- Email: [email protected]
Health issues for adolescents
Current Paediatrics (2001) 11, 120d125 ^ 2001 Harcourt Publishers Ltd doi:10.1054/cupe.2001.0159, available online at http://www.idealibrary.com on
Health issues for adolescents R. Jones Consultant Paediatrician, Community Child Health, Child Health Department at Bath & West Community NHS Trust, UK KEYWORDS adolescent, health services, teenage pregnancy
Summary Although adolescence is a relatively healthy time of life, it is also a time when unhealthy behaviours can develop, which may have long-term effects on adult health and well being. Issues such as smoking, drug taking, mental health and teenage pregnancy have been targeted in health-promotion programmes. Unfortunately, so far, although there have been positive improvements in terms of increasing adolescents’ knowledge about risk, there have been few interventions which have been shown to change behaviours. Adolescents’ uptake of primary health services has improved when services have been developed in consultation with them. Hospital services must also take into account the specific developmental and social needs of this age group. ^ 2001 Harcourt Publishers Ltd
PRACTICE POINTS E E E
E E
Adolescence is a relatively healthy time Knowledge about danger and risk may not influence behaviour High teenage pregnancy rates are related to poor educational achievement and poverty, and require multifaceted solutions Most health interventions in this age group have been poorly evaluated Confidentiality is a key determinant of whether services are accessed
RESEARCH DIRECTIONS E
E
In primary care, long-term studies looking at different types of clinic provision, especially in relation to sexual health services Further assessment of peer group interventions, looking at long-term effects using larger populations
INTRODUCTION Adolescents are viewed by many paediatricians and other health professionals as healthy, but most would acknowledge that behaviours developed during this time
E-mail: [email protected]
can have a major impact on health and well being in adult life. Health inequalities also develop during this period. Evidence shows that young people do not feel that they are well served by the health services. Surveys of their contacts with GP services bear this out e in terms of attendance rates and consultation times. When they do make contact with services, adolescents feel frequently unable to discuss their health needs, mainly due to concerns about a perceived lack of confidentiality. At a time when huge resources are being targeted at the treatment of adult disease, very little money or effort is targeted at trying to address potential causes of later ill health, in childhood or in adolescence. The last Conservative Government sought advice and comments from a wide range of bodies identified to have an interest in the health of children and adolescents, but, as yet, there has been a failure to implement existing guidelines, and unfortunately there is evidence that some services are being fragmented rather than improved. The possible re-organization of Community Child Health services into Primary Care Trusts may serve to increase fragmentation of services further e particularly to vulnerable groups of young people such as those ‘looked after’ and adolescents in the Child Protection System.
HOW IS ADOLESCENCE DEFINED? The term ‘Adolescence’ is taken to mean the period between childhood and adulthood, during which the
HEALTH ISSUES FOR ADOLESCENTS previously dependent child develops into an independent adult. Social changes over the last 50 years have meant that young people are often not independent until their mid 20s, both in terms of housing and financial support, and this has made it less easy to define the endpoint of adolescence. The starting point has sometimes been defined in terms of the start of secondary education at the age of 11 years, but the tendency towards an earlier onset of puberty means that again, the definition has become less certain. This review will describe evidence about the health and well being of young people aged 10d19 years, as described in the WHO definition of adolescence. Sadly, the word ‘adolescent’ is sometimes used as a disparaging term, to imply that a person is incapable of rational thought, prone to rebelliousness and unpredictable behaviour, immature and unable to take on the challenges of adulthood. Adolescents are not a homogeneous group, and it is therefore not surprising that interventions designed to influence their behaviours, which do not take into account variations in maturity and life experiences, are unlikely to be successful. Many solutions to the difficulties faced by adolescents, in terms of extra protection and better services, are desirable not just for this age group, but for all patients. As is the case with adult medicine, many of the real and perceived difficulties facing adolescents require social and political (e.g. housing, money, education) solutions, rather than, or in addition to, medical solutions.
