • For pubertal assessment (Tanner staging) consider asking the adolescent to make a self assessment.

    Management

    General considerations:

    • Depends on the issues identified during psychosocial interview.
    • Adolescent health concerns can generally be viewed in terms of risk and protective factors.
    • If there are significant health risk behaviours, devise an immediate management plan which may include formal mental health assessment and admission (e.g. intentional overdose, see Poisoning – Acute guidelines for initial management).
    • Remember to document the adolescent’s contact details if follow-up is required.
    • Consider opportunistic vaccination.

    Medicare cards:

    • Anyone over the age of 15 years should be encouraged to obtain their own Medicare card.

    Transition to adult services

    • Transition to adult services should be considered from mid-adolescence and include formal support and education.
    • Most health services will aim to transition an adolescent to adult services by their 18th birthday or once their final year of high school is completed.
    • For complex cases, a period of overlap between paediatric and adult services may be required to permit adequate communication between specialists and safe transition. 

    Consider consultation with local paediatric team when:

    • For all adolescents deemed to be at significant risk.
    • Depending on local resources and the adolescent’s presentation, mental health, adolescent medicine or social work may be the most appropriate team to consult.

    For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services.

    Consider discharge when:

    • If indicated, an assessment by mental health staff including a risk assessment has been completed.
    • A clear discharge destination established, with follow-up and referrals to necessary services made.

    Parent information

    Kids Health Info

    Referral pathways and services

    National services

    Headspace: Centres act as a one-stop-shop for young people seeking help with mental health, physical health (including sexual health), alcohol and drugs issues, or work and study support.

    Youth beyond blue: Beyond blue’s youth program - provides online forums, the ‘check-in’ app, information and resources about mental illness in those aged 12 – 25 years. 

    Reachout: online resource that provides innovative e-mental health services directly to adolescents and young people. 

    Head to Health: Australian Department of Health site for access to digital mental health resources.

    Referral for counselling / psychology services:

    • GPs can refer patients to psychologists under a Mental Health Plan (under the Better Access initiation) for up to 10 sessions per calendar year.
    • Local psychologists can be found via the Australian Psychological Society’s ‘find a psychologist’ search function.

    24-hour telephone help lines:

    Kids Help Line                                                                                               1800 55 1800

    Lifeline                                                                                                           13 11 14

    Beyond blue                                                                                                  1300 224 636

    Suicide Call Back Service                                                                            1300 659 467

    Suicide HelpLine (VIC)                                                                                 1300 651 251 

    Mental Health Line (NSW)                                                                            1800 011 511

    13 HEALTH (QLD)                                                                                         13 43 25 84 

    State-based services

    Victoria

    Child & Adolescent Mental Health Services (CAMHS): Victorian government mental health services are region-based

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

    Melbourne Sexual Health Centre: Free, confidential, anonymous, sexual health service, fact sheets and national STI management guidelines

    health.vic Sexual Health Services: resources and clinics across Victoria that provide sexual health services for LGBTI people. 

    Action (Youth) Centre - (Family Planning Victoria): Free service and information for those under 18 years about sexual health issues, safe sex and support groups for those with gender identity issues.

    YSAS (Youth Support and Advocacy Service): Outreach teams across Melbourne and regional Victoria for young people experiencing significant problems with alcohol and/or drug use.

    YoDAA: Victoria’s Youth Drug and Alcohol Advice service - provides information and support for youth AOD needs or anyone concerned about a young person. 

    Young People's Health Service (FRONT YARD) : Free service, that focuses on the needs of the homeless or disadvantaged

    Infoxchange Service Seeker: Search for local community support services e.g. local doctor, dentist, counselling services, drug and alcohol services.


    New South Wales

    Child and Adolescent Mental Health Services: services delivered across NSW Health with referrals made via the NSW Mental Health Line (1800 011 511) for 24-hour advice, assessment referral information.

    Youth Health and Wellbeing: includes links to Assessment Guideline for providers caring for young people aged 12 – 24 years across settings, as well as links to other resources 

    Sexual health Infolink: telephone referral line (1800 451 624, weekdays 9 – 5:30) staffed by specialist sexual health nurses, as well as internet-based information and referral service, providing access to all aspects of sexual health care. Specialises in HIV and STI risk assessment and treatment.

    Playsafe: sexual health information, online help service and and links to appropriate medical centres. 

    Family planning NSW

    Your room: information on alcohol and other drug use, including fact sheets (multiple languages), assessment tools and links to support services.

    Family and Community Services – support to find a home: homelessness service, including specific services for young people. Affiliated with Link2home, 24-hour information line (1800 152 152).

    Health Services for Young People

    Our Health Our Ways videos

    Transition Care Network: improving delivery of healthcare for young people with chronic health problems and disabilities as they transition from paediatric to adult health services. 


    Queensland

    Child and Youth Mental Health Services: specialise in helping infants, children and young people up to age 18 years with complex mental health needs.

    Youth Sexual health: information on sexual health checks, family planning, contraception and STI screening and treatment.

    Dovetail: provides clinical advice and professional support to workers, services and communities who engage with young people affected by alcohol and other drug use

    Queensland Youth AOD Services Guide: created by Dovetail, this guide provides an overview of youth alcohol and other drug treatment services across Queensland. For help outside of hours, call the 24-hour Alcohol and Drug Information Service (ADIS) on 1800 177 833.

    Youth Housing and Accommodation

    Brisbane Youth Service

    Micah Projects: Support and advocacy services

    Clarence St, Mater Young Adult Health Service: Youth drug and alcohol service

     

    Additional notes and resources

    Decision Making by and for Individuals under the Age of 18 

    HEEADSSS Assessment learning video resource

    Youth friendly confidentiality resources

    Youth Health Risk Assessment

    HEADSSS: get the conversation started (NSW only)

    Queensland Health: Sexual health guidelines

       

    Last Updated September 2019

  • Reference List

    1. Bird, S. Consent to medical treatment: the mature minor. Australian Family Physician. 2011. 40: 159-160.
    2. Jaworska, N et al. Adolescence as a unique developmental period. Journal of psychiatry & neuroscience : JPN. 2015. 40 (5): 291-293.
    3. Klein, D et al. HEEADSSS 3.0: The psychosocial interview for adolescent updated for a new century fueled by media. Contemporary Pediatrics. 2014.
    4. Sawyer, S et al. The age of adolescence. The Lancet Child & Adolescent Health. 2018. 2 (3): 223-228.
    5. WHO. World Health Organization: Adolescent health 2019. Retrieved from https://www.who.int/maternal_child_adolescent/adolescence/en/ (viewed April 2019).