Learning objectives from Dr Claires Lecture on DV Flashcards
What are the learning objectives
Learning Outcomes :
At the end of this session you should know :
- How to facilitate a meaningful mental health consult
- What tools can assist in diagnosis and risk management
- How to assess a patient who discloses Intimate Partner Violence
- What are some tools to assist patients with AOD concerns
- How do you choose a medication for a patient with anxiety/depression
How do we Engage and assess the adolescent patient - RCH guidelines
Engaging with and assessing the adolescent patient
Important other factors
- Adolescent gynaecology — lower abdominal pain
- Adolescent gynaecology — heavy menstrual bleeding
- Sexually transmitted infections (STIs)
- Management of eating disorders in the emergency department
- Mental state exam
Key points
- Adolescence is a transitional phase of growth and development between childhood and adulthood
- Adolescents have the legal right to confidential health care
- Adolescents less than 18 years old may be considered ‘mature minors’, capable of giving informed consent
- The HEEADSSS interview for psychosocial screening is an important component of adolescent assessments
Background
What is adolescence?
- Historically spanning from ages 12–18 years, approximating the phase between pubertal onset and legal ‘independence’, and generally corresponding with attendance at high school
- More recently the term has expanded to include young adulthood, up to 25 years of age
Adolescent health care considerations
- Increased risk-taking behaviours and psychosocial issues, contributing to morbidity and mortality
- Rarely access routine health care, so any contact should be an opportunity for preventative health care
- Some health services manage those aged >16 years through adult services or on adult inpatient wards
- Planning for transition to appropriate adult services should start well before age 18
Assessment
- An adolescent consultation should include time with the adolescent and guardian/s together, as well as dedicated time with the adolescent alone
Confidentiality and consent
- Be explicit about confidentiality requirements and obtain permission prior to contacting other relevant professionals, such as school or youth agencies
- Adolescents have the legal right to confidential health care unless:
- they cannot be considered a mature minor and/or
- there is significant concern regarding risk (ie harm to self or others, physical or sexual abuse)
Mature minors can give informed consent if they have sufficient understanding and intelligence to enable full comprehension of what is proposed [as per Australian common law - Gillick competency]
Most adolescents aged 16–18 are presumed to be mature minors (legislation differs by State)
Younger adolescents may sometimes be considered mature minors and be capable of providing informed consent depending on the nature of the proposed intervention. Interventions include history, physical examination, procedures and treatments
Adolescents involved with child protection services require special consideration with respect to confidentially and consent. The relevant State-based service may be able to assist when consent cannot be obtained in the usual way
Psychosocial interview
The HEEADSSS interview is a useful screening tool, that can also aide engagement. It is best completed with the adolescent alone.
Parents should be asked if they have any concerns prior to leaving the room and again at the close of the interview
Preface the interview by discussing confidentiality and explaining that you are about to ask lots of personal questions about the adolescent’s life, interests and behaviours, as these may be affecting their health and wellbeing
Try to use open-ended, non-judgmental questions that avoid assumptions
General statements instead of personalising questions can be less intrusive (eg “some young people experiment with cigarettes, alcohol or drugs. In your year, do people smoke/drink/use illicit drugs? What about your friends? And you?”)
The HEEADSS framework is designed to progress from important but less threatening questions to those considered highly personal
It is often not possible to cover every aspect of the interview in a single encounter. You may focus on the most relevant areas for your patient or population
You may choose to end the psychosocial interview by asking the adolescent who they can trust and confide in if they have problems
The HEEADSSS psychosocial interview for adolescents
Home:who, where, recent changes (moves or new people), relationships, stress or violence, smartphone or computer use (in home vs room)
Education & Employment:where, year, attendance, performance, relationships and bullying, supports, recent moves, disciplinary actions, future plans, work details
Eating and Exercise:weight and body shape (and relationship to these), recent changes, eating habits and dieting, exercise and menstrual history
Activities:extra-curricular activities for fun: sport, organised groups, clubs, parties, TV/computer use (how much screen time and what for)
Drugs and Alcohol:cigarettes, alcohol and illicit drug use by friends, family and patient. Frequency, intensity, patterns of use, payment for, regrets and negative consequences
Sexuality and Gender:gender identity, romantic relationships, sexuality and sexual experiences, uncomfortable situations/sexual abuse, previous pregnancies and risk of pregnancy, contraception and STIs
Suicide, Depression & Self-harm:presence and frequency of feeling stressed, sad, down, ‘bored’, trouble sleeping, online bullying, current feelings (eg on scale of 1 to 10). thoughts or actions of self-harm/ hurting others, suicide risk: thoughts, attempts, plans, means and hopes for future
Safety:serious injuries, online safety (eg meeting people from online), riding with intoxicated driver, exposure to violence (school and community), if high risk - carrying weapons, criminal behaviours, justice system
** HEEADSSS screen may be adapted for local use
Examination
General considerations for physical examination of an adolescent patient:
Use of a chaperone is recommended
Ensure privacy
For pubertal assessment (Tanner staging) consider asking the adolescent to make a self assessment
Management
General considerations
Depends on the issues identified during psychosocial interview
Adolescent health concerns can generally be viewed in terms of risk and protective factors
If there are significant health risk behaviours, devise an immediate management plan which may include formal mental health assessment and admission (eg intentional overdose, see Poisoning — acute guidelines for initial management)
Remember to document the adolescent’s contact details if follow-up is required
Consider opportunistic vaccination
Medicare cards
Anyone over the age of 15 years should be encouraged to obtain their own Medicare card
Transition to adult services
Transition to adult services should be considered from mid-adolescence and include formal support and education
Most health services will aim to transition an adolescent to adult services by their 18th birthday or once their final year of high school is completed
For complex cases, a period of overlap between paediatric and adult services may be required to permit adequate communication between specialists and safe transition
Consider consultation with local paediatric team when
Assessing any adolescent deemed to be at significant risk
Note: Depending on local resources and the adolescent’s presentation, mental health, adolescent medicine or social work may be the most appropriate team to consult
For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services
Consider discharge when
An assessment by mental health staff including a risk assessment has been completed, if indicated
A clear discharge destination has been established, with follow-up and referrals to necessary services made
Parent information
Adolescent transition – resources
Raising Children – Teens (12–18 years)
Referral pathways and services
National services
Headspace: Centres act as a one-stop-shop for young people seeking help with mental health, physical health (including sexual health), alcohol and drugs issues, or work and study support
Youth beyond blue: Beyond blue’s youth program - provides online forums, the ‘check-in’ app, information and resources about mental illness in those aged 12–25 years
Reachout: online resource that provides innovative e-mental health services directly to adolescents and young people
Head to Health: Australian Department of Health site for access to digital mental health resources
Referral for counselling / psychology services:
GPs can refer patients to psychologists under a Mental Health Plan (under the Better Access initiation) for up to 10 sessions per calendar year
Local psychologists can be found via the Australian Psychological Society’s ‘find a psychologist’ search function
24-hour telephone help lines:
Kids Help Line 1800 55 1800
Lifeline 13 11 14
Beyond blue 1300 224 636
Suicide Call Back Service 1300 659 467
Suicide HelpLine (VIC) 1300 651 251
Mental Health Line (NSW) 1800 011 511
13 HEALTH (QLD) 13 43 25 84