ARE ADOLESCENTS HEALTHY? Although the mortality rate for all children at all ages has declined over the last 20 years, there has been a widening in the class gradient. This is more marked in boys, and is mainly due to differences in accident rates in later childhood and adolescence. Half of all deaths in the age group 11d19 years are due to injury or poisoning. Male adolescents are almost twice as likely as female adolescents to die (70 per 100,000 compared with 30 per 100,000). In older male adolescents, the mortality rate is contributed to by an increase in suicide, which has risen steadily since the 1970s. At least 12% of injury deaths in males aged 15d19 years are classified as suicide, but this is probably an underestimate, given that a further 11% are given an open verdict e possibly influenced by the social taboo which still exists around a suicide verdict. Alcohol consumption is a major contributory factor in about 60% of the fatal accidents involving young men during the hours of darkness. A recent suggestion to try to tackle the high number of deaths in young male drivers has been to impose a curfew on their driving during the late evening and early morning hours. Cancer deaths are the second most important category in the 10d19 years age group.1
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GENERAL HEALTH British adolescents, like most of their counterparts world wide, say that they feel ‘healthy’, and it is therefore important not to overmedicalize their lives.2 Those who smoke, drink alcohol excessively, take illegal drugs and take little exercise are less likely to report that they feel healthy. Wealth, as in adults, is positively associated with feeling both happy and healthy. For young people aged 15d24 years, the most common reason for hospital admission is injury, followed, in girls, by admission for childbirth or termination of pregnancy. Most adolescents visit their GP between two and three times each year, with almost 100% visiting at least once. Research has shown that the most frequently mentioned topics that adolescents would like to discuss with their doctor are sex, stress, relationships, diet, general health, depression, worries about size or shape, drugs, pregnancy and contraception.3
CHRONIC ILLNESS Larger numbers of chronically ill children now survive until their 20s and this has increased the burden to hospital services of caring for sick young people, especially those with cystic fibrosis, congenital heart disease and renal disease. Transition of care between paediatric and adult services, often occurring at a time of poor disease control, and when young people become increasingly frustrated at what they see as the overmedicalization of their lives, needs to be handled very sensitively. Diabetic control can be particularly problematic in adolescence. Standard insulin regimes are inappropriate to maintain good control during a time of rapid growth and hormone production, and risk-taking behaviours such as drug and alcohol use can have a major effect on blood sugar control. Many young diabetics react by denial, omitting all or some of their prescribed insulin and precipitating keto acidosis and weight loss. Adolescents who have cancer have to contend with a series of challenges, ranging from lost schooling, loss of privacy, decreased independence, the effects of surgery and radiotherapy, and late effects of treatment e including effects on growth and fertility. Adolescents with a disability may have particular problems in developing a greater degree of autonomy over their lives, and an inability to develop their interests in teen culture to the same extent as their non-disabled peers. In later adolescence, as the support provided through education diminishes or ceases altogether, many disabled adolescents become lonely and isolated, and their families can find it difficult to provide the continuing levels of care that they need.
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MENTAL HEALTH The Audit Commission has estimated that as many as one in five adolescents suffers from a mental health problem, the most common problems being depression, anxiety and anorexia nervosa.4 The most worrying aspect of mental health in adolescence is the high suicide rate in young men aged 15d19 years. More young women than young men actually attempt suicide (about one in 100) but there are four times as many successful suicides in young men. Overall, about 7% of adolescents report having suicidal ideas, and more than one in four adolescents say that they feel depressed at least once a week. The main risk factor for successful suicide is a previous attempt. Suicide is frequently associated with substance misuse, low selfesteem, and social isolation. Anorexia nervosa is now thought to affect 1% of girls, and about one-tenth as many boys. Girls who go on a strict diet are 18 times more likely to develop an eating disorder than those who do not diet. Poor body image can lead to low levels of self-esteem. The finger of blame in relation to the increase in eating disorders has been pointed at the media and the advertising industry, who tend to use images of thin women in programmes and advertisements. There is a complex interaction between young people who are suffering from depression, those who drop out of school, drug misusers, and those who indulge in risky sexual behaviour. The mnemonic HEADSS can be used by paediatricians whenever they take a history from adolescents; it means ‘home, education, peer activities, drugs, sexuality and suicide’.5 Child and family mental health services seem to be chronically overstretched and underfunded, and unable to respond rapidly to the high level of need, especially in relation to the management of young people with behavioural problems. Problems such as school phobia and truancy require ‘joined-up thinking’, acceptance that there may be other issues involved such as bullying or depression, and multidisciplinary working towards a solution. Services for vulnerable groups, such as those ‘looked after’ by the local authority, and postadoption support services, which many believe should be proactive rather than reactive, are not given priority or funding in most parts of the country.
HEALTH BEHAVIOURS THAT MAY CONTRIBUTE TO LATER ILL HEALTH, AND EVIDENCE ON MEASURES AIMED AT INFLUENCING LIFESTYLE CHOICE Lack of exercise Young people are becoming less active, with girls aged 15 years taking, on average, less than 2.5 hours exercise
CURRENT PAEDIATRICS each week, and boys doing only slightly better at just over 3.5 hours.6 Older adolescents are even less fit. Some factors have been found to be important in encouraging adults to take up exercise programmes, including personal instruction, continued support and participation in an exercise which doesn’t require attendance at a special centre. These factors have not, as yet, been evaluated in adolescents. Lack of exercise may adversely affect bone mass, potentially resulting in more fractures in later life. There is a socio-economic gradient in perceived levels of fitness, which may be explained by the fact that wealthier families have access to cars and the opportunity to take adolescents to sports centres and out of school activities.
