This lecture we’ll briefly review the key attitudes, core knowledge and skills required by clinicians to deliver quality healthcare to adolescents. These are the same competencies, regardless of whether the clinician is a doctor, a nurse, or an allied health professional. Although, obviously, the focus will change, slightly, according to the clinicians role. A useful resource, from the World Health Organization, is the Adolescent Job Aid, shown here on the left. A desktop resource for primary care clinicians that has been developed for use in low and middle income settings. It has sections on general aspects of adolescent friendly health care including adolescent development, confidentiality, and psychosocial history taking. Together with an approach to common adolescent presentations. One of the challenges we've highlighted is how clinicians need to build new relationships with adolescents, while retaining the strength of any existing relationships with parents. One area that many clinicians struggle with in the early stages of their training, is young people's sexual health. In many societies and cultures, adults have difficulty accepting that young people's sexual development is a natural and positive part of human growth and maturation. And sadly, our actions as clinicians often reflect this. Yet we know that young people will not willingly seek care if they encounter providers whose attitudes convey that adolescents should not be seeking sexual health services. Young people may be deeply embarrassed and refuse to return, if reception staff ask, for example, personal questions in a voice that is loud enough to be overheard by others. Youth may reject sexual health services, and indeed any health service, if health service staff fail to take seriously the young person's need for services. If they fail to treat the young person with respect, and especially if they try to dissuade the sexually active young person to cease being sexually active. In such cases young people may give up, not on having sexual intercourse, but on trying to access sexual health services such as reliable contraception or HIV testing. It is important to appreciate that regardless of whether the parent has accompanied their child to clinic or not, it is the young person who is the patient, not the parent. This panel comes from a systematic review that aimed to identify the indicators that are most relevant for young people in terms of quality health care. The studies that were identified came from all over the world, including a number of low and middle income country studies. Not withstanding this diversity, there was really consensus about what was most important, as outlined here, with some examples around each indicator. One of the studies was this one from New Zealand, which sought to identify the qualities that adolescents at a children's hospital expect in their clinicians. You can see it's all about attitude. Not the adolescents, mind you, but the providers. How different are these qualities that adolescents are after for what you would want in your own doctor? My guess is that they are very similar. But I think that many adults are surprised to hear that young people, aged 13, 14, 15, 16 years old, have the same expectations as they do. As we can see, adolescents expect their doctors and other clinicians to provide confidential care, which is what we'll talk about now. Many young people fear that health workers will not maintain confidentiality and will provide information to parents and other family members. In many parts of the world these fears are well founded, as there is widespread lack of training about the importance of confidentiality for adolescence, and cultural views that do not support this element of care. However, it has been well studied that adolescents are more willing to communicate with and seek health care from physicians who assure them of confidentiality. Young people will avoid seeking healthcare for fear of being scolded or humiliated by hostile or judgemental providers. Even in the United States, one in five adolescents have forgone needed care because of confidentiality concerns. Adolescents with sensitive issues are certainly less likely to return to a clinician if their parents are told about their visit. Adolescents can be highly sensitive about being even seen attending health services, particularly for highly stigmatised conditions. While the stigma around HIV/AIDS may seem obvious, young people are also highly embarrassed and even ashamed about, for example, mental health conditions. And even obesity for some. Such emotions can function as a barrier to health care. Misinformation in the general community may further contribute to stigma. For example, widespread community attitudes that HIV positive status implies that a young woman must be a sex worker, is obviously a barrier to acceptability of attending a service for treatment, and reluctance to be seen taking medication publicly. While confidential healthcare is a legal requirement in many parts of the world, without additional strategies to change community attitudes, the level of access and acceptance of services may not improve. Each country has specific laws that clinicians must function within to provide healthcare to legal minors. I'm based in Australia, where our legal system was historically dependent on British legal statutes. Thus in Australia we use the mature minor, or Gillick principle as described by British taut law. This outlines that our minor is capable of giving informed consent when he or she achieves a sufficient understanding and intelligence to enable him or her to understand fully what is proposed. From Kessler in Australia, there is no age specificity about the mature minor principle, as I mentioned in an earlier lecture. However, the law generally assumes that a young person is likely to be a mature minor at 16 years of age, and is commonly a mature minor at 14. In Australia, what this means in practice is that a doctor can legally provide healthcare to adolescence of any age, for any health issue, not just sexual reproductive health services, as long as the health professional considers them to be a mature minor. Do