Care of the Adolescent
Phillip S. Ebrall
As adults, we may recall our adolescence as a time of optimism, idealism, and potential (1). Sadly, today more than ever, adolescence is also a time of stress and social conflict (2), with some youth finding the structure they seek for their lives in the shopping malls of suburbia (3). On the one hand, adolescence is a time when the individual faces many potential health care problems, and on the other, it is the ideal time for preventive care (1). Adolescent medicine has existed as a discipline for about 35 years; today it is growing, with a developing number of professional organizations for those interested in providing health services to this group (4,5).
Adolescent health care makes front page news (6) but has not, until now, seriously drawn the interest of the chiropractic profession. The medical profession is coming to grips with its responsibilities to provide specialized health care for the adolescent population (7,8,9), and the Society for Adolescent Medicine (8) has identified five key issues:
Quality of health care for adolescents
Research
Health services for adolescents
Communications among health professionals who are caring for adolescents
Training of individuals who are providing care to adolescents
These five issues are equally applicable to chiropractors, even though it is accepted that the precedence for providing health care to the adolescent has been within orthodox medicine, particularly with pediatricians (9).
ADOLESCENT CARE: BEYOND PEDIATRICS
The increasing responsibility demonstrated by the chiropractic profession for developing a specialized pediatric knowledge base from the chiropractic perspective (10), in addition to conducting continuing education and postgraduate programs evolved from the accepted, broad-scope pediatric knowledge base (11), cannot be considered to automatically confer those particular abilities demanded for the provision of competent “adolescent” care.
Adolescents have needs and problems sufficiently distinguishable to warrant consideration as a distinct group for health care provision (12); consequently, the differences between the adolescent patient and the pediatric patient are many. Pediatrics has its own complexities but they can broadly be considered to be congenital, developmental, or transitional related to the commencement of schooling. Therefore, pediatrics can be considered the specialty of the neonate, the preschooler, and of childhood, ranging up to the onset of puberty, at which time the greatest musculoskeletal and psychosocial developments are unleashed. Development during adolescence is complicated by the major social adjustments associated with sexuality and the expanded transition to life outside the family orbit.
With the pediatric patient, the parent or guardian is more often the historian and the doctor-patient relationship exists largely within the patient’s existing frame of reference: the family. The adolescent period sees progression to the patient being the historian and beginning to take responsibility for his or her own health. Not that this happens easily. The response of adolescents suggests that the health professions are failing in their specific efforts to reach them (13). Not only was consultation time considered to be inadequate, but adolescents felt that medical practitioners were hard to approach and impersonal. Among the suggestions and strategies to remedy this problem is the requirement for greater awareness of youth needs and greater availability of doctors to young people (13).
Adolescence is the time of the greatest growth and change of the musculoskeletal system, and the more doctors of chiropractic who accept the unique challenges
associated with the provision of quality, competent, and relevant adolescent health care, the greater will be the enrichment of our society. By taking up the stimulating challenge of providing specialized musculoskeletal care during this period, chiropractors can make two unique contributions to a young life: first, the relief of pain through the correction of musculoskeletal dysfunction; second, the provision of a corrected structural foundation to allow for a more normal adult life.
associated with the provision of quality, competent, and relevant adolescent health care, the greater will be the enrichment of our society. By taking up the stimulating challenge of providing specialized musculoskeletal care during this period, chiropractors can make two unique contributions to a young life: first, the relief of pain through the correction of musculoskeletal dysfunction; second, the provision of a corrected structural foundation to allow for a more normal adult life.
The World Health Organization has identified two approaches necessary to effectively deliver complete health care to adolescents, namely “curative” and “preventive” (14). Traditionally, the curative care for adolescents is delivered by remote professional figures who are specialists in mainly medical areas. Chiropractors already have a reputation of being easily approachable primary contact practitioners (15,16,17) and are in a unique position to develop a practice style of curative musculoskeletal care with which adolescents can feel comfortable.
The curative approach is problem oriented. The chiropractor’s ability to gain ready access to an adolescent population must be supported by clinical competency, not only in the wide spectrum of musculoskeletal disorders encountered during adolescence, but also with the extremely wide range of psychosocial issues that are integral to adolescent care. The preventive approach is designed to address the needs of adolescents and involves a wide selection of qualified paramedics with an emphasis on the psychosocial aspects. There is a very broad scope here for chiropractors to implement preventive strategies related to neuromusculoskeletal health.
