Adolescence on the health agenda

The importance of adolescent health and the reasons why it should be included in the health agenda are discussed and the distinction between physical event of transfer from a pediatric to an adult setting and the process of transition is appreciated.

Abstract

Adolescence is on the health agenda. Government policy statements, university and community-based programmes, hospital departments, societies for adolescent health with policy documents, and well-thumbed specialist journals bear witness to the fact. Yet some physicians still ask why adolescent health is on the agenda or whether there will be sufficient new information to keep it there in the 21st century. Adolescence refers to the developmental period between childhood and adulthood, a time of rapid biological, cognitive, and psychosocial maturation. Ingersoll1Ingersoll GM Adolescence.2nd ed. Prentice-Hall, Englewood Cliffs, NJ1989Google Scholar defines adolescence as "a period of personal development during which a young person must establish a personal sense of individual identity and feelings of self-worth which include an alteration of his or her body image, adaptation to more mature intellectual abilities, adjustments to society's demands for behavioural maturity, internalizing a personal value system, and preparing for adult roles". Depending on the culture and the context, adolescents are commonly known as "teenagers", "young people", or "youth", and the age range varies, 10-24 years being the widest definition in common use.2World Health Organization The health of young people. WHO, Geneva1993Google Scholar In developed countries, adolescents comprise about 15% of the population. The sharp fall in infant mortality in the developing world over the past few decades has seen a substantial increase in adolescents, who are now estimated to make up 30% of the world's population3Blum RW Ziangdong M International profile.in: Textbook of adolescent medicine. Saunders, Philadelphia1992: 28-33Google Scholar In medical circles, the perspective on adolescents and their health is as likely to depend as much on the position of the viewer as on the reality of adolescent health issues. A simplistic view–that adolescence is either the end of childhood or the start of adult life–reinforces the notion of adolescence as the healthiest period. Indeed, health definitions that focus on physical wellbeing support this belief since mortality and morbidity rates are low in comparison with those for other groups.4Schabas R Opportunities for health. Ministry of Health, Toronto, Canada1992Google Scholar, 5US Office of Technology Assessment Adolescent health. US Office of Technology Assessment, Washington, DC1991Google Scholar The different views that can be held by a paediatrician or by an adult physician might suggest the potential for professional tensions around adolescent health but it is more likely that the dichotomy, that adolescence is either an endpoint or a starting-point, renders this developmental period invisible from either medical perspective. 31% of US children and adolescents have a chronic health problem, with 6·5% experiencing some disability, most commonly due to mental health and respiratory disorders.6Newacheck PW Halfon N Prevalence and impact of disabling chronic conditions in childhood.Am J Publ Health. 1998; 88: 610-617Crossref PubMed Scopus (316) Google Scholar, 7Newacheck PW Taylor WR Childhood chronic illness: prevalence, severity, and impact.Am J Publ Health. 1992; 82: 364-371Crossref PubMed Scopus (542) Google Scholar The survival of children with conditions that had previously been fatal is a success story of paediatrics, but many of these successes carry the burden of severe, prolonged disability which significantly affects the young person's social life, mental health, educational achievement, and future employment.8Pless IB Cripps HA Davies JMC Wadsworth MEJ Chronic physical illness in childhood: psychological and social effects in adolescence and adult life.Devel Med Child Neurol. 1989; 31: 746-755Crossref PubMed Scopus (79) Google Scholar, 9Pless IB Nolan TN Revision, replication and neglect: research on maladjustment in chronic illness.J Child Psychol Psychiatry. 1991; 32: 347-365Crossref PubMed Scopus (85) Google Scholar, 10Lavigne JV Faier-Routman J Psychological adjustment to pediatric physical disorders: a meta-analytic review.J Pediatr Psychol. 1992; 17: 133-157Crossref PubMed Scopus (455) Google Scholar The burden of such chronic illness on families is significant, whether measured financially or emotionally, though the ability of families to have both positive and negative impacts on the way an adolescent copes with his or her condition is well documented too.11Wolman C Resnick MD Harris LJ Blum RW Emotional well-being among adolescents with and without chronic conditions.J Adolesc Health. 