you know the legal context of providing health care to adolescents in your country? You may want to find out. For a doctor or other health professional to consider a young person to be a mature minor, they must assess the patient's cognitive and emotional understanding of their clinical situation, their capacity to weigh up options and their consequences. The young person's ability to express their own wishes and their capacity to make decisions in other areas of their life. What this means in practice is that in Australia, doctors and other health professionals are able to prescribe contraception to legal minors if young people tell us that they're sexually active, that they wish to use a more reliable form of contraception, can understand what is required to have a long acting form of contraception in place, and can appreciate the need for various other health checks. An interesting challenge about the knowledge we now have of the timing of adolescent neuro-cognitive maturation, is whether knowledge about the length of time taken for the adolescent brain to fully mature might be explicitly used as a rationale as to why young people shouldn't be able to access health care that is currently legally available to them and in their best interests. This paper by Sarah Johnson on colleagues nicely articulates a number of these concerns, and I commend it to you. It's also important to appreciate that there are clear exceptions to confidential healthcare for adolescents, just like there are for adults. Again in Australia, and you may want to clarify in your own country, these are articulated around the four themes I've outlined here. When the young person consents to disclosing to others, such as their parent, when the young person is at risk for severe harm, such as if they are at risk of suicide. When there is a legal requirement for disclosure, such as in the case of a notifiable disease, and when it is necessary for the young person's well being, for example if it's an extreme emergency. I hope you can appreciate that the reason I've used Australian examples so heavily here, is that the legal context of healthcare delivery varies significantly country by country. All clinicians need a close knowledge of the law. However, it is also important to appreciate, as one lawyer reminded me recently, that medical practice is always ahead of the law. By this she meant that laws change following changes to community attitudes and changes to clinical practices. A commonly taught framework for undertaking a comprehensive assessment of the adolescent patient is the schema I've outlined here known as HEADSS. Many clinicians have found that asking a series of questions about home, education, activities, drugs and alcohol, sexuality, and around mental health concerns, is an excellent strategy to engage with young people clinically, to explore this stage of adolescent development, to identify health related behaviours as well as strengthen some protective factors. This information can also be used to help formulate an intervention for the problem that the young person has presented, if you like, to individualise it, to help it make sense to the young person's life. Whether for that problem or as well when delivering anticipatory guidance. After taking a psychosocial history, is also a time to be summarising back to the young person what you think is going well in their life, and what areas might be challenging for them, that require greater engagement with health services, potentially also with their parents. Outlined here are some of the basic questions within a comprehensive psycho-social assessment, such as using a HEADSS assessment. You can see I've used the expanded framework here. There's an extra e and a couple of extra s's that many people use within the basic framework. And for those of you wishing more detail, I would urge you to read the Goldenring and Rosen paper about how to frame such questions that are respectful to young people and more engaging for them. Clearly, a comprehensive assessment like this takes time. Most people would try and undertake a basic assessment within about 20 minutes. Some clinicians avoid this approach, thinking that they don't have the time. All I can say is that the more experienced that I've become as a clinician, the more universally I try and apply this approach, knowing that I miss important health information when I don't. But how do busy clinicians and busy health services find time for these types of approaches? This is a challenging question for health services across the world. And one which needs significant advocacy within health services to achieve the time required to deliver comprehensive healthcare. And finally, a word about adolescent clinical examinations. After taking a psycho-social assessment, integrating this within the reason that the young person has presented to health care for, it's also important to explain to adolescents as you proceed what you wish to examine and why. And to offer an explanation and reassurance about normal findings as you go along. Many male clinicians feel more comfortable having a female chaperone while examining female adolescents. Interestingly, the examination can be a time when, in the absence of direct eye contact and having established some trust, a number of young people feel more comfortable asking questions of the clinician. But regardless of the presenting complaint and the required examination for that, the clinical examination offers an important opportunity to also measure vital signs, such as blood pressure and pulse, height and weight, and ensure that these and the body mass index are plotted on a growth chart. The examination also provides an opportunity to access pubertal development. Clinical examination can also identify evidence of emotional distress, such as scars from self harm that were not shared during the initial consultation due to embarrassment and shame. Just as it is important to provide feedback to young people following a psycho-social assessment, so too is it important to feedback the results of the examination in order to reassure young people that their physical development is on track, or if it's not.