Age of Adolescence
Adolescence is accepted as commencing around the time of puberty during the second decade of life. Accordingly, 10 years is considered a demarcation for entry into adolescence (18), although 12 may be a more convenient age with regard to age and school grouping (19). The point at which adolescence ends, however, is not as clearly defined. Traditionally it has been 21 years, with the proviso that, in special cases such as chronic disease, care may continue past 21 (9,20); however, contemporary thinking is that the end point of “adolescence,” or, as it is becoming known more generically, “youth” (21), is more realistically about age 25 (22), the time when the “late adolescent” period blends into young adulthood. There are two arguments in favor of the 25th birthday being considered the more appropriate end point to adolescence, namely:
1. Though adolescence is a period of physical growth, including the “growth spurt” of high peak annual height velocity (23,24), growth actually concludes with the fusion of the secondary ossification centers of the spine by about the 25th year (24,25,26,27), notwithstanding that the spurt occurs earlier in girls than boys (28).
2. Adolescence is a period of psychosocial growth and central nervous system maturation, with the development of formal operational thinking (4). In recognition of this, the statistical measurement of young people is grouped as 15 to 19 and 20 to 24 years of age. The former statistical grouping excludes late adolescents; the latter includes them (19). These psychosocial considerations support the view that adolescence is a cultural phenomenon that is an inevitable by-product of adult, Western civilization (29).
Therefore, from the chiropractic perspective of the neuromusculoskeletal system, the most appropriate age range for “adolescence” is 10 to 24 years, and on this basis the typical adolescent population in Western countries represents about one-quarter of the total national population. Within a 3-km radius of the clinics in an Australian study, the proportion of adolescents ranged from 23.4% in the rural/urban fringe to 29.4% in an outer metropolitan suburb (30).
The clear implication is that a chiropractic practice reasonably can expect to have adolescents as patients, and specific reports of the use of chiropractors by adolescents are now becoming available (31,32). They suggest attendance by adolescents for new visits can range up to 29% of all new patient visits, thereby approaching their proportional representation in the population at large (between 24% and 29%); however, for return visits the rate is only about half of what could be expected: about 12%.
Of greater concern, however, was the adolescent participation rate in chiropractic management under the provisions of workmen’s compensation. In the Australian studies, adolescents aged in their early 20s had double the national average participation rate (18% compared with 9%). The implications are obvious; musculoskeletal injury in general and low back injury in particular represent the lion’s share of work-related, compensable injury in the United States (33). The majority of this musculoskeletal injury is amenable to chiropractic management (34), a fact no longer overlooked by health economists, who continue to demonstrate the significant cost effectiveness of the chiropractic management of low-back pain (35). Add to this the various preventive strategies used within chiropractic practice, such as “Back School” (36) and preemployment assessment (37), and chiropractors can be seen as holding a preeminent position for the provision of care for the adolescent.
GROWTH AND DEVELOPMENT DURING ADOLESCENCE
Adolescence is a journey through physiologic, cognitive, and psychologic stages, an integral aspect of which is the development of the adolescent as a sexual being. A successful journey through adolescence will result in the successful development of the individual’s sexuality and subsequently largely determine his or her nature as an adult.
Western society places unreasonable pressure on adolescents, which is reflected in the difficulty they have with finding their roles as sexual beings. Television and take-away videos provide easy and non-stop access to distorted sexual attitudes and activity. Many youth have faced the horror of child sexual and verbal abuse, and all are affected by the quality (good or bad) of the sexuality education we, as adult society, give them. The comprehension of adolescent sexuality is not easy, even for health care workers. It is a physioanatomic, biologic, psychosocial, moral, and ethical phenomenon, existing as a continuum (instead of an endpoint) within a community that is grappling with its own constantly changing stressors and varying standards of sexuality.
The sexuality issues of the adolescent begin during childhood. Those youth who lived with a childhood of abuse, neglect, parental divorce, family chaos, or other negative experiences have less than the ideal template for the development of their adolescent sexuality. Parental attitudes toward clinically normal sexual development are vitally important to the overall development of the emerging individual.