1994; 15: 199-204Summary Full Text PDF PubMed Scopus (163) Google Scholar, 12Jessor R Successful adolescent development among youth in high risk settings.Am Psychol. 1993; 48: 117-126Crossref PubMed Scopus (430) Google Scholar, 13Krohne HW Parental child rearing and anxiety development.in: Hurrelman K Losel F Health hazards in adolescence. Walter de Gruyter, New York1990: 115-130Google Scholar, 14Grotevant HD Cooper CR Patterns of interaction in family relationships and the development of identity exploration in adolescence.Child Devel. 1985; 56: 415-428Crossref PubMed Google Scholar There is now consensus that young adults should receive health care in adult-oriented settings.15Blum RW Garrell D Hodgman CH et al.Society for Adolescent Medicine position paper: transition from child centered to adult health care systems for adolescents with chronic conditions.J Adolesc Health. 1993; 14: 570-576Summary Full Text PDF PubMed Scopus (1019) Google Scholar, 16Sawyer SM Blair S Bowes G Chronic illness in adolescents—transfer or transition to adult services?.J Paediatr Child Health. 1997; 33: 88-90Crossref PubMed Scopus (121) Google Scholar For those with chronic health problems, this transition to adult health care is defined as "the purposeful, planned movement of adolescents and young adults with chronic physical and medical conditions from child-centred to adult-oriented health care systems".15Blum RW Garrell D Hodgman CH et al.Society for Adolescent Medicine position paper: transition from child centered to adult health care systems for adolescents with chronic conditions.J Adolesc Health. 1993; 14: 570-576Summary Full Text PDF PubMed Scopus (1019) Google Scholar Three key concepts underpin this transition. The first is the need to understand that the cultures of child health and adult medicine providers are different, and that practices thought appropriate in one setting may not be valued in the other.17Rosen D Between two worlds: bridging the cultures of child health and adult medicine.J Adolesc Health. 1995; 17: 10-16Summary Full Text PDF PubMed Scopus (141) Google Scholar The second is to appreciate the distinction between the physical event of transfer from a paediatric to an adult setting and the process of that transition.16Sawyer SM Blair S Bowes G Chronic illness in adolescents—transfer or transition to adult services?.J Paediatr Child Health. 1997; 33: 88-90Crossref PubMed Scopus (121) Google Scholar This means that careful and well-timed preparation will promote the move from one setting to another. The third is to recognise that normal adolescent development (characterised by inconsistent behaviour, a sense of invulnerability, experimentation, and the poor influence of future health outcomes on current behaviours) can be at odds with the appropriate expectations of parents, doctors and nurses that a young person will increasingly be responsible for his or her own health care. There can be no single ideal model for this transition of care, and the approach that works well in one setting may not do in another. A disease-specific model based on multidisciplinary, subspeciality care is one where the young person moves with age from a subspecialty paediatric service (eg, cystic fibrosis and congenital heart disease) to a general medicine adult service, perhaps via an interim service for young adults located within either the paediatric or the adult setting. In contrast, a primary-care model is where a general practitioner coordinates the provision of medical care and provides continuity in the face of changing specialty providers from the paediatric and the adult systems. An example of this would be spina bifida, where a family practitioner can provide a continuum of care with referral to paediatric and adult specialists as appropriate (eg, urology and podiatry). Barriers to the timely transfer of young people to the adult health care system include resistance from the patient and his or her parents, who do not wish to change arrangements they are happy with; obstruction from paediatricians and adult physicians who, respectively, do not wish to part with and take on the patient; and organisational problems. The lack of health professionals with special training in the needs of adolescents remains a significant limitation to health-care access for many young people.19Sawyer SM Collins N Bryan D Brown D Hope MA Bowes G Young people with spina bifida: transfer from paediatric to adult health care.J Paediatr Child Health. 