1

Referred Adolescent
or walk-
walk-in

When? Screening Form Clinical

1SKR I & II Presentations

Assessment

• Preferably during
psychosocial Yes 2Problems No

history with ALL

adolescent. HEADSS Health
Promotion

Yes

• If NOT possible;
3URGENT

selected / No

Refer
screened Counseling

adolescent & with

appointment. Appointment
Date
2
Unit 1 : Overview of Adolescent Problems &
Services

Unit 2 : Understanding The Teenager

Unit 3 : “CRET”
- Communication Skill / Confidentiality
- Rapport, Empathy and Trust

Unit 4 : Using HEADSS

Unit 5 : Face Your Fears 3

60

40
%
15-17 years
20 18-19 years
20-24 years
0

AIHW, 1999

4
80

60 Marijuana

40 Tobacco
%
20 Alcohol

0
Year 7 Year 9 Year 11

Adolescent Health and Wellbeing Survey, 2000

5
• Nor Afiah et al. (2006) conducted a cross-
sectional study of 136 Form 6 students.
• The prevalence of smoking was 22.8%
whereas the prevalence of alcohol intake was
47.8%.
• There were significant associations between
smoking and males and smoking and alcohol
intake

6
 Alcohol dependence

Road Traffic Accidents

Depression

Bipolar affective disorder Females

Suicide and self harm Males
Social phobia

Schizophrenia

Borderline Personality Disorders

Eating Disorders

0 5 10 15
DALYs (‘000)
7
 Parental views of
adolescent health issues
100

80

National problem

60
Local problem
%
Friends need help
40

Own teenager

20

0
Substance Sexuality Mental health Fisher Pediatrics 1992
8
abuse
25

55

20

9
• Healthy adolescent development
• Medico legal and ethical perspectives
• Engaging the young person
– Taking a psychosocial history (HEADSS)
– Confidentiality
• Promoting self-management in chronic illness
• Transition to adult health care
• Communicating with other professionals
10
• Physical
• Cognitive
• Psychosocial

11
12
13
• Greater capacity for abstract thinking
– Formal operational thought (Piaget)
• Greater capacity for comparison
• The main focus for young people is the ‘here and now’

Investing in one’s health is about future gains. 14

 Separate from ones parents
 Coherent sense of oneself
 Come to terms with ones
physical self
 Come to terms with ones
sexual self
 Provide for oneself financially

15
• Ongoing • Influenced by the environment
• Uneven • Mediated by relationships
• Complex • Triggered by participation

16
• Early (10 – 14) Biological focus
Am I normal?
• Middle (15 – 17) Peer focus
Who am I?
Where do I belong?
• Late (18 – 19) Educational & vocational
focus, intimate relationships
Where am I going?

17
• 12-17 year old adolescents
• 81 focus groups

• 1 in 3 females & 2 in 3 of males said they would not

seek help for their health concerns
• Many defined health solely in terms of physical well
being
• If they did seek help, most went to family, friends
and trusted others
18
• What if professional help is needed?
– Tendency to seek someone who they knew and
trusted
– Health professionals viewed as credible sources of
help

Booth et al, J Adol Health 2004

19
• Most important qualities in health professionals
– honesty
– confidentiality
– good listening skills
– good medical knowledge
• Fewer young people report presence of these
qualities in their health professional compared with
their parents

20
• 1 in 4 young people do not trust health professionals
to keep their information confidential
• 1 in 5 reported with-holding information because of
fear their parents would find out
• Young people and their parents would like to discuss
more topics (eg mental health issues) with their
health care provider
• Limited planning with respect to transition to adult
health services
Farrant. J Paeds & Child Health 2003

21
 Seeking help

Young people are more likely to seek help

if they know that they can trust that
helper to take their concerns seriously,
not to talk about them, not to act
prematurely, and to actively involve them
in decision making.
Keys Young (1997) Research and consultation
among young people on mental health issues