Regardless of one’s chosen scope of chiropractic practice, an understanding of adolescent sexuality is vital for the establishment of an adequate professional relationship with the adolescent as a patient. Should your scope of practice be broad enough to include the room to work with issues of adolescent sexuality, then further study and membership of appropriate professional bodies is essential. On a day-to-day basis, the chiropractor needs to understand that the adolescent patient is neither a child nor an adult; therefore, management strategies that are otherwise effective in one’s practice may singularly fail for the adolescent patient. Furthermore, adolescence is a journey in itself and not just a whistle-stop one passes through while progressing from the cradle to the grave. As such, it has a myriad of nuances that interact to varying degrees at varying times. Fortunately for the practitioner, however, the journey through adolescence largely can be considered to occur in three stages.
Stages of Adolescence
Adolescence can be viewed in terms of early, mid, and late, each with its own characteristics and problems.
Traditionally, the early stage is ages 10 to 14 years, the middle stage is ages 14 to 18, and the late stage is ages 18 to 21 or 22, with a crossover phase into adulthood and growth completion between the ages of 21 and 24 years. The stages are only guidelines, however, and it is important to remember that all patients have the right to present in the stage of development in which they find themselves at the time. On the basis of there being some sort of mean range within which developmental landmarks generally occur, it can be said that some teenagers have precocious development whereas others are delayed, but, remember, the term “delayed” is only a label and one must be cautious when thinking about whether or not to apply it.
Each stage has its own characteristics for growth, cognition, psychosocial self, family relationships, peer group relationships, sexuality, and chronological age range. They are listed in Table 21.1. There are further stages that can add to one’s concept of adolescence, such as those of Kolberg, Freud, Sears, Havighurst, Kinsey, Lidz, and Gillian, Miller, and Chodorow; these can be explored at one’s discretion and leisure.
Early Adolescence The chronological age range of early adolescence is 10 to 14 years. Sexual function will occur before biologic maturation, and generally the concepts of sexuality are initiated in the youth’s mind by the events of puberty. The body increases in height and weight as growth accelerates, and the secondary sexual characteristics appear. The time lapse between childhood and adulthood stages is from 2 to 4 or perhaps 5 years.
Growth is initiated by the hypothalamus through stimulation of the anterior pituitary and is controlled by various hormones. The amount of sex steroids produced by the body slowly increases from approximately age 6 years. Puberty commences with the triggering of gonadotropin-releasing hormone (Gn-RH). It is believed that this system is controlled by a highly sensitive negative feedback system that inhibits the synthesis of effective levels of Gn-RH earlier in life. As age increases, it is thought that the sensitivity of the negative feedback mechanism decreases and the hormones reach endocrinologically effective levels. The critical weight hypothesis of Frisch-Revelle (38) suggests that the decreasing sensitivity is related to a statistically significant correlation between menarche and the achievement of a critical body weight of 47.8 kg. The hypothesis has been modified to relate more to a ratio between body fat, total body water, and lean mass (22) and remains a useful clinical indicator.
The biologic changes are categorized by Tanner, with genital maturity ratings that range from 1 to 5 (Tables 21.2 and 21.3). They apply to the secondary sexual characteristics of the man and woman, and allow
a “staging” of the individual’s biologic development (Figs. 21-1 and 21-2). Although not used during day-to-day chiropractic practice, the stages do form an important part of the patient record for complaints such as delayed menarche (primary amenorrhea) or short stature. Because evaluations of Tanner staging should only be performed by a chiropractor in the presence of a chaperone of the same sex as the patient or in the presence of the patient’s parent or guardian, it is often easier to use the “self-reporting” method, in which the patient is asked to identify which of a series of Tanner drawings most closely resembles himself or herself. This method has been found to be reasonably reliable (39), has been recommended by other chiropractic authors (40), and is much more practical for use outside the office, for example, when conducting preparticipation examinations for a sporting organization.
a “staging” of the individual’s biologic development (Figs. 21-1 and 21-2). Although not used during day-to-day chiropractic practice, the stages do form an important part of the patient record for complaints such as delayed menarche (primary amenorrhea) or short stature. Because evaluations of Tanner staging should only be performed by a chiropractor in the presence of a chaperone of the same sex as the patient or in the presence of the patient’s parent or guardian, it is often easier to use the “self-reporting” method, in which the patient is asked to identify which of a series of Tanner drawings most closely resembles himself or herself. This method has been found to be reasonably reliable (39), has been recommended by other chiropractic authors (40), and is much more practical for use outside the office, for example, when conducting preparticipation examinations for a sporting organization.
