After reading this chapter you should be able to:
manage transition of adolescents with chronic health needs to adult services
assess and diagnose risk-taking behaviours including non-adherence, self-harm, alcohol and substance misuse and make appropriate referral to specialist services
to assess, diagnose and manage eating disorders and know the risks and complications of treatment
to assess, diagnose and manage problems relating to sexual health including contraception, sexually transmitted disease and teenage pregnancy
Adolescent health needs
Adolescence is defined as the transition from childhood to adulthood and is characterised by typical physical, psychological and social changes that do not occur at any other time during a person’s life. The onset of adolescence is heralded by the physical changes of puberty, whereas in later adolescence key psychosocial transitions signal the emergence into adulthood. The key events of adolescence are:
completion of growth and sexual development
development of a personal identity which is distinct from that of their carers
formation of intimate relationships with members of their peer group
development of autonomy and independence
The WHO defines adolescence as 10–19 years and youth defined as up to 25 years. However, it is increasingly argued that there are biological, psychological and social reasons to extend the definition of adolescence beyond 19 years of age and even up to 25 years as the neurobiological changes of adolescence continue into the third decade of life.
Adolescence is a time of great opportunity where the individual develops interests, friendships, lifestyles and belief systems that form a basis for their adult lives. It is also a time of great health vulnerability with an increased risk of death and morbidity from injury, an increased susceptibility to mental illness and poorer outcomes from any pregnancy.
Control of long-term conditions such as asthma, epilepsy, arthritis and diabetes often deteriorates during adolescence, and risks from acute infections (such as meningococcal disease), allergic disease (fatal anaphylaxis) and cancer are also increased compared to school-age children. Young people with neurodevelopmental disorders are at increased risk of health-related problems as they navigate the psychological and social transitions to adulthood. When considering young people aged 10–19 years, it is important to recognise that the patterns of mortality, morbidity and presentation of illness are very similar to those of young adults and therefore the needs of young people in relation to healthcare providers are similar to those of young adults. Increasingly, the two age groups are considered together as adolescents and young adults (AYA) in a healthcare context.
Risk-taking behaviours during adolescence contribute to mortality and morbidity during this key developmental stage. It is now understood, however, that the risk-taking behaviours which create health vulnerabilities are a key and necessary aspect of development which facilitate the transition to adulthood.
The challenge for paediatricians is to:
understand the unique patterns of illness and injury during adolescence and their social determinants
provide developmentally appropriate healthcare services for young people and support their transition to adulthood with an improvement rather than a deterioration in their health
work with young people, families, other health providers and governments to ensure services and policies are in place which promote the health needs of adolescents and young adults
research and innovate to enhance the health of young people and improve access to developmentally appropriate healthcare through meaningful and ethical participation
promote the health and safety of young people, respect their individual rights, reduce health inequalities and tackle the social determinants of health as this is likely to have important health and economic consequences into the future.
The use of formal interview tools can help discussions with adolescents and ensure that important areas that may impact on health are addressed. One such tool is the structured HEEADSSS method of interview developed by Drs Goldenring and Rosen that provides introductory phrases for each of the listed topics.
H – Home environment
E – Education and Employment
E – Eating
A – Activities (peer related)
D – Drugs
S – Sexuality
S – Suicide/depression
S – Safety
As young people acquire independence during the transition to adulthood, they are permitted greater rights as citizens and this includes the right to vote, the right to work and the right to make decisions for themselves free from parental involvement. They are also granted the right to participate in a range of activities that are prohibited for children such as consensual sexual intercourse, getting married, driving motor vehicles, buying alcohol and tobacco, gambling and obtaining financial credit.
In England and Wales, the Children Act 1989 applies to all children and young people up to their 18 th birthday and outlines the responsibility of the state and parents in this regard. There is, however, other UK legislation that permits young people to receive adult responsibilities at ages younger than 18yrs. For example, young people can apply for a provisional driving licence at 17yrs of age, can legally have consensual sex from 16yrs of age and are assumed to have mental capacity to make some decisions from age 16ys or earlier.
The key to understanding the legal framework is the issue of context. There is no single piece of UK legislation that defines adulthood, rather a series of different pieces of legislation that define when a young person can acquire the right to adult responsibilities. From a healthcare perspective, it is crucial that paediatricians have expertise in the legal framework of consent and confidentiality in relation to children and young people. This topic is presented in more detail in Chapter 32 on Ethics and Law.
Substance misuse by adolescents and young adults is a major public health concern as it contributes to morbidity and mortality in adolescence. Over the lifetime of an individual, much of the morbidity and mortality attributed to alcohol, tobacco and other drugs can be traced to behaviours that begin during adolescence. Substance use is also associated with risks of abuse, poor educational and employment outcomes, criminality, disrupted peer and family relationships as well as a range of mental and physical health disorders.
Alcohol, tobacco and cannabis are the substances most often used by adolescents although trends in drug use do vary over time. There have been recent reductions in prevalence of adolescent alcohol use and smoking in the UK but with increases in the use of cannabis, novel psychoactive substances and vaping. Shifting trends in drug use are predictable and cyclical, although they are influenced by population level factors such as legislation, taxation and law enforcement activity.