1998; 34: 414-417Crossref PubMed Scopus (58) Google Scholar Except perhaps for psychiatric illness, young people. presenting with acute conditions (eg, appendicitis, fracture) pose few problems in obtaining immediate health care. There is, however, little guarantee that other common and important youth health issues (eg, nicotine addiction, alcohol dependence, or eating disorders) will be even identified let alone managed.20Blum RW Beuhring T Wunderlich M Resnick M Don't ask, they won't tell: the quality of adolescent health screening in five practice settings.Am J Publ Health. 1996; 86: 1767-1772Crossref PubMed Scopus (100) Google Scholar This sanguine view of adolescent health contrasts starkly with concerns in the community about the health and wellbeing of young people, concerns that focus on drug use, unemployment, suicide, depression or self-harm, sexually transmitted disease, and social disconnectedness. This paradox-the relative clinical invisibility of young people despite a high level of social concern-may be explained by the different definitions of "health" that can be used. Raphael21Raphael D Determinants of health in North-American adolescents: evolving definitions, recent findings and proposed research agenda.J Adolesc Health. 1996; 19: 6-16Summary Full Text PDF PubMed Scopus (62) Google Scholar has identified definitions of adolescent health that include both clinical and social science perspectives: low mortality and morbidity apart, a healthy lifestyle and the avoidance of health-risk behaviours are part of the definition as is the social-science perspective that sees healthy adolescence as the successful transition from childhood to adulthood. In many communities young people are more likely to die from injuries than from all other causes combined. In Canada in 1994, there were 56 deaths from leukaemia, 37 from cerebral palsy, 26 from muscular dystropy, 23 from cystic fibrosis, and 20 from HIV infection-but 1233 deaths as a result of injury.22Pless IB Childhood injury prevention: time for tougher measures.Can Med Assoc J. 1996; 155: 1429-1431Google Scholar In the USA in 1995 nearly three-quarters of deaths within the age range 10-24 years were attributed to injuries from just four causes (motor vehicle accidents 30%, homicide 20%, suicide 13%, other unintentional injuries 10%).23Anderson N Kochanek KD Murphy SL Report of final mortality statistics, 1995.in: Mon Vital Stat Rep no 45. National Center for Health Statistics, Hyattsville, MD1997Google Scholar In contrast with most medical conditions of childhood and adolescence injuries are usually preventable.24Bergman FP Grossman DC Prevention of traumatic deaths to children in the United States: how far have we come and where do we need to go?.Pediatrics. 1996; 97: 791-797PubMed Google Scholar In the past two decades, adolescent mental health has become a major public health focus. Depression is the most commonly reported mental health condition in adolescents and it is the largest single risk factor for suicide and suicidal behaviour.25Shaffer D Gould MS Fisher P et al.Psychiatric diagnosis in child and adolescent suicide.Arch Gen Psychiatry. 1996; 53: 339-348Crossref PubMed Scopus (1037) Google Scholar, 26Patton GC Harris R Carlin JB Hibbert ME Coffey C Schwartz M Bowes G Adolescent suicidal behaviours: a population-based study of risk.Psychol Med. 1997; 27: 715-724Crossref PubMed Scopus (173) Google Scholar 1540% of young people report some features of depression.27National Health and Medical Research Council Depression in young people: clinical practice guidelines. Australian Government Publishing Service, Canberra1997Google Scholar Not all meet diagnostic criteria for depression but they are at greater risk of major depression, poor socialisation, self-harming behaviours, substance abuse, eating disorders, reduced educational achievement, and unemployment.28Patton GC Hibbert M Rosier MJ Carlin JB Caust J Bowes G Is smoking associated with depression and anxiety in teenagers?.Am J Publ Health. 1996; 86: 225-230Crossref PubMed Scopus (271) Google Scholar, 29Patton GC Selzer R Coffey C Carlin JB Wolfe R Onset of adolescent eating disorders: population based cohort study over 3 years.BMJ. 1999; 318: 765-768Crossref PubMed Scopus (512) Google Scholar, 30Zubrick SR Sirburn SR Gurrin L et al.Western Australian Child Health Survey: education, health and competence. Australian Bureau of Statistics and TVW Telethon Institute for Child Health Research, Perth, WA1997Google Scholar Over the past 30 years, there has been a 3-fold increase in the suicide rate of young Australian males and a two-fold increase in the rate for females aged 15-24, and in 1995 25% of all deaths in young men were suicides.31Harrison J Moller J Bordeaux S Youth suicide and self-injury in Australia. Australian Institute of Health and Welfare, Canberra1997Google Scholar Health risk behaviours can have significant implications during adolescence; examples here are sexually transmitted diseases and unplanned pregnancies resulting from unsafe sex. Mental ill-health during adolescence can also affect health outcomes, including progression from occasional to regular smoking and from dieting to eating disorders.28Patton GC Hibbert M Rosier MJ Carlin JB Caust J Bowes G Is smoking associated with depression and anxiety in teenagers?.Am J Publ Health. 