TABLE 21.1 | ||||||||||||||||||||||||||||||||||||
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TABLE 21.2 | ||||||||||||||||||||||||||||
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TABLE 21.3 | |||||||||||||||||||||
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Adolescent growth, these times of tremendous biological change, occurs at different chronological ages in men and women. Female puberty is heralded by thelarche (the budding of the breast) at about age 11 (range, 8 to 15 years of age), which is Tanner stage 2. Puberty starts 1.5 to 2 years later in boys and takes nearly twice as long to complete. Menarche occurs approximately
2.5 years after the onset of puberty, or during stage 4, at which time the girl has attained 90% to 95% of her adult height.
2.5 years after the onset of puberty, or during stage 4, at which time the girl has attained 90% to 95% of her adult height.
 FIGURE 21-1 Tanner stages for male pubertal development. Modified from Strasburger VC, Brown RT. Adolescent Medicine: A Practical Guide. Boston: Little, Brown & Co., 1991; p. 3. |
 FIGURE 21-2 Tanner stages for female pubertal development. Modified from Strasburger VC, Brown RT. Adolescent Medicine: A Practical Guide. Boston: Little, Brown & Co., 1991; p. 4. |
In boys, the first observable change is testicular enlargement, beginning at 11.6 years of age (range, 10 to 14.8 years of age). The male growth spurt usually begins at Tanner stage 3, peaks during stage 4, and is all but complete by stage 5; however, some boys will continue to grow up to 2 cm more in height over the ensuing 5 years. Another characteristic of importance to manual practitioners is the period of male puberty, which sees rapid muscle growth, the “strength spurt,” at the end of stage 4.
Linear growth follows these early changes in sexual characteristics, with an initial increase in the length of the long bones, which causes a rise in the body’s center of gravity. This is followed by growth of the spine, which reestablishes equilibrium in the ratio of upper to lower body segments. This is the “growth spurt” of Tanner, or the period of peak height velocity, which in
girls commonly starts during Tanner stage 2, reaches a peak midway between stages 3 and 4, and ends at stage 5. In boys, the peak height velocity occurs later, during genital stage 4. During the growth spurt the “average” girl will grow at a peak velocity of 8 cm per year and the “average” boy at 10 cm per year, adding as much as 20 cm to his height. Similar dimensional increases occur in every body system apart from the lymphatic, in which total tissue volume decreases.
girls commonly starts during Tanner stage 2, reaches a peak midway between stages 3 and 4, and ends at stage 5. In boys, the peak height velocity occurs later, during genital stage 4. During the growth spurt the “average” girl will grow at a peak velocity of 8 cm per year and the “average” boy at 10 cm per year, adding as much as 20 cm to his height. Similar dimensional increases occur in every body system apart from the lymphatic, in which total tissue volume decreases.
Because youth enter puberty at such varying times, any comparison between individuals is best made on the basis of Tanner staging. We therefore have chronological age, Tanner stage, cognitive level, and psychosocial development as aspects to consider when talking about adolescents. It is essential to understand these relationships with their standard deviations to correctly evaluate normal and problematic growth states such as delayed puberty, short stature, or delayed menarche.
Piaget has described the cognitive stages of development, which reach the concrete operational stage between the ages of 7 and 11 years. The adolescent generally will be making the entry into adolescence and puberty from the concrete stage; however, the stage may last until well into adolescence. Concrete thought is limited to considering things and specific situations in existential terms, with no ability to extract general principles from one experience and apply them to a wholly new experience.
A feature of the concrete operational stage of interest to chiropractors is the monosyllabic nature of responses to questioning. There should be some ability to understand the concepts of symmetric relationships and serializations, although this ability can be expected to vary greatly between adolescents. Concrete thinkers may well be interested in the physical aspects of their bodies but may be unable to express themselves clearly and in detail. Questionnaires can be useful at this stage to identify the key points of a health history. Teaching aids are also of great benefit to extend the patient’s knowledge and understanding. The thinking of the concrete adolescent is very much in the present, with a resultant difficulty to think in futuristic terms.
