Bradford VTS Online Resources:
Clinical Knowledge
Adolescents, Teenagers & Young People's Health
DOWNLOADS
path: TEENS
AYPH – kee data on young people’s: health: https://ayph-youthhealthdata.org.uk/
WEBLINKS
- Children & Young People super-condensed curriculum – what you should know (RCGP)
- https://what0-18.nhs.uk– amazing website for patients and doctors –click professional area for great safety netting leaflets, wonderful clinical protocols at a glance.
- Establishing youth-friendly health and care services
We ignore Adolescent health
- If you would like to have a go at adding some “top tips” to this page for this specialty (and have your name displayed proudly with bradfordvts), please email me – rameshmehay@googlemail.com
Adolescent health is a mostly neglected area for two reasons.
- We/our practice/the health service don’t see them as high priority
- They don’t come to see us
YOUNG PEOPLE have constantly appeared to be at the bottom of the heap when it comes to their health and wellness . Did you know that it wasn’t until 1954 that there was any recognition of the possible role of general practice in adolescent health in the literature? What’s even worse is that it wasn’t until the 1980s that any kind of relevant research was published!
Even today, young people are misperceived. They’re thought to be a healthy and balanced population who seldom trouble the General Practitioner because they do not need to. We ask ourselves – “what can be perhaps wrong with them?”. But this is an enormous false impression. They require from us more than you can possibly know. Just from one perspective – mental in adolescents is so taken so lightly that it is mostly disregarded. And when they do pluck up the courage to come, we end up allocating them less time than with other age groups!
And in QoF – absolutely nothing seems to be concentrated on adolescent health. Once more, they’re seen as low priority. Financial motivations drive health practices to focus on things that can be measured and thus rewarded. Establishing a healthy and balanced connection with young people seems to have fallen to the bottom of the ladder.
Why are teenagers so reluctant to see us?
There seems to be 3 major reasons.
- They continually report troubles accessing the system – especially for delicate problems.
- They believe that they are not being taken seriously.
- Finally, they, feel that they cannot necessarily trust the system.
Why do we find teenagers difficult to consult with?
- Because they disengage with us and just sit there saying very little, even when we try hard to show we care
- Because they can often be argumentative or defensive or even offensive
- Because we find them hard work and we have to put a lot of energy in
- Because we see them as taking a lot of our time to consult with, especially when we have other patients
- Because adults, who we also see, are just simply so much easier.
Are remote consultations the answer?
Will remote consultations improve the access problem? Remote consultations will become part of the General Practice new norm. The assumption that tech-savvy teens will welcome virtual consulting is another misconception. Whilst they may enjoy sharing the most specific information of their lives with their followers on social networks, the majority of still wish to be able to see a health professional on a one-on-one face-to-face basis.
So what is the way forwards? Introducing HEADS SSS
So how should General Practice react to the needs of young people? How do we create that trusting connection with a young person early on in their life story? One way in is to use the HEADS SSS framework. S
- HOME – ask how home life is
- EDUCATION – ask how school is
- ACTIVITY – what sorts of hobbies and things they like doing
- DRUGS – a lot of people their age engage in drugs. Do they?
- SEX & SEXUALITY – their sex life, how they identify themselves
- SPIRITS – what are their moods like, any self harm, any suicidal ideation?
- SAFETY & SAFEGUARDING – any issues around being safe
- SLEEP & SCREENS – what time they sleep, do they get a good night’s rest? what is their screen time on digital devices like
The HEADS SSS framework is basically a bit like the clinical “REVIEW OF CLINICAL SYSTEMS” that a doctor does when they want an overall comprehensive overview that everything is medically okay. Except the HEADS SSS framework is about holistic coverage of their entire life rather than just the medical life.
What’s the purpose of the HEADS SSS framework?
- As a way to gently explore different areas of a young person’s life and hopefully make a connection with them somewhere (rapport building)
- As a way to discover unanticipated problems that may be separate or partly responsible for the presenting complaint (problem discovery)
- As a way to understand the complexities within a young person’s life (medico-social complexity)
- As a way to give the young person a voice and help them express themselves more fully (patient empowerment)
Any advice on how to carry out the HEADS SSS framework?