1996; 86: 225-230Crossref PubMed Scopus (271) Google Scholar, 29Patton GC Selzer R Coffey C Carlin JB Wolfe R Onset of adolescent eating disorders: population based cohort study over 3 years.BMJ. 1999; 318: 765-768Crossref PubMed Scopus (512) Google Scholar The contribution of adolescent health-risk behaviour to the adult burden of disease is, therefore, significant. Health-risk behaviours in adolescents do not occur in isolation but tend to cluster.28Patton GC Hibbert M Rosier MJ Carlin JB Caust J Bowes G Is smoking associated with depression and anxiety in teenagers?.Am J Publ Health. 1996; 86: 225-230Crossref PubMed Scopus (271) Google Scholar, 29Patton GC Selzer R Coffey C Carlin JB Wolfe R Onset of adolescent eating disorders: population based cohort study over 3 years.BMJ. 1999; 318: 765-768Crossref PubMed Scopus (512) Google Scholar, 32Donovan JE Jessor R Structure of problem behaviour in adolescence and young adulthood.J Consul Clin Psychol. 1985; 53: 890-904Crossref PubMed Scopus (1018) Google Scholar, 33Neumark-Sztainer D Story M Dixon LB et al.Patterns of health compromising behaviours among Minnesota adolescents: sociodemographic variations.Am J Publ Health. 1996; 86: 1599-1606Crossref PubMed Scopus (86) Google Scholar, 34Korhn M Lizotte A Perez C The interrelationship between substance abuse and precocious transitions to adult statuses.J Health Soc Behav. 1997; 38: 87-103Crossref PubMed Scopus (185) Google Scholar Understanding these patterns should provide insight into causation and promote opportunities for primary prevention and early intervention strategies. Why is it that some young people cope better than others despite harsh backgrounds while other socially advantaged young people sustain significant morbidity from their behaviours? The notions of vulnerability and resilience35Rutter M Resilience: some conceptual considerations.J Adolesc Health. 1993; 14: 626-631Summary Full Text PDF PubMed Scopus (534) Google Scholar, 36Losel F Bleisener T Resilience in adolescence: a study on the generalizability of protective factors.in: Hurrelman K Losel F Health hazards in adolescence. Walter de Gruyter, New York1990: 299-320Google Scholar, 37Luthar S Ziglar E Vulnerability and competence: a review of research on resilience in childhood.Am J Orthopsychiatr. 1991; 6: 6-22Crossref Scopus (562) Google Scholar have broadened the field of study beyond risk factors to increasingly include protective factors. For example, parent-family connectedness and perceived school connectedness have been shown to be powerful protective factorP even for those with multiple risk factors.39Borowsky IW Resnick MD Ireland M Blum RW Suicide attempts among American Indian and Alaska Native youth: risk and protective factors.Arch Pediatr Adolesc Med. 1999; 153: 573-580Crossref PubMed Google Scholar No longer can adolescence be viewed as a time of optimal health and wellbeing. However, to date, much of the response and the advocacy has come from the margins of health and welfare rather than mainstream medicine. It is as if the reframing of many of the issues as "social" has allowed the health professional to avoid dealing with them. Medicine may thus have surrendered many health issues to the youth or education sectors without appreciating that these sectors cannot deal with them alone. While medicine has responded reactively to the youth crisis of the moment, be it HIV or suicide, we have failed to build partnerships with these other sectors, and this has limited our capacity to achieve sustained responses. Nevertheless, a framework has emerged for best practice in clinical settings with young people (panel 1). Clinicians specialising in adolescent health–mostly in student health, sexual health, or mental health settings–recognise that an understanding of adolescent development and a set of special skills are central to working with patients of this age regardless of the presenting complaint. The skills include an approach to confidentiality (panel 2); seeing the young person alone for at least part of the consultation; and taking a psychosocial history to gain an understanding of health