22
The ‘Five Cs’ & The ‘D’
Confidentiality Developmental
stage
Communication
Compassion
Convenience
Cost
23
• Legal requirement to maintain confidentiality when
requested by a mature minor who is assessed as
competent.
• All information should be regarded as confidential
until discussion and negotiation have taken place
• A clear statement at the beginning of contact with
an adolescent that explains confidentiality policy
with exceptions is important

24
• The duty of
confidentiality does not
preclude encouraging
and empowering young
people to talk to
parents about
important issues - this
may be the goal of
future consultations

25
• Balancing the rights of the young person to
confidentiality and the need for safety and meeting
obligations to parents and the law
• How much confidentiality can you promise?
• 3 exceptions – If I believe that you
– are at risk of physical or sexual abuse
– are going to seriously harm yourself
– are going to seriously harm others

26
• Young people find it
embarrassing and
uncomfortable
disclosing sensitive
information

27
Identify | Fear | Expectatio
xpectation
n

28
29
30
Wrong conclusion

31
32
Pecah di Perut

33
34
……NEEDS KNOWLEDGE
35
• Young people worry that
they would not be
understood, or taken
seriously, or may be judged
– Recognition that the young
person is the patient, and not
their parents
– Important to listen to their
concerns

• Needs to be reflected in
service
– eg youth friendly reception
area and staff

36
• Flexible hours
• Accessible location
• Waiting times

37
38
• Communication skills
• Empowering young people
• Helping parents

39
40
• See the young person on their own
• Explain confidentiality
• Explain your process
– who you are
– what you are doing
– why you are doing it

• HEADSS assessment

41
• Introduce yourself to the young person first
• Explain who you are and what you do
• Get them to introduce accompanying others
• Negotiate for some time alone
– See parents and young person together, then the young
person alone, then reconvene

42
• Compliment them on turning up
• Compliment them on an aspect of their person
– appearance, clothing, hair
• Find out what is important in their lives
• Let them teach you something
– “Tell me what parties are like for young people
nowadays”

43
• Don’t use medical
jargon
• Try not to speak in their
language
• Appear unhurried even
if time is limited
• Be open, honest and
flexible

44
• “You don’t know until you ask!”
• Adolescents are less likely to volunteer
information unless directly asked
– fear of being “found out”
– fear of being judged and told off
– lack of understanding of confidentiality issues

45
• To engage the adolescent
• finding out what is important to them
• To identify individual risk factors
• mortality & morbidity data
• co-occurrence of risks
• contribution to adult burden of disease

46
• To identify key socialising influences
• To identify factors that may promote resiliency
• To be able to effect an individual pathway for early
intervention
• Anticipatory guidance
• Health promotion

47
Risk and protective factors

100
80
alcohol
60
%40 cigarettes
marijuana
20
other drugs
0
0-1 2-3 4-6 7-9 >=10
Risk factors

48
Family

49
Peers

Family

50
School

Peers

Family

51
Community

School

Peers

Family

52
 Protective factors

100
80 alcohol
60 cigarettes
%
40 marijuana
20
0
0-1 2-3 4-6 7-10
Protective factors
53
• High risk adolescents
• injuries, alcohol intoxication, drug use and
overdoses
• Chronically ill adolescents
• pubertal delay, growth delay
• lower emotional well being
• poor psychosocial outcomes
• Role of teaching hospital
• increased focus on preventive health
• setting benchmark for care and practice
• teaching and training
54
• Barriers to screening (health professionals)
– Time
– Financial disincentives
– Perceived lack of expertise in dealing with adolescent
health issues
– Perceived lack of expertise in intervention strategies
– Lack of ancillary resources

Veit, MJA 1995, 1996; Blum, J Adol Health Care 1990

55
• By all health professionals
• Needs to be done opportunistically
• Taking a psychosocial history
– using HEADSS framework
• Studies have shown that this is not done well
– time-consuming, embarrassing, not knowing what
to do with the information

56
 RCH: General Screening in inpatient
adolescents

Total Adolescent Medical Surgical

(n=100) (n=20) (n=40) (n=40)
% % % %
Height 17 45* 20* 0*

Weight 98 100 95 100

Pubertal 12 45* 8* 0*
Stage

Hepatitis 9 5 5 15
B
*p<0.005
57
RCH: Psychosocial Screening in inpatient
adolescents