Poor diet As is the case in the adult population, levels of obesity in adolescence are increasing. Over 60% of girls aged 12d15 years think that they are overweight, and half of all 16-year-old girls say that they want to lose weight. Socio-economic factors are important again; adolescents from lower socio-economic classes eat more high fat foods such as crisps and cakes, and less fresh fruit and vegetables, than their peers from higher socio-economic classes. Most UK-school-based interventions which have been aimed at increasing consumption of fresh fruit and vegetables have failed, as have interventions based in primary care. Over the last 10 years, there has been a steady decline in consumption of red meat and full-fat milk amongst adolescents from all socio-economic groups. A study in Sheffield7 showed that adolescent girls who drank more milk significantly enhanced bone mineral acquisition, and this simple intervention might impact on the levels of osteoporosis in women in later life.
Smoking About half of all school pupils have smoked and one in three 15d16-year-olds would classify themselves as a smoker. The majority say that they would like to give up. Rates of smoking have increased over the last 20 years, with more young girls smoking now than when the ‘Health of the Nation’ targets were set. Most adult smokers start smoking in the period of mid-adolescence, and this should therefore be the time to target antismoking messages.8 If the availability of cigarettes was limited to those over 18 years, the rate of smoking in adults might be reduced. Uptake is most highly related to parental and peer group behaviour and attitudes to smoking. Anti-smoking programmes have not addressed the fact that adolescents, like adults, may need support (such as nicotine patches) to stop smoking. There is no difference in levels of knowledge about dangers associated with smoking between smokers and non-smokers. Health education at
HEALTH ISSUES FOR ADOLESCENTS school has certainly raised awareness of the dangers of smoking, but this has not yet been translated into a reduction of smoking rates, except during the early, well-funded and well-supported stages of research programmes. Health education has been most successful in influencing adolescents from advantaged rather than disadvantaged social groups. Sixty percent of young people believe that cigarette advertising has ‘quite a lot of impact’ on themselves and their peers. Restrictions on smoking at home, bans on smoking in public places and enforced bans on smoking at school can have a positive effect in reducing teenage smoking levels.9
Drug taking After a period of increasing use of drugs by school-aged adolescents, levels of drug taking have stabilized, with about one-quarter of 15 year olds reporting that they have taken cannabis, and one-third being offered it. The number of regular drug users throughout the adolescent years is much lower, at about 1%. About 70% of smokers have tried drugs, compared with about 10% of nonsmokers. Most interventions have been disappointing, with those based in schools being particularly unsuccessful.
Alcohol consumption Almost one in three 12 year olds and about half of all 15 year olds drink ‘regularly’, with about half drinking in their own home. Girls are drinking almost as much as boys by the time they are 15 years old, and they tend to favour sweet drinks such as ‘alcopops’. Many programmes attempting to reduce both drug and alcohol use have focussed on knowledge and attitudes rather than peer or community influences, and, perhaps unsurprisingly, few interventions have been effective.
Teenage sexuality Age at first intercourse is decreasing. Since the 1960s, the median age has decreased from 21 years for women and 20 years for men to 17 years for both men and women. There is a strong socio-economic gradient; the median age is 16 years for boys in social class 5 compared with 18 years for those in social class 1. As many as 20% of 13 year olds have had sexual intercourse. Younger age at first intercourse is associated with a higher number of sexual partners. Meanwhile, sexual stereotyping continues, with boys influenced by peer pressure which condones promiscuity, whilst girls are expected to invest in romance and love. The rate of pregnancy in girls under 16 years old was 9.4 per thousand in 1996. One in three pregnant adolescents seeks an abortion, and the teenage birth rate is the highest in Western Europe. However, if
123 the teenage fertility rate is compared with the number of sexually active women at a point in time, the underlying trend in teenage fertility has been downwards. Differences in fertility rates between points in time and between areas seems to be related to both access to, and use of, contraceptive services by young people.10 Many teenagers who conceive have actually sought health care related to contraception in the previous year. Teenagers whose pregnancies end in termination are more likely to have received emergency contraception and less likely to have been on the contraceptive pill than those who continue with a pregnancy.11 Most adolescent girls in British studies know about emergency contraception, but they are often unsure about exactly how to access it. Unintended pregnancies are associated with poor outcomes for both mother and child in terms of health, wealth and educational achievement. The Social Exclusion Unit Report on teenage pregnancy12 recognizes the complex interconnected issues which may account for the high rate of teenage pregnancies, including poor educational achievement and poverty. It lays to rest the idea that young girls are motivated to become pregnant in order to get a council flat, and emphasizes instead the mixed messages that they are presented with. Lessons are drawn from research in the USA and Europe, and a British research agenda is now being developed to look at possible solutions. Peer interventions have had some success in decreasing participants’ beliefs that sexual activity is ‘beneficial’ to teenagers, but programmes are costly to deliver in terms of curriculum time and input from teaching and medical staff.13 There appears to have been a dramatic increase in the last 10 years in the rate of sexually transmitted diseases, but it is possible that increased attendance by young people and better diagnostic tests, in particular for Chlamydia, may account for some of this rise. Sexually transmitted infections can have long-term sequelae in terms of later cervical cancer, pelvic inflammatory disease and infertility, so it is important to try to address the increase. However, this will be difficult whilst sexual health services continue to be fragmented. Young people’s combined sexual health/family planning/sexual advice clinics seem to have a positive effect on reducing pregnancy rates, and greater success in attracting boys.14
PRIMARY CARE SERVICES FOR ADOLESCENTS Some GPs offer health checks to all adolescents on their lists, hoping that once young people have accessed their surgery for a ‘well-person’ check, they will find it easier to access services in the future. Unfortunately, most studies show that less than half of those offered an appointment attend, and, as often happens, the inverse care law applies, with those in most need of services being least likely to
124 attend. Attempts at changing health behaviours among young people who do attend have also been largely unsuccessful. Specific ‘young person’ clinics, often held ‘after hours’, have had varied success. Lack of funding, which often means that young people are not consulted about the timing and venue of proposed new services before they are set up, is cited as a frequent problem. Adolescents continue to have anxieties about confidentiality. Several studies have shown that about a quarter of 15 year olds believe that a doctor can share health information with other professionals and with their parents against their wishes. It is therefore important for practices to have a clear policy that is distributed to their target population. Open-access clinics and phone-line advice services undoubtedly help to improve accessibility for many adolescents. Use of the internet is increasing rapidly among adolescents, and sites such as www.thesite.org and www.teenagehealth.org provide advice and information on a wide range of health-related topics, using appropriate language.