The implication for clinical practice is that therapeutic recommendations need to be accompanied by evidence of an immediate benefit. For example, “sex is OK” because “it feels good right now”; the risk of pregnancy and delivery is 9 months in the future and is not comprehensible. The future cannot be appreciated except as a direct projection of clearly visible, current operations. The difficulty of counseling around inappropriate behavior is compounded by the concept of “magical thinking,” in which the adolescent feels he or she is untouchable. Accordingly, they do not perceive the risks that attend risky behavior because they feel they are “special” and essentially “untouchable” by any future danger. This magical thinking can extend well into late adolescence (to include about 30% of late adolescents) and even adulthood, as evidenced by the number of adults who take drugs, smoke, drive irresponsibly, and abuse alcohol. Generally the adolescent progresses to formal operational thinking by mid adolescence.
The psychosocial self of adolescence is dominated by the rapid physiologic growth changes of puberty with its various aches and musculoskeletal pains. These can lead to a hypochondriacal phase until the changes become more familiar. The family relationship lessens, with a commensurate strengthening of the peer group relationship. As the teenager starts to move away from the parent he or she forms stronger friendships and bonds with peers, the new source of one’s sense of self-worth. This is a time of strong comparison with one’s peers, and friendships tend to be of the same sex, with some possible homosexual experimentation.
Mid Adolescence The chronological age range is 14 to 18 years and the formal operational thinking patterns are now developing. This abstract thinking permits the conceptualization of possibilities beyond past and present experiences. The emerging phase is attended by a preoccupation with fantasy and ideas, which develop into a strong ability to comprehend logic that can be used in profound arguments to counter parental direction. Any guidance given by health care workers needs to be extremely clearly presented with fully explained rules or recommendations, especially with preventive health strategies.
These youth are balancing the newfound power of formal operational thinking with the emergence of a need for independence. They lack the level of experience needed to avoid errors in judgment, especially when “magical thinking” remains, but they can achieve independence and make career and lifestyle choices while their personal value system emerges. Formal thought may not be applied at all times; some simple situations may not need it, whereas some other occasions may overwhelm the person, who then reverts to irrational thought.
The psychosocial self shows a stronger reliance on peers with an acquisition of greater independence and emancipation from the parents. The kind of youth with which one associates reflects one’s sense of self worth. Individuals with undesirable peer group associations, such as those with drug-taking habits, seem more prone to depression at this stage. Though self-confident youth generally associate with similarly self-confident youth, parents and health care workers should be aware of the futility of attempting to force certain relationships onto the adolescent.
Heterosexual experimentation is inevitable and parental attitudes become critical. A youth who is
rebelling against authority may demonstrate such rebellion sexually. Coital activity is common, with the resultant high rates of pregnancy, abortion, and sexually transmitted diseases, which in turn can further complicate parent-adolescent relationships. The developing emancipation and heterosexual experimentation strengthens cognitive abilities. Various adults may serve as role models (good or bad), and youth often turn to other adults for counseling in addition to or instead of their parents. It is at this time that the chiropractor’s influence is significant, especially because questions of a moral, ethical, and religious nature are often asked. The difficulties experienced vary greatly. Some adolescents may pass through this stage with little upheaval, whereas others may turn to experimentation with drugs and may exhibit transient school dysfunction, moodiness, and irritability. This is a relevant time to consider the appropriate type of counseling should it be indicated.
rebelling against authority may demonstrate such rebellion sexually. Coital activity is common, with the resultant high rates of pregnancy, abortion, and sexually transmitted diseases, which in turn can further complicate parent-adolescent relationships. The developing emancipation and heterosexual experimentation strengthens cognitive abilities. Various adults may serve as role models (good or bad), and youth often turn to other adults for counseling in addition to or instead of their parents. It is at this time that the chiropractor’s influence is significant, especially because questions of a moral, ethical, and religious nature are often asked. The difficulties experienced vary greatly. Some adolescents may pass through this stage with little upheaval, whereas others may turn to experimentation with drugs and may exhibit transient school dysfunction, moodiness, and irritability. This is a relevant time to consider the appropriate type of counseling should it be indicated.
Late Adolescence The chronological age range is from 18 years to the end of skeletal growth, between 21 and 24 years. By the 25th birthday, all secondary ossification centers should be fused and growth should be complete. The adolescent will exhibit sound formal operational thinking with strong cognitive skills and can be considered an adult, with both the independence and experience needed to reduce errors in judgment. There is some final physiologic fine tuning, such as regulation of menstruation and male muscular development. The male growth spurt should be all but complete by Tanner stage 5; however, it must be appreciated that some men will continue to grow up to 2 cm more during the ensuing 5 years. Another characteristic of importance to chiropractors is the period in men that sees rapid muscle growth, the “strength spurt,” at the end of stage 4.