risk and protective factors (panel 3). These clinicians recognise the importance of nurturing the young person's growing sense of independence and they understand connectedness to family, peers, and community are central to better health and wellbeing and that this demands collaboration with other types of professional who work with young people within the education, youth, welfare, or juvenile justice sectors.Panel 1Framework for working with young peopleBe empathic, respectful, and nonjudgmental.Understand confidentiality and consent requirements.Understand adolescent development.Recognise the importance of privacy.Be vigilant with boundaries.Provide a safe environment.Understand the linkage between physical and emotional well being.Understand that family, school and peers are key agents of socialisation.Have good communication skills.Provide adolescent accessible services.Panel 2ConfidentialityHighlight your approach to confidentiality with both young person and parent at start of consultation.See young person alone for at least part of consultation.Treat all information obtained from young person as confidential until you have clarified it with them (this can be challenging)In many countries, confidentiality is a legal requirement over 16 years of age. Negotiation or compromise may be required for younger adolescents and will vary accoring to their cognitive maturity, their personal and social situation, and the particular issue.Exceptions to confidentiality for medical professionals are if the young person is at risk of significant harm, such as suicide, or if they are subject to physical or sexual abuse.Panel 3HEADSS framework for talking a physiosocial history Tabled 1TopicExamplesH (Home)Where do you live? Who do you live with?E (Education)Are you at school? What year are you in? What is your favourite subject?A (Activities)What do you do for fun? What do you do with your friends?D (Drugs)Some young people experiment with cigarettes and alcohol. In your year at school, do people smoke/drink/use illicit drugs? What about your friends? And you?S (Sexuality)Most young people become more interested in closer relationships at your age. Do you have a close friend? Have you ever been sexually active?S (Depression and suicide)Many young people feel down or sad at times. When did you last feel like this? Have you ever felt that life is not worth living?Source: Goldenring JM, Cohen E. Getting into adolescent heads. Contemp Pediatr 1988 (July: 75-90). Open table in a new tab Be empathic, respectful, and nonjudgmental. Understand confidentiality and consent requirements. Understand adolescent development. Recognise the importance of privacy. Be vigilant with boundaries. Provide a safe environment. Understand the linkage between physical and emotional well being. Understand that family, school and peers are key agents of socialisation. Have good communication skills. Provide adolescent accessible services. Highlight your approach to confidentiality with both young person and parent at start of consultation. See young person alone for at least part of consultation. Treat all information obtained from young person as confidential until you have clarified it with them (this can be challenging) In many countries, confidentiality is a legal requirement over 16 years of age. Negotiation or compromise may be required for younger adolescents and will vary accoring to their cognitive maturity, their personal and social situation, and the particular issue. Exceptions to confidentiality for medical professionals are if the young person is at risk of significant harm, such as suicide, or if they are subject to physical or sexual abuse. Tabled 1TopicExamplesH (Home)Where do you live? Who do you live with?E (Education)Are you at school? What year are you in? What is your favourite subject?A (Activities)What do you do for fun? What do you do with your friends?D (Drugs)Some young people experiment with cigarettes and alcohol. In your year at school, do people smoke/drink/use illicit drugs? What about your friends? And you?S (Sexuality)Most young people become more interested in closer relationships at your age. Do you have a close friend? Have you ever been sexually active?S (Depression and suicide)Many young people feel down or sad at times. When did you last feel like this? Have you ever felt that life is not worth living?Source: Goldenring JM, Cohen E. Getting into adolescent heads. Contemp Pediatr 1988 (July: 75-90). Open table in a new tab Source: Goldenring JM, Cohen E. Getting into adolescent heads. Contemp Pediatr 1988 (July: 75-90). Hampering acceptance of this clinical framework, which is the "heart and soul" of adolescent medicine, has been the lack