The period of adolescence includes the ongoing state of brain development and is a time of risk-taking and sensation-seeking behaviours. Such behaviour would include substance use that may lead to permanent changes. The CRAFFT screen is a brief screening tool that has been validated in the adolescent primary care setting to identify problematic substance use and uses a series of six questions to explore the topic and help identify those young people who may need support.
Alcohol is the drug most commonly used by adolescents and is a CNS depressant that stimulates the endorphin and dopaminergic reward systems. It is rapidly absorbed and has physical, mood and cognitive effects.
Recent UK data show that although rates of alcohol use continue to rise with increasing age, the number of young people who drink and the amount that they drink appears to be decreasing gradually over time. Similarly rates of hospitalisation of young people for alcohol-related conditions are falling.
Alcohol use increases with age and, among 15 year olds in England, 18% report drinking in the previous week. Alcohol use in young people remains a serious public health concern as alcohol contributes to preventable deaths and injury and alcohol use established in adolescence tracks into adulthood.
Alcohol use in young people has been associated with the following:
injury—motor vehicle accidents, falls, interpersonal violence
victim of physical/sexual assault
sexual risk behaviours
self-harm and suicidality
Alcohol is neurotoxic and whilst the extent of the effects on the developing adolescent brain have not been fully elucidated, it is known that binge drinking and heavy alcohol use in adolescence has effects on brain structure and function including impaired learning, impaired memory and disruption of the sleep-wake cycle. Young people do appear to be more tolerant of the acute intoxicating effects of alcohol and show fewer acute withdrawal effects than adults.
Children of parents with an alcohol use disorder are four to ten times more likely to develop the same problem. The perceptions of parental approval of alcohol use and the parents’ use of alcohol have been identified as risk factors for adolescent initiation of drinking behaviours. Early initiation of alcohol before 14 years of age is associated with an increased risk of alcohol use disorder.
Marketing and media influences have a substantial effect on alcohol use by young people. This includes alcohol industry–sponsored advertising but also the depiction of alcohol use in media and exposure to alcohol use by peers and older adults through the internet and social media.
Alcohol use disorders
The diagnostic criteria for alcohol use disorders describe a maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by two or more of the following, occurring at any time in the same 12-month period:
alcohol often taken in larger amounts or over a longer period than was intended
persistent desire or unsuccessful efforts to cut down or control alcohol use
excess time is spent in obtaining alcohol, using alcohol or recovering from its effects
craving for, or a strong desire to use alcohol
recurrent alcohol use resulting in a failure to fulfil major role obligations
continued alcohol use despite having social or interpersonal problems caused by alcohol
important social, occupational or recreational activities are given up because of alcohol use
recurrent alcohol use in situations in which it is physically hazardous
If alcohol misuse is identified as a potential problem, then a brief assessment of the duration and severity of the alcohol misuse is required. Young people under 16 years of age with alcohol use disorder should be referred to a specialist child and adolescent mental health service (CAMHS).
Tobacco and vaping
Smoking is the primary cause of preventable morbidity and mortality in the UK, accounting for one in six of all deaths. One in five young people try smoking at some point; however, regular smoking is less common and there has been recent and significant downward trend in smoking by young people.
Risk factors for smoking in adolescence include
low socioeconomic status
low educational attainment
parental, sibling or peer smoking
those with low self-esteem or depression
lesbian, gay and bisexual young people
Nicotine is a highly addictive substance and abstinence leads to withdrawal symptoms:
All young people who smoke should be advised to stop and should be offered referral to a local smoking cessation service or given information on how to access such services. Interventions can increase the chances of smoking cessation and generally fall into two categories: medication and psychological support. The evidence suggests that smokers are four times more likely to quit successfully by using a combination of pharmacological and psychological intervention.
Nicotine replacement therapy
Nicotine replacement therapy (NRT) works by substituting the nicotine provided in cigarettes, alleviating nicotine withdrawal symptoms and allowing users to gradually reduce their dependence on nicotine. NRT includes nicotine-containing chewing gum, transdermal patches, lozenges, mouth spray, inhalator and nasal spray and is usually taken for 8 to 12 weeks.
E-cigarettes and vaping
Electronic cigarette use (also known as vaping) is increasing amongst adolescents and young adults and there is emerging evidence that they may be effective in helping adult smokers to quit. NICE advises that young people wishing to stop smoking should be advised that whilst the safety and quality cannot be assured, e-cigarettes are likely to be less harmful than cigarettes. Recent reports of vaping-associated lung injury have added to concerns regarding their safety.
Marijuana is derived from the dried seeds, stems, leaves and flowering tops of the plant Cannabis sativa and is the most commonly used illegal substance in the UK. It may be smoked, vaped or ingested with smoking being the most common route ( table 3.1 ).
spliff or joint – rolled in a cigarette paper
blunt – a hollowed out cigar
bowl – a pipe
bong – a water pipe
|hash or hashish |
Onset of use typically occurs in adolescence although the peak prevalence of use is among young adults. Adolescents and young adults are more susceptible than adults to the adverse effects of marijuana use and more likely to develop cannabis use disorders.