The psychosocial self will by now be resolving the issues of emancipation and the youth-parent relationship, which should be more adult-adult in nature and more comfortable. Ideally, a young adult emerges, a person who likes him or her self as a man or woman and has come to grips with important issues of human sexuality. The body image will be secure and the gender role established, two keys to potential success during late adolescence and adulthood. Any necessary corrections to the musculoskeletal system from the chiropractor’s viewpoint will have been made and the entry into adulthood should be based on a firm, pain-free, fully functional structural foundation. Those youth who still experience difficulty in this stage may also experience considerable anxiety or depression, and care must be taken to distinguish between genuine physical need for adjustive treatment and a perceived demand based on the patient remaining in a “comfort zone.” The rest of this transitional period involves the acquisition of adult lifestyles and habits, and one or several of a variety of sexual orientations will be adopted. This is also the time for establishment of vocational skills and of training to meet the complexities of modern society.
YOUTH-ORIENTED PRACTICE
Adolescence is the bridging period between childhood naïveté and adult experience. As such, it is reasonable to treat adolescent patients with an understanding based on their individual psychologic and physiologic development, taking care to develop a doctor-patient relationship built on mutual trust and respect. The process of physical change that occurs during adolescence is a cause of increased self-consciousness, self-awareness, and self-centeredness. On the one hand the adolescent is striving to gain independence, and on the other hand he or she may be in need of your support and understanding, not just as a chiropractor but also as a person.
The joy of working with adolescent patients comes from their capacity to warmly return the effort you put into your relationship with them. If you are a caring chiropractor and exhibit empathy, you will be rewarded with countless opportunities to improve the quality of life of your adolescent patients through the shortterm benefits of the relief of musculoskeletal pain and the long-term benefit of the provision of a healthy body and mind as a springboard into adult life. The doctor’s attitude needs to encompass the concepts of both the appropriate treatment program for the immediate presenting complaint and of a tailored preventive health care program based on long-term advice and guidance.
Bennett (41), a leading adolescent medicine physician, has identified seven important steps to promote a successful doctor-patient interview. These steps, and their application in the chiropractic office, are:
1. See the patient alone, at least for part of the interview.
Start the initial interview with the parent present if the patient (usually in the 10- to 16-year-old age group) attends with their parent, but then excuse the parent at the point where you wish to establish your one-onone relationship with the patient. Doing this will avoid the appearance of you being aligned with the parents and will invite a more mature and responsible response within this doctor/patient relationship. Before relaying any information to the parent, ask your patient for permission to do so. Use your judgment and perhaps ask the patient if he or she agrees with you “filling [the parent] in on the basic details.” This will let you retain an area of confidentiality with the patient and will strengthen parental cooperation with your proposed treatment plan.
2. Define the basis of confidentiality.
Your adolescent patients must feel they can trust you, especially in personal areas that to them may be highly sensitive. Exceptions are, of course, proposed self-destructive or dangerous behavior; however, you can also lay a ground rule with your patients when alone with them that “if any problems come up that are too big for the both of us,” you will help form a team with the appropriate professional (maybe a clinical psychologist) and maybe a parent to work it through together. This signals a comfort zone to your patients and shares the decision-making responsibilities without disempowering or “controlling” them.
It is important for all parties to know that the history you have taken and will continue to take when alone with the patient is confidential between you and the patient and will only be shared with parent(s) or guardian(s) with the patient’s permission. In practical terms this arrangement works well, usually because the patient has willingly attended with the assistance of the parent who is keen to help their child grow to greater independence; however, there are no predictable answers for the rare case in which, subsequent to a breakdown in communication between the younger adolescent and the parent, the parent may insist on exercising what they see as their right to know the contents of their child’s history and treatment file.
As a guide, the issues at play are the age of the patient (whether they are legally a minor), the social standing and emancipation of the patient (whether they have left home and can demonstrate independence), and the agreement reached between all parties during your initial interview. You may elect to have the parent sign a “consent to treatment” clause on the patient’s history that includes statements of confidentiality. You may elect to operate “a family history” with no recorded confidential matters, or you may elect to tough it out fully on the side of the adolescent. Legal opinion will vary widely, not only between but also within jurisdictions.