SECONDARY CARE SERVICES The welfare of children and young people in hospital was highlighted first in the Platt Report in 1959, and later in the Court Report, which emphasized the importance of a service centred on the child and the family. The Audit Commission looked at hospital services for all children in 1990, and the National Association for the Welfare of Children in Hospital also set standards for the care of children in hospital. Adolescents have specific psychosocial and developmental needs, which may be best addressed by separate provision; their views should certainly be sought when planning new provision.15 Recreational activities have been found to increase selfesteem and social competence in adolescents with chronic diseases. Privacy remains an important issue, and the ability to cook for themselves and access a more interesting diet has been highlighted by many adolescents. In the outpatient setting, adolescents prefer a separate waiting area ‘away from screaming babies’, appropriate books, magazines, information leaflets, posters and music. They say that they want more information from medical staff e about their condition, investigations, and proposed treatment regimes.16 Again, their preferences are not dissimilar to those of many other groups of health service users.
CONCLUSION Adolescents, despite being a relatively healthy group, have specific healthcare needs and concerns.
CURRENT PAEDIATRICS Paediatricians need to be mindful of their different beliefs about risk, and bear in mind that in this age group, whilst it is fairly easy to impart knowledge, this does not necessarily lead to behavioural change. Rather than trying to predict what services they might find acceptable and appropriate, health professionals should ask adolescents themselves.
REFERENCES 1. West P. Youth. In: Gordon D, Shaw M, Dorling D, Davey Smith G, eds. Inequalities in Health. Glasgow: The Policy Press, 1999; 12d22. 2. Young People and Health e Health behaviour in school-aged children in 1997. London: HEA, 1999. 3. Jones R, Finlay F, Simpson N, Kreitman T. How can adolescents’ health care needs and concerns best be met? Br J Gen Pract 1997; 47: 631d634. 4. Children in Mind. Audit Commission Publications, 1999. 5. Goldenring J M, Cohen E. Getting into adolescents’ heads. Contemp Paediatr 1988; 5: 75d90. 6. Balding J. Young People in 1998. Exeter: Schools Health Education Unit, 1999. 7. Cadogan J, Eastell E, Jones N, Barker M E. Milk intake and bone mineral acquisition in adolescent girls: randomised, controlled intervention trial. BMJ 1997; 315: 1255d1260. 8. West P, Sweeting H, Ecob R. Family and friends’ influence on the uptake of regular smoking from mid-adolescence to early adulthood. Addiction 1999; 94: 1397d1412. 9. Wakefield M, Chaloupa F, Kaufman N J, Orleans C, Barker D, Ruel E. Effects of restrictions on smoking at home, at school, and in public places on teenage smoking: cross sectional study. BMJ 2000; 321: 333d337. 10. Wellings K. Promoting the Health of Teenage and Lone Mothers; Setting a Research Agenda. London: HEA, 1999. 11. Churchill D, Allen J, Pringle M et al., Bradley S. Consultation patterns and provision of contraception in general practice before teenage pregnancy: case control study. BMJ 2000; 321: 486d489. 12. Social Exclusion Unit. Teenage Pregnancy. London: Stationery Office, 1999. 13. Mellanby A R, Phelps F A, Crichton N J, Tripp J H. School sex education: an experimental programme with educational and medical benefit. BMJ 1995; 311: 414d417. 14. Nicoll A, Catchpole M, Cliffe S, Hughes G, Simms I, Thomas D. Sexual health of teenagers in England and Wales: analysis of national data. BMJ 1999; 318: 1321d1323. 15. Viner R, Keane M. Youth Matters. Caring for Children in the Health Service. London, 1998. 16. Boswell K, Finlay F, Jones R, Hill P. Perceived ideal outpatient department, and hospital ward for children, adolescents and their families. Clin Child Psychol Psychiatr 2000; 5: 213d219.