The effects of inhalation are usually apparent within 30 minutes and typically lasts 2–3 hours, but with ingestion the effect-onset is delayed and lasts longer. The recognised effects of acute intoxication from cannabis are:
Short-term effects may include impairments of
short-term memory which will affect learning and retention of information
motor coordination—increasing the risk of injury through accidents
judgment and risk perception—increasing the risk of injury, assault and potentially harmful or risky sexual behaviours
Repeated use of cannabis leads to tolerance, and a cannabis withdrawal syndrome has been described with symptoms of withdrawal being similar to those of nicotine withdrawal. They typically appear within one day of cessation, peak after one week, and may last up to two weeks. Withdrawal symptoms include irritability, depression, anxiety, restlessness, reduced appetite, sleep problems and weight loss.
Repeated exposure to cannabis in adolescence leads to neurotoxic effects in brain structure and function which persist into adulthood and may not be entirely reversible. This includes an association between frequent use of cannabis and a significant decline in IQ whilst heavy cannabis use has also been associated with poor educational and social outcomes. Given the importance of educational attainment to adolescent development and outcomes, the cognitive effects of cannabis are of particular concern.
Adolescent-onset cannabis use is associated with mental disorders including a risk of developing a psychotic disorder (including schizophrenia) which is increased in those with a family history. Regular use in adolescence is also associated with anxiety, depression, suicidality and deterioration in symptoms in those who already have depression, bipolar disorder or schizophrenia.
Assessment should include enquiring about cannabis use in the past year and this may be incorporated into adolescent psychosocial screening tool such as HEEADSSS. If the young person endorses use in the last year, then the CRAFFT questions can help to elicit problematic substance misuse. Cannabis use is detectable on urine toxicology testing although this is not true for synthetic cannabinoids. Emergency presentations related to cannabis are rare. For those with acute marijuana intoxication, supportive care is all that is required.
There are no specific pharmacotherapies available to treat cannabis use disorder and intervention is based on motivational enhancement and cognitive behavioural therapies, which may be delivered in individual or group settings.
Other drugs of abuse
Use of other drugs of abuse such as opioids, MDMA (ecstasy), benzodiazepines, amphetamines, LSD, ketamine and novel psychoactive substances is much less common in adolescence, but they are all associated with significant potential harms.
Novel psychoactive substances are synthetic drugs that are designed to mimic the effects of other psychoactive substances. They can be grouped into four main categories—stimulants, cannabinoids, hallucinogens and depressants—and all can be taken in a number of ways. Toxicity is a significant concern for novel psychoactive substances and they are not “safe” alternatives.
Inhalants are most frequently used by younger adolescents (10–12yrs) and use decreases with age. The four groups of inhalants are volatile solvents, aerosols, nitrites and medical gases. They have a rapid onset of action, low cost and are often readily available in legal products such as spray paint, glues, cleaning fluid, permanent markers and deodorants. They are typically inhaled from a plastic bag (“bagging”) or saturated cloth (“huffing”).
Indicators of inhalant abuse may be subtle and it may only be suspected when potential inhalants are discovered by parents/carers. Abusers may have chemical odours on the breath or clothes, show a change in behaviour or develop a marked decrease in appetite. Young people may exhibit confusion, poor concentration, depression, irritability, hostility and paranoia and inhalation of solvents may lead to peri-nasal and peri-oral rashes and epistaxis. Social and educational decline and neglect of personal care are commonly seen. Initially they cause stimulation progressing to depression and their use often escalates as the ‘high’ is short lived. Inhalant abuse can lead to sudden death and for chronic users may lead to irreversible neurological, renal, cardiac or hepatic injury.
Nitrites including amyl, butyl and isobutyl nitrites are known as ‘poppers’. They lead to vasodilatation, increased sexual pleasure and a mild high or ‘rush’.
In recent years, abuse of ‘laughing gas’—nitrous oxide—has increased as the drug is sold in balloons or canisters and is inhaled for a rapid onset. Inhalants are not detected by routine urine drug screenings.
Self-harm is defined as self-poisoning or self-injury irrespective of the apparent purpose of the act and includes any form of behaviour that leads to self-injury. National guidance avoids the use of the term ‘deliberate’ and other descriptions that imply the presence or absence of suicidal intent such as ‘attempted suicide’, ‘parasuicide’, ‘non-suicidal self-injury’.
Community-based studies estimate around 10% of young people reported self-harm whilst other UK and European studies have suggested rates between 15% to 22%. Young females report two to four times higher rates of self-harm than young males and there has been a trend of increasing hospitalisations in young people for self-harm ( Figure 3.1 ). Most young people who do self-harm do not attend hospital and many do not seek or access medical or psychological treatment. Suicide is a leading cause of death in young people and the risk is greater for boys than girls.