Good communication skills is the key. You can’t do a good HEADS SSS enquiry just be KNOWING the components. You need the communication skills to do each of the components in a conversational style that is most likely to enhance responses than close them off. Here are a few of the consultation skills that may help…
- If you’re a novice and the HEADS SSS framework is new to you, consider (in the beggining) going through it methodically in order. As you get more confident and competent, you can then do any of the items in any order – preferably in a way that fits naturally with the story they are telling.
- Be genuinely interested in what they say and respond with follow up questions that help the conversation naturally flow. This will help you build rapport and trust and if there is anything within an area that is worry/shameful/embarrasing, they are then more likely to disclose it.
For instance… “So whose at home > mum dad and my sister > oh okay. and how are things at home > okay i suppose > for some people family relationships can be up and down. what’s yours like? > yeah, up and down > and would you say more ups or more downs? > dunno. just the downs can be real bad > oh, i am sorry to hear that. it can be hard when downs are quite badly down. so how bad does it get? > well mum has depression. it’s not her fault. sometimes the drink just takes over and then she lashes out. > and when you mean she lashes out does that mean she becomes angry with her voice or does she become physical too? > sometimes it gets really bad > you mean physical? > yeah > she hits out at dad a lot and he ends up in bruises > oh dear im sorry to hear that. it’s not nice to see someone you love getting hurt like that. > but he is a good dad > yeah, he sounds like a good dad. is your mum ever physical with you or your sister? > only now and then, but mostly dad gets it > thanks for sharing that with me. it must have been hard to share that with me and you’ve been incredibly courageous. i admire that about you. ” - Please do not treat HEADS SSS as 8 quick questions to ask like a tick box type exercise like a lot of medical students and FY doctors do. Don’t just ask the question and move on to the next. As in point 2 – be genuinely interested in the story or otherwise you will NOT get a true reflection of what someone’s life is like. Be naturally curious about elements of their story. Explore those areas you are naturally curious about. Use repetition “he lashes out?” or paraphrase “he becomes physical with you?” If you’re a doctor or nurse – consider this – how would you feel if the trainee (student nurse/medical student) that you are supervising presents to you a history which is both innaccurate and missing gaps? Would their diagnosis and susequent management plan suffer? Of course they would. And the same goes for HEADS SSS – if you do it poorly, there is no point doing it. Because you get an inaccurate unreliable picture which makes you miss things in the medical social diagnosis of their problems. And some of those things will be at the heart of all their current problems. So we need to spend time building rapport and holistically enquiring the different areas of their lives to help give these young people a voice..
- Use encouraging phrases to get them to open up more. “Thanks for sharing that with me, it must have been difficult”. “You’ve been very brave in sharing that with me and I appreciate that”, “Please continue, you’re doing well.” Also, empathising statements can also help young people open up and talk more. “That sounds like a very difficult time”. “I’m sorry to hear that”. “Oh really, oh dear”. “Oh, gosh”. “I see what you mean”. “If I were in your position I would feel the same”. “That sounds like a lot of pressure on you”.
- Don’t be uncomfortable asking the questions. Of course, be sensitive but don’t show that you’re uncomfortable asking them. For example, with sex – say it how it is, like as if you’ve asked the question loads of times before and that it’s no big deal and that you wouldnt be shocked at whatever is said. If a patient senses your uncomfortableness – they become uncomfortable too – and they then get embarassed, ashamed or shy and then they shut down on you. This is not fair on them. So instead of saying, “how is errrm, you know, errr, your sex life” say something which is more direct but sensitive like “i need to ask you some personal questions. is that okay > so can i start by asking if you’re sexually active? > yes > and is that with one person or more than one? and….”
'Teachable Moments'
My name is John Poynton. I am chief executive of Redthread, a youth work charity that works in partnership with health, particularly emergency departments at major trauma centre hospitals. The charity meets young people when they are victims of violence and attends the emergency departments. It uses that window of opportunity or teachable moment to help with wrap-around support and to encourage and empower young people to help to break their cycle of violence. There is a recognition in working with the London major trauma centres and other local emergency departments and the major trauma centres across the midlands that by the time a young person attends a major trauma centre with a major trauma stabbing or shooting injury, they have often already attended on average four to five times with lower-level injuries. The idea is that violence breeds more violence. Some victims will go on to become perpetrators if there is not an opportunity to interrupt the cycle of violence, and others will go on to become victims time and time again.