Total Adolescent Medical Surgical

(n=100) (n=20) % (n=40) % (n=40) %
%
None 62 20 65 40

Inadequate 29 35 35 20

Thorough 3 35 0 0

Complete 7 45 0 0

58
59
60
61
62
63
• Active listening
– this allows the young person to explore their thoughts
and why they think that way

• Minimal verbal and non-verbal encouragement

• Probing questions
• Clarification
• Reflection
• Multiple choice question
64
• Home
• Education/Employment (Eating/ Exercise)
• Activities and Peer Relations
• Drugs/cigarettes/alcohol
• Sexuality
• Suicide/depression/ (Safety/ Spirituality)

Goldenring and Cohen

Contemporary Paediatrics 1988

65
• Where do you live?
• Who lives with you?
• How do you get along with
each member?
• Who could you go to if you
needed help with a
problem?
• Have there been any recent
changes?
• What things do you enjoy
doing together with your
family?

66
• What do you like about school?
• How much school have you
missed in the last 3 months?
• What are you good/not good at?
• How do you get along with
teachers and other students
• Have your grades changed
recently?
• Many young people experience
bullying at school. Have you ever
had to put up with this?
• What are your future plans? 67
• What sort of things do you do in your
spare time out of school?
• What do you like to do for fun?
• Tell me about parties
• Do you belong to any clubs or groups?
• What sort of things do you like to do with
friends?
• How much TV do you watch each night?
How much time do you spend on the
computer?

68
• Many young people at your age are starting to
experiment with cigarettes or alcohol
• Have any of your friends tried these or maybe
other drugs like marijuana, IV drugs or ecstasy?
• How about you, have you tried any?
• What effects do drug-taking, smoking or alcohol
have on them/you?
• Do they/you have any regrets about taking
drugs?
• How much are they/ you taking and how often,
and has use increased recently?
69
• Some young people are getting
involved in sexual relationships,
have you had a sexual
experience with a guy or girl or
both?
• Has anyone touched you in a
way that has made you feel
uncomfortable or forced you
into a sexual relationships?
• How do you feel about
relationships in general and
about your own sexuality?
70
• How do you feel in yourself
at the moment on a scale of
1 to 10?
• What sort of things do you
do if you are feeling
sad/angry/hurt?
• Is there anyone you can talk
to ?
• Do you feel this way often?

71
• Some people who feel really
down often feel like hurting
themselves or even killing
themselves, have you ever felt
this way?
• Have you ever tried to hurt
yourself?
• What prevented you from doing
so?
• Do you feel the same now?
• Have you a plan?
72
• Reduce the focus on the person
– “ Some young people have tried smoking…”
• Give them a choice of answers
– “ It seems to me that you are feeling frustrated or
do you feel angry?”
– “ Have you tried other drugs such as speed,
ecstasy, or cocaine…”

73
• Suggest an explanation and invite them to
agree or disagree
– “You may disagree with this but it seems to me
that you feel upset with your parents for …..”
• Scaling
– “Give school a mark of 10 .. If 10 is great and 1 is
terrible, how would you rate school?”

74
• Give them developmentally appropriate
information
• Dispel any myths
• Use their interests to help motivate
• Getting them to make the decision

75
• The physical examination
– sensitive
– privacy
– privacy
– comment and reassure
• Ask them if they have any questions about their bodies
– Assess pubertal stage, height ,weight BMI
• Tanner charts - self assessment

76
Boys 2 – 18 Date of Birth:____________ Girls 2 – 18 Date of Birth:____________
• Provide feedback
– Impressions of their presentation
– Comment and compliment on areas that are
going well
– Highlight areas that need further work
• Outline and negotiate management plan
• Liaise with other health providers/ school/ youth
agencies if required
– Permission if need to talk to others
– Rehearse what to say
81
• Sensitive method if referral is needed
• Provide hope

82
Thank You

83