of a research base. Over the past decade, however, research evidence has been accumulating. For example, the highest level of evidence (from a randomised trial40Ford CA Millstein SG Halpern-Felsher BL Irmin Jr, CE Influence of physician confidentiality assurances on adolescents' willingness to disclose information and seek future health care: a randomised controlled trial.JAMA. 1997; 278: 1029-1034Crossref PubMed Google Scholar) supports the value of a standardised approach to confidentiality with all young people. Reassuringly, there is also strong evidence that consulting with young people can be taught to established practitioners and to medical students and young doctors.41Sanci LA Coffey CM Veit FC Day N Bowes G Evaluation of a program in adolescent health care for family physicians designed according to evidence-based practice in continuing medical education: a randomised controlled trial.J Adolesc Health. 1999; 24: 81Google Scholar There is, however, little evidence to support other well accepted clinical approaches. The provision of hospital care within adolescent units rather than on general medical wards is an example. Young people have voted with their feet–they prefer these units–and the growth of them in countries such as Australia might suggest that there is supportive research evidence. Expert opinion (including that of young people) apart, there is no such evidence.42Viner R Keane M Evidence-based best practice for the care of young people in hospital. Caring for Children in the Health Services, London1998Google Scholar The lack of appropriate services for young adults with chronic illness and disabilities is painfully obvious to the patients, their parents, and their paediatricians but without an evidence base, health service development in this area is hard to justify to health funders. There are structural barriers too. Healthcare funding based on medical insurance impedes access to health for young people in many countries. However, increasing medical specialisation does not necessarily translate into improved health or developmental outcomes. The separation of medicine into disease-based "silos" of knowledge is of great benefit for disease-specific research and practice. However, best "disease" management will be most effectively delivered using clinical frameworks that feature the person rather than the disease. This means that appreciation of the breadth of adolescent health issues is required by multiple health practitioners, not only those within general practice, paediatric and adult medicine, obstetrics and gynaecology or psychiatry. A further consequence of medical specialisation is that a range of health concerns (such as the health of young people in trouble with the law) become invisible in the current disease paradigm. A major challenge for the specialty is promotion of research programmes to generate an evidence base to support (or refute) current practice and to evaluate different models of clinical care. How this evidence is applied will vary according to the clinical setting, medical culture, and health-funding system. In the USA, adolescent medicine, like paediatrics, is a primary care specialty, and community-based settings (school or youth clinic) tend to be based in referral hospitals, or academic settings. A key role for all these professionals is to ensure that the voice of youth health is heard above the clamouring demands of the medical curriculum. Collaboration with community providers from a range of sectors is central to achieving better health outcomes. The understanding that school connectedness has a direct influence on emotional well being and health suggests powerful opportunities for interventions that promote health. Programmes and interventions that promote a sense of attachment and belonging within the school environment are proving particularly exciting.43Glover S Burns J Butler H Patton G Family Matters. 1998; 49: 11-16Google Scholar, 44Felner R Felner T Primary prevention programs in the educational context: a transactional-ecological framework and analysis.in: Bond L Compas B Primary prevention and promotion in schools. Sage, California1989Google Scholar The problems of our young people will not go away. However, adolescence will only remain on the health agenda if we avoid a narrow, disease-based definition of health and acknowledge the breadth of developmental, social and economic influences on adolescent health and well being. The challenge for Adolescent Medicine is to develop an evidence base in support of its practice. How such evidence is disseminated to the spectrum of clinicians who see young people will depend on how well the range of structural barriers can be surmounted.