So, a TEACHABLE MOMENT is an amazing opportunity in that clinical setting for health workers (like doctors and nurses) to get young people to reduce ANY risk taking behaviour that lead them to being with you today. It doesn’t just have to be about violence. It might be sexual behaviour and repeated infections or a painful case of herpes genitalis. It might be drug use that led to a fracture as a result of risky physical activity. it might be alcohol use that led to a road traffic accident.
But how do you do it?
- Don’t tell them off or be paternalistic or like a headmistress telling them off and making them feel inferior.
- Talk about it on neutral territory – don’t add any form of your own personal judgement. No full blown lecture.
- Instead engage in a neutral discussion where you get THEM to reflect and THEM to form their own conclusions (which hopefully aligns with yours). Remember, we are more likely to change from our own internal voices, than the voices around us. Remember, we are more likely to change from our own internal voices than the voices around us – this is a concept that aligns with the theory of self-determination and intrinsic motivation. This idea suggests that individuals are more likely to adopt and sustain behavioral changes when they feel a sense of autonomy, competence, and relatedness to the change process
- Non-judgmental, open-ended questions help engage in neutral discussion. “So how do you feel about the events that led you to being here?”
- Keep it brief. A message can be conveyed in a small amount of time. Any conversation that lingers loses effectiveness, as it tends to turn into a lecture.
- Smile. Lighten up, and use humour when possible. As the popular saying suggests, a smile goes a long, long way. In an article featured in the journal of Experimental Psychology, researchers discovered that smiling, which engages our facial muscles, leads to increased positive emotions. When we smile, the amygdala, the brain’s emotional center, is activated, releasing neurotransmitters that promote a positive emotional state. By smiling, not only can we uplift ourselves, but we can also influence teenagers to adopt a more positive attitude during conversation. Smiling allows us to view the world with optimism, even if our mouths are concealed behind masks. We can still perceive the twinkle in someone’s eyes that accompanies a genuine smile. As renowned jazz artist Louis Armstrong famously sang, “When you’re smiling, the whole world smiles with you.”
- If they feel downbeaten about the event, remind them: bad events don’t have to define who you are; you define yourself. Dr. Seuss said it best: “When something bad happens, you have three choices. You can either let it define you, let it destroy you, or you can let it strengthen you.”
So Luke, good news, everything should now be on the mend. The leg has been fixed and unfortunately you’ll have to stay in that plaster for several weeks and then when it comes off, you’ll need some physio to build those muscles up. Now, I believe all of this happend from a skateboarding accident. Is that right? > yeah. I’m pretty good on the skateboard normally though. > I see, what was it about this skateboarding incident that led to this? anything? > well, i’d been drinking with some mates. it was a stupid thing to do > mmm why do you say it was stupid? > because look where it has landed me > yes you are in a bad way with that leg. They’ve pinned it and some of your activities are going to be limited for a few weeks im afraid > yeah i know. wish i hadnt bloody well done it > okay so what has happened has happened. no point beating yourself up about it. i wonder if there’s anything you can do or tell yourself to stop this from happening again. actually before i jump the gun, how would you feel if this happened again, say this time with a broken arm or dare say it, a broken skull? > no way, im not going through this again > okay, so it would be a super bad thing, i can’t go through it again > okay so the next time your out with mates and you drink and then they all egg you on to skateboard and do all sorts of things what can you do to stop you from getting pulled in? > i’ll just say no to them > mmm that may or may not work. in that situation, friends can put the pressure on and its hard to say no. do you ever feel that > yes i do > so is there anything physical you can do you think > well i suppose for starters, leave the skateboard at home if I know they’re going to be drinking. > that sounds like a good plan for starters.
Teachable Moments is a bit like the concept “Failing Forwards” – using failure as a positive thing – embracing it – so that you learn from it – and get to a better future self.
Teachable moments can be done anywhere…
- Parents
- Teachers
- GP
- A&E
- Social Services
Teachable moments can be done around
- STIs
- Alcohol
- Physical injuries from risky behaviour
- Drugs
- Any lifestyle change
What are the big health concerns with young people?
Other Top Tips