FURTHER READING Coleman J. Key data on Adolescence. Trust for the Study of Adolescence. Brighton, 1997. Rogers A, Popay J, Williams G, Latham M. Inequalities in Health and Health Promotion: Insights from the Qualitative Research Literature. London: HEA, 1997. Meyrick J, Swann C. An overview of effectiveness of interventions and programmes aimed at reducing unintended conceptions in young people. London: HEA, 1998.
HEALTH ISSUES FOR ADOLESCENTS Macfarlane A. Adolescent Medicine. London: Royal College of Physicians, 1996. Audit Commission. Children First: a Study of Hospital Services. London: HMSO, 1993.
125 Jones R, Dennison C, Coleman J. Developing Indicators for Community Approaches to Health Promotion with Young People. Trust for the Study of Adolescence. Brighton: TSA, 2000.
Health issues for adolescents R. Jones Consultant Paediatrician, Community Child Health, Child Health Department at Bath & West Community NHS Trust, UK KEYWORDS adolescent, health services, teenage pregnancy
Summary Although adolescence is a relatively healthy time of life, it is also a time when unhealthy behaviours can develop, which may have long-term effects on adult health and well being. Issues such as smoking, drug taking, mental health and teenage pregnancy have been targeted in health-promotion programmes. Unfortunately, so far, although there have been positive improvements in terms of increasing adolescents’ knowledge about risk, there have been few interventions which have been shown to change behaviours. Adolescents’ uptake of primary health services has improved when services have been developed in consultation with them. Hospital services must also take into account the specific developmental and social needs of this age group. ^ 2001 Harcourt Publishers Ltd
PRACTICE POINTS E E E
E E
Adolescence is a relatively healthy time Knowledge about danger and risk may not influence behaviour High teenage pregnancy rates are related to poor educational achievement and poverty, and require multifaceted solutions Most health interventions in this age group have been poorly evaluated Confidentiality is a key determinant of whether services are accessed
RESEARCH DIRECTIONS E
E
In primary care, long-term studies looking at different types of clinic provision, especially in relation to sexual health services Further assessment of peer group interventions, looking at long-term effects using larger populations
INTRODUCTION Adolescents are viewed by many paediatricians and other health professionals as healthy, but most would acknowledge that behaviours developed during this time
E-mail: [email protected]
can have a major impact on health and well being in adult life. Health inequalities also develop during this period. Evidence shows that young people do not feel that they are well served by the health services. Surveys of their contacts with GP services bear this out e in terms of attendance rates and consultation times. When they do make contact with services, adolescents feel frequently unable to discuss their health needs, mainly due to concerns about a perceived lack of confidentiality. At a time when huge resources are being targeted at the treatment of adult disease, very little money or effort is targeted at trying to address potential causes of later ill health, in childhood or in adolescence. The last Conservative Government sought advice and comments from a wide range of bodies identified to have an interest in the health of children and adolescents, but, as yet, there has been a failure to implement existing guidelines, and unfortunately there is evidence that some services are being fragmented rather than improved. The possible re-organization of Community Child Health services into Primary Care Trusts may serve to increase fragmentation of services further e particularly to vulnerable groups of young people such as those ‘looked after’ and adolescents in the Child Protection System.
HOW IS ADOLESCENCE DEFINED? The term ‘Adolescence’ is taken to mean the period between childhood and adulthood, during which the
HEALTH ISSUES FOR ADOLESCENTS previously dependent child develops into an independent adult. Social changes over the last 50 years have meant that young people are often not independent until their mid 20s, both in terms of housing and financial support, and this has made it less easy to define the endpoint of adolescence. The starting point has sometimes been defined in terms of the start of secondary education at the age of 11 years, but the tendency towards an earlier onset of puberty means that again, the definition has become less certain. This review will describe evidence about the health and well being of young people aged 10d19 years, as described in the WHO definition of adolescence. Sadly, the word ‘adolescent’ is sometimes used as a disparaging term, to imply that a person is incapable of rational thought, prone to rebelliousness and unpredictable behaviour, immature and unable to take on the challenges of adulthood. Adolescents are not a homogeneous group, and it is therefore not surprising that interventions designed to influence their behaviours, which do not take into account variations in maturity and life experiences, are unlikely to be successful. Many solutions to the difficulties faced by adolescents, in terms of extra protection and better services, are desirable not just for this age group, but for all patients. As is the case with adult medicine, many of the real and perceived difficulties facing adolescents require social and political (e.g. housing, money, education) solutions, rather than, or in addition to, medical solutions.