From a pragmatic point of view, such disputes tend to happen as the adolescent is attempting to assert independence and, though in some jurisdictions the “age of consent” may be literally enforced, issues of patient confidentiality tend to revolve around the level of independence and intellectual cognizance of the patient.
3. Respond openly to the adolescent’s initial reactions.
If your patient has not been to a chiropractor before, his or her expectation of the experience will be based on any previous interaction with the medical profession. You can defuse hostility by commenting on the patient’s apparent and expected discomfort. Do not handle this lightly or with humor. At all times be “matter of fact” and fully professional, but demonstrate your awareness of what the patient is feeling and act in a manner that allows him or her to place his or her confidence in you.
It is a good idea to “talk through” all that you do, from the simple scoliosis screen to the complex neurological evaluation. The assessment of sexual development can be an acute embarrassment to both you and the patient. A very effective method in the chiropractic office, as previously mentioned, is to show the patient a set of sketches of the Tanner staging (breast contour and pubic hair development for girls, and testicular size, penis size, and pubic hair development for boys), then ask the patient to indicate which sketch they feel most accurately looks like them at this time. Be sure to include sketches of both circumcised and uncircumcised penises.
This approach allow you to gently work with any “taboo” or fear of sexual matters and development and to open a conversation in which the patient may raise any questions with you. As with all inquiry about personal matters your approach must be open-ended. Such questions are best phrased “most young men I see wonder whether their penis is like other people’s” or “most young ladies I see wonder whether their breasts are the right shape” and “what do you think about yours?” or “how often do you or your friends wonder about that?” Again, it is vital to be non-judgmental and to demonstrate genuine empathy with this very special human being who is putting trust in you.
4. Clarify the reasons for the consultation.
From the adolescent patients’ point of view, their care is largely “symptom care” (curative) and it is very important for you to explain why you may be conducting adjunctive assessments of areas that they may not relate to the presenting complaint. The patient may also be in your office against his or her will because a parent (perhaps also a patient of yours) has brought them to you “to fix their headache and bad temper.” Be alert for signs of this and make the effort to establish a reason for the consultation that the patient accepts and understands.
If you detect a problem that the patient is reluctant to confront you, then the open-ended questioning style can be used to invite a response. Again, you may say “I see many patients of your age who worry about… being too heavy or too light… being too short or too tall…whether smoking is really bad,” and so on. Two-way conversations, in a discussive manner with complete honesty in your responses, are a very effective method of communication with adolescents.
5. Be a good listener.
The conversation must be “two-way,” meaning you are expected to listen. In fact, the art of adolescent health care may be summarized by saying “hear what
your patient is telling you.” Listen, listen, then listen. Adolescents frequently convey their concerns in an indirect style of conversation. Listen for the subtle nuances that may tell you what the patient is really trying to say, but do not try and listen for cues to generate an automatic response from you. Neuro-linguistic programming has no place in adolescent health care. Converse and listen with honesty and integrity.
your patient is telling you.” Listen, listen, then listen. Adolescents frequently convey their concerns in an indirect style of conversation. Listen for the subtle nuances that may tell you what the patient is really trying to say, but do not try and listen for cues to generate an automatic response from you. Neuro-linguistic programming has no place in adolescent health care. Converse and listen with honesty and integrity.
6. Allocate ample time.
The examination and treatment of the adolescent can not be rushed. The real investment you make in adolescent health is your time and your availability; now and then you may actually adjust! The chiropractic office that wants to earn its place in the overall network providing adolescent health care needs to be an office where the adolescent comes first. Late afternoons, early evenings, and Saturdays are good times to have your office open for adolescents. On weekdays consider structuring the hours at the end of the day as “adolescent only” hours, with music in your office to match, but be sure to retain a high level of professionalism in the dress of yourself and your staff. The adolescent patient expects to see professional figures, not confused grownups attempting to dress like kids. Also, make sure your office works in an open and relaxed manner to reflect a well-planned schedule that has ample time allocated for each individual patient. The greatest honor your adolescent patient can give you is to bring a friend with them to watch their treatment session with you, perhaps because the friend may have a similar problem to that of your patient. You need to have enough time within the patient visit framework to accommodate the friend and his or her problem. This is not to suggest you should treat the friend at this time; rather, this situation can be viewed as being an ideal patient and future patient education session. With 12 or more patients an hour and the waiting room full, you will not have the time and your young patient will know it.
