16
Adolescent health
Chapter map
Adolescents are different from children or adults, and have different needs. In the consultation, the best overall approach is to show equal respect and attention to the young teenagers and their parents. As they get older, we talk principally with the young patient, and involve them in decision-making (including consent issues). This chapter will consider issues of consultation and consent, and the particular challenges of adolescence.
16.3.2 Periods, pregnancy and contraception
16.6 Transition to adult services
No decisions about me without me. Equity and Excellence: Liberating the NHS, 2010Adolescence is the period of transition from childhood to adulthood. It begins with the first signs of puberty, and ends when the young person is ‘mature’ – physically (end of growth and sexual development) and emotionally. Societal recognition of when maturity is reached varies across cultures, and some do not recognize adolescence at all.
- Biological maturity – completion of physical growth and sexual development
- Psychological maturity – development of an identity separate from parents and family
- Social maturity – an ability to contribute to, and interact with, society (e.g. through relationships, in the workplace).
The phase of adolescence roughly corresponds to age 10-19 (WHO definition).
One in every five people in the world is an adolescent, and 85% of them live in developing countries (WHO).16.1 Approach to consultation
Efforts to make paediatric areas child friendly may result in an environment that is unsuitable for the adolescent patient. At the very least, pack away the toddler toys before your 16 year old patient walks in! Dedicated adolescent areas are best, but not always available. Give opportunity for the young person to talk and ask questions, listening carefully to what they say and respecting their views. The monosyllabic adolescent may be much happier to talk if you offer to see him without his parent. Arranging to see him on his own first next time may send a powerful message that you see his role as key. But this will not always be appropriate or possible – the overriding principles are sensitivity, respect and flexibility. These also apply to physical examination and any procedures. Check whether the young person would like their parent present, and consider the need for a chaperone (p. 25, ‘Chaperones’).
16.2 Consent
In England and Wales a young person of 16 years or over is deemed legally competent and able to make decisions about their own medical treatment. The Gillick Principle allows a teenager under this age to give consent for treatment if the doctor is satisfied that they are competent to do so.
PRACTICE POINT Competency – 4 CsTreatment overrides non-treatment in dispute. If despite careful counselling and discussion, there remains disagreement between a competent young person and their parent(s), and refusal of treatment will result in serious harm then treatment should be given. This applies up to age 18. So treatment should go ahead if either party (child or parent) wants the treatment, even if the other dissents. In practice, it is difficult or impossible to force treatment on an unwilling adolescent, and agreement through sensitive negotiation and compromise is better.
PRACTICE POINT16.3 Physical problems
16.3.1 Puberty and growth
Problems of growth and sex development are considered in chapter GD.
16.3.2 Periods, pregnancy and contraception
Primary amenorrhoea (never having had a period) is usually physiological due to delay in onset of puberty (Section 13.2.5). However, think of Turner syndrome (Section 13.2.3). Primary or secondary amenorrhoea may be due to pregnancy, eating disorders (especially anorexia nervosa), chronic illness, stress, and intense physical training. It may also be seen in hyperthyroidism, and rarely brain tumours. Dysmenorrhea (painful periods) can usually be controlled with simple analgesics, but sometimes the combined oral contraceptive pill is used.
Around 30% of teenagers in the UK have sexual intercourse before their 16th birthday (Section 6.1.1). Teenage girls who become pregnant have higher rates of postnatal depression, and their babies are 60% more likely to die in infancy. Prevention is through appropriate and accessible sex education, promotion of self-esteem, delaying age at first sex, and provision of contraception. Condom use will also reduce rates of sexually transmitted infections.
16.3.3 Acne
Pubertal androgens increase skin sebum production, which tends to block pores and promote infection and inflammation.
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