ARE ADOLESCENTS HEALTHY? Although the mortality rate for all children at all ages has declined over the last 20 years, there has been a widening in the class gradient. This is more marked in boys, and is mainly due to differences in accident rates in later childhood and adolescence. Half of all deaths in the age group 11d19 years are due to injury or poisoning. Male adolescents are almost twice as likely as female adolescents to die (70 per 100,000 compared with 30 per 100,000). In older male adolescents, the mortality rate is contributed to by an increase in suicide, which has risen steadily since the 1970s. At least 12% of injury deaths in males aged 15d19 years are classified as suicide, but this is probably an underestimate, given that a further 11% are given an open verdict e possibly influenced by the social taboo which still exists around a suicide verdict. Alcohol consumption is a major contributory factor in about 60% of the fatal accidents involving young men during the hours of darkness. A recent suggestion to try to tackle the high number of deaths in young male drivers has been to impose a curfew on their driving during the late evening and early morning hours. Cancer deaths are the second most important category in the 10d19 years age group.1
121
GENERAL HEALTH British adolescents, like most of their counterparts world wide, say that they feel ‘healthy’, and it is therefore important not to overmedicalize their lives.2 Those who smoke, drink alcohol excessively, take illegal drugs and take little exercise are less likely to report that they feel healthy. Wealth, as in adults, is positively associated with feeling both happy and healthy. For young people aged 15d24 years, the most common reason for hospital admission is injury, followed, in girls, by admission for childbirth or termination of pregnancy. Most adolescents visit their GP between two and three times each year, with almost 100% visiting at least once. Research has shown that the most frequently mentioned topics that adolescents would like to discuss with their doctor are sex, stress, relationships, diet, general health, depression, worries about size or shape, drugs, pregnancy and contraception.3
CHRONIC ILLNESS Larger numbers of chronically ill children now survive until their 20s and this has increased the burden to hospital services of caring for sick young people, especially those with cystic fibrosis, congenital heart disease and renal disease. Transition of care between paediatric and adult services, often occurring at a time of poor disease control, and when young people become increasingly frustrated at what they see as the overmedicalization of their lives, needs to be handled very sensitively. Diabetic control can be particularly problematic in adolescence. Standard insulin regimes are inappropriate to maintain good control during a time of rapid growth and hormone production, and risk-taking behaviours such as drug and alcohol use can have a major effect on blood sugar control. Many young diabetics react by denial, omitting all or some of their prescribed insulin and precipitating keto acidosis and weight loss. Adolescents who have cancer have to contend with a series of challenges, ranging from lost schooling, loss of privacy, decreased independence, the effects of surgery and radiotherapy, and late effects of treatment e including effects on growth and fertility. Adolescents with a disability may have particular problems in developing a greater degree of autonomy over their lives, and an inability to develop their interests in teen culture to the same extent as their non-disabled peers. In later adolescence, as the support provided through education diminishes or ceases altogether, many disabled adolescents become lonely and isolated, and their families can find it difficult to provide the continuing levels of care that they need.
122
MENTAL HEALTH The Audit Commission has estimated that as many as one in five adolescents suffers from a mental health problem, the most common problems being depression, anxiety and anorexia nervosa.4 The most worrying aspect of mental health in adolescence is the high suicide rate in young men aged 15d19 years. More young women than young men actually attempt suicide (about one in 100) but there are four times as many successful suicides in young men. Overall, about 7% of adolescents report having suicidal ideas, and more than one in four adolescents say that they feel depressed at least once a week. The main risk factor for successful suicide is a previous attempt. Suicide is frequently associated with substance misuse, low selfesteem, and social isolation. Anorexia nervosa is now thought to affect 1% of girls, and about one-tenth as many boys. Girls who go on a strict diet are 18 times more likely to develop an eating disorder than those who do not diet. Poor body image can lead to low levels of self-esteem. The finger of blame in relation to the increase in eating disorders has been pointed at the media and the advertising industry, who tend to use images of thin women in programmes and advertisements. There is a complex interaction between young people who are suffering from depression, those who drop out of school, drug misusers, and those who indulge in risky sexual behaviour. The mnemonic HEADSS can be used by paediatricians whenever they take a history from adolescents; it means ‘home, education, peer activities, drugs, sexuality and suicide’.5 Child and family mental health services seem to be chronically overstretched and underfunded, and unable to respond rapidly to the high level of need, especially in relation to the management of young people with behavioural problems. Problems such as school phobia and truancy require ‘joined-up thinking’, acceptance that there may be other issues involved such as bullying or depression, and multidisciplinary working towards a solution. Services for vulnerable groups, such as those ‘looked after’ by the local authority, and postadoption support services, which many believe should be proactive rather than reactive, are not given priority or funding in most parts of the country.
HEALTH BEHAVIOURS THAT MAY CONTRIBUTE TO LATER ILL HEALTH, AND EVIDENCE ON MEASURES AIMED AT INFLUENCING LIFESTYLE CHOICE Lack of exercise Young people are becoming less active, with girls aged 15 years taking, on average, less than 2.5 hours exercise
CURRENT PAEDIATRICS each week, and boys doing only slightly better at just over 3.5 hours.6 Older adolescents are even less fit. Some factors have been found to be important in encouraging adults to take up exercise programmes, including personal instruction, continued support and participation in an exercise which doesn’t require attendance at a special centre. These factors have not, as yet, been evaluated in adolescents. Lack of exercise may adversely affect bone mass, potentially resulting in more fractures in later life. There is a socio-economic gradient in perceived levels of fitness, which may be explained by the fact that wealthier families have access to cars and the opportunity to take adolescents to sports centres and out of school activities.