7. Answer questions simply and honestly, and particularly in a nonjudgmental manner.
Adolescents, especially when in a group situation such as a basic health class you may be teaching at your local high school, have a great talent for asking questions from left field. Any hesitation or embarrassment you may feel will be picked up by their sixth sense. Always answer as best you know how, at all times showing genuine respect for their concerns and point of view. Above all, if you do not know an answer, say so! Offer to find out about an issue and report back next visit.
Outreach Activity
Care of the adolescent is not limited to your chiropractic office, nor is it limited to the simple “fee for service” paradigm. Chiropractors, as primary health care providers (42), have the potential to provide a wide range of community services, many of which may be focused on the particular needs of early and mid adolescents. Some of these services may include acting as the physician at your local high school, providing a service at no cost to the school community but one that places you in the forefront as a gatekeeper for adolescent health concerns in your community.
You may offer your professional services as a team physician for a particular sporting club in your community and extend your duties to the junior ranks as well as the senior players you are paid to look after. Or you may work with your local high school by offering to conduct an annual “pre-participation” sports examination. There is no reason why you could not offer this service free to your local high school and set an example in community participation and interaction. The format and content of such examinations are beyond the scope of this chapter; however, you can obtain relevant information from your professional association and detailed formats from the literature (43,44).
A number of chiropractic communities are also extending their services at no cost to the socially disadvantaged through “Hands on Health” clinics and other such services aligned with welfare agencies. Within this system you will be working with homeless youth, dysfunctional youth, and, at times, detainees. It is imperative that you have a high level of competence with the essential components and substance of adolescent health care to be able to adapt your assessment and intervention to what will sometimes be a practice environment that is essentially incompatible with the generally accepted patient management strategies, the absence of which places a greater responsibility on you as a practitioner.
THE INITIAL VISIT
There are several scenarios within which you will conduct your initial consultation with an adolescent patient, notwithstanding any outreach activity in which you may be involved. The most likely scenarios are (1) when the parent, who is a patient of yours, brings their son or daughter to you for either a “check-up” or for your opinion on a particular problem, in which case the patient will generally be in early or mid adolescence; and (2) when a patient in the late adolescent stage will seek your services through their own volition. Depending on the nature of your practice, you may also receive adolescent patients on referral from other primary health care practitioners or on referral through the new patient being a friend of an adolescent patient of yours. The following recommendations for the conduct of
the initial visit are intended for the scenario where the patient attends with a parent or guardian.
the initial visit are intended for the scenario where the patient attends with a parent or guardian.
The aim of the initial visit is twofold: first you need to establish the framework in which the patient is operating, the health status they carry from childhood, the things that worry them and that they think you can do something about, and other concerns that they do not see as being any of your business. Second, the patient needs to establish how he or she sees you and your clinic and to work out what it means to him or her. Only the most optimistic practitioner would think they will subtly gather a little more “historical” information on each subsequent visit, realizing they are establishing a long-term doctor-patient relationship that has the potential to span many years.
Introduction to the Clinic
The normal administrative matters for new patients of your clinic should be conducted for the adolescent patient, including the taking of demographic information and determining the terms of payment. There is no reason why the fee for an adolescent consultation should be any different to the normal office fees; however, more time will be spent with the adolescent patient, especially during the initial visit, than with an adult. A separate file should be established in the name of the patient and it should indicate the name by which the patient prefers to be called. It is inappropriate for any person other than the doctor to elicit any healthrelated or psychosocial information from the patient before the consultation.
The adolescent should be advised at this stage that he or she may be required to expose parts of the body for examination by the doctor; simultaneously inform him or her that a gown and a private room in which to change will be provided. This should apply to male patients as well as to female patients, and the patient should be instructed to keep underwear on. It is beneficial for clinic reception staff and chiropractic assistants to be trained by the doctor to have an understanding that a “guidance-cooperation” relationship is appropriate and effective for most early to mid adolescents, whereas a “mutual participation” relationship is more suited for some mid and most late adolescents.
Consent
All patients are required to give informed consent before you commence examination, treatment, and management. In addition, a consent from the parent(s) or legal guardian(s) of the patient, on behalf of the patient, is required when the patient may be either viewed as a minor in the jurisdiction of practice or be deemed incompetent to give informed consent because he or she is intellectually challenged. The issue of consent is not new to the chiropractic literature (45,46,47
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