Poor diet As is the case in the adult population, levels of obesity in adolescence are increasing. Over 60% of girls aged 12d15 years think that they are overweight, and half of all 16-year-old girls say that they want to lose weight. Socio-economic factors are important again; adolescents from lower socio-economic classes eat more high fat foods such as crisps and cakes, and less fresh fruit and vegetables, than their peers from higher socio-economic classes. Most UK-school-based interventions which have been aimed at increasing consumption of fresh fruit and vegetables have failed, as have interventions based in primary care. Over the last 10 years, there has been a steady decline in consumption of red meat and full-fat milk amongst adolescents from all socio-economic groups. A study in Sheffield7 showed that adolescent girls who drank more milk significantly enhanced bone mineral acquisition, and this simple intervention might impact on the levels of osteoporosis in women in later life.
Smoking About half of all school pupils have smoked and one in three 15d16-year-olds would classify themselves as a smoker. The majority say that they would like to give up. Rates of smoking have increased over the last 20 years, with more young girls smoking now than when the ‘Health of the Nation’ targets were set. Most adult smokers start smoking in the period of mid-adolescence, and this should therefore be the time to target antismoking messages.8 If the availability of cigarettes was limited to those over 18 years, the rate of smoking in adults might be reduced. Uptake is most highly related to parental and peer group behaviour and attitudes to smoking. Anti-smoking programmes have not addressed the fact that adolescents, like adults, may need support (such as nicotine patches) to stop smoking. There is no difference in levels of knowledge about dangers associated with smoking between smokers and non-smokers. Health education at
HEALTH ISSUES FOR ADOLESCENTS school has certainly raised awareness of the dangers of smoking, but this has not yet been translated into a reduction of smoking rates, except during the early, well-funded and well-supported stages of research programmes. Health education has been most successful in influencing adolescents from advantaged rather than disadvantaged social groups. Sixty percent of young people believe that cigarette advertising has ‘quite a lot of impact’ on themselves and their peers. Restrictions on smoking at home, bans on smoking in public places and enforced bans on smoking at school can have a positive effect in reducing teenage smoking levels.9
Drug taking After a period of increasing use of drugs by school-aged adolescents, levels of drug taking have stabilized, with about one-quarter of 15 year olds reporting that they have taken cannabis, and one-third being offered it. The number of regular drug users throughout the adolescent years is much lower, at about 1%. About 70% of smokers have tried drugs, compared with about 10% of nonsmokers. Most interventions have been disappointing, with those based in schools being particularly unsuccessful.
Alcohol consumption Almost one in three 12 year olds and about half of all 15 year olds drink ‘regularly’, with about half drinking in their own home. Girls are drinking almost as much as boys by the time they are 15 years old, and they tend to favour sweet drinks such as ‘alcopops’. Many programmes attempting to reduce both drug and alcohol use have focussed on knowledge and attitudes rather than peer or community influences, and, perhaps unsurprisingly, few interventions have been effective.
Teenage sexuality Age at first intercourse is decreasing. Since the 1960s, the median age has decreased from 21 years for women and 20 years for men to 17 years for both men and women. There is a strong socio-economic gradient; the median age is 16 years for boys in social class 5 compared with 18 years for those in social class 1. As many as 20% of 13 year olds have had sexual intercourse. Younger age at first intercourse is associated with a higher number of sexual partners. Meanwhile, sexual stereotyping continues, with boys influenced by peer pressure which condones promiscuity, whilst girls are expected to invest in romance and love. The rate of pregnancy in girls under 16 years old was 9.4 per thousand in 1996. One in three pregnant adolescents seeks an abortion, and the teenage birth rate is the highest in Western Europe. However, if
123 the teenage fertility rate is compared with the number of sexually active women at a point in time, the underlying trend in teenage fertility has been downwards. Differences in fertility rates between points in time and between areas seems to be related to both access to, and use of, contraceptive services by young people.10 Many teenagers who conceive have actually sought health care related to contraception in the previous year. Teenagers whose pregnancies end in termination are more likely to have received emergency contraception and less likely to have been on the contraceptive pill than those who continue with a pregnancy.11 Most adolescent girls in British studies know about emergency contraception, but they are often unsure about exactly how to access it. Unintended pregnancies are associated with poor outcomes for both mother and child in terms of health, wealth and educational achievement. The Social Exclusion Unit Report on teenage pregnancy12 recognizes the complex interconnected issues which may account for the high rate of teenage pregnancies, including poor educational achievement and poverty. It lays to rest the idea that young girls are motivated to become pregnant in order to get a council flat, and emphasizes instead the mixed messages that they are presented with. Lessons are drawn from research in the USA and Europe, and a British research agenda is now being developed to look at possible solutions. Peer interventions have had some success in decreasing participants’ beliefs that sexual activity is ‘beneficial’ to teenagers, but programmes are costly to deliver in terms of curriculum time and input from teaching and medical staff.13 There appears to have been a dramatic increase in the last 10 years in the rate of sexually transmitted diseases, but it is possible that increased attendance by young people and better diagnostic tests, in particular for Chlamydia, may account for some of this rise. Sexually transmitted infections can have long-term sequelae in terms of later cervical cancer, pelvic inflammatory disease and infertility, so it is important to try to address the increase. However, this will be difficult whilst sexual health services continue to be fragmented. Young people’s combined sexual health/family planning/sexual advice clinics seem to have a positive effect on reducing pregnancy rates, and greater success in attracting boys.14
PRIMARY CARE SERVICES FOR ADOLESCENTS Some GPs offer health checks to all adolescents on their lists, hoping that once young people have accessed their surgery for a ‘well-person’ check, they will find it easier to access services in the future. Unfortunately, most studies show that less than half of those offered an appointment attend, and, as often happens, the inverse care law applies, with those in most need of services being least likely to
124 attend. Attempts at changing health behaviours among young people who do attend have also been largely unsuccessful. Specific ‘young person’ clinics, often held ‘after hours’, have had varied success. Lack of funding, which often means that young people are not consulted about the timing and venue of proposed new services before they are set up, is cited as a frequent problem. Adolescents continue to have anxieties about confidentiality. Several studies have shown that about a quarter of 15 year olds believe that a doctor can share health information with other professionals and with their parents against their wishes. It is therefore important for practices to have a clear policy that is distributed to their target population. Open-access clinics and phone-line advice services undoubtedly help to improve accessibility for many adolescents. Use of the internet is increasing rapidly among adolescents, and sites such as www.thesite.org and www.teenagehealth.org provide advice and information on a wide range of health-related topics, using appropriate language.
SECONDARY CARE SERVICES The welfare of children and young people in hospital was highlighted first in the Platt Report in 1959, and later in the Court Report, which emphasized the importance of a service centred on the child and the family. The Audit Commission looked at hospital services for all children in 1990, and the National Association for the Welfare of Children in Hospital also set standards for the care of children in hospital. Adolescents have specific psychosocial and developmental needs, which may be best addressed by separate provision; their views should certainly be sought when planning new provision.15 Recreational activities have been found to increase selfesteem and social competence in adolescents with chronic diseases. Privacy remains an important issue, and the ability to cook for themselves and access a more interesting diet has been highlighted by many adolescents. In the outpatient setting, adolescents prefer a separate waiting area ‘away from screaming babies’, appropriate books, magazines, information leaflets, posters and music. They say that they want more information from medical staff e about their condition, investigations, and proposed treatment regimes.16 Again, their preferences are not dissimilar to those of many other groups of health service users.
CONCLUSION Adolescents, despite being a relatively healthy group, have specific healthcare needs and concerns.
CURRENT PAEDIATRICS Paediatricians need to be mindful of their different beliefs about risk, and bear in mind that in this age group, whilst it is fairly easy to impart knowledge, this does not necessarily lead to behavioural change. Rather than trying to predict what services they might find acceptable and appropriate, health professionals should ask adolescents themselves.
REFERENCES 1. West P. Youth. In: Gordon D, Shaw M, Dorling D, Davey Smith G, eds. Inequalities in Health. Glasgow: The Policy Press, 1999; 12d22. 2. Young People and Health e Health behaviour in school-aged children in 1997. London: HEA, 1999. 3. Jones R, Finlay F, Simpson N, Kreitman T. How can adolescents’ health care needs and concerns best be met? Br J Gen Pract 1997; 47: 631d634. 4. Children in Mind. Audit Commission Publications, 1999. 5. Goldenring J M, Cohen E. Getting into adolescents’ heads. Contemp Paediatr 1988; 5: 75d90. 6. Balding J. Young People in 1998. Exeter: Schools Health Education Unit, 1999. 7. Cadogan J, Eastell E, Jones N, Barker M E. Milk intake and bone mineral acquisition in adolescent girls: randomised, controlled intervention trial. BMJ 1997; 315: 1255d1260. 8. West P, Sweeting H, Ecob R. Family and friends’ influence on the uptake of regular smoking from mid-adolescence to early adulthood. Addiction 1999; 94: 1397d1412. 9. Wakefield M, Chaloupa F, Kaufman N J, Orleans C, Barker D, Ruel E. Effects of restrictions on smoking at home, at school, and in public places on teenage smoking: cross sectional study. BMJ 2000; 321: 333d337. 10. Wellings K. Promoting the Health of Teenage and Lone Mothers; Setting a Research Agenda. London: HEA, 1999. 11. Churchill D, Allen J, Pringle M et al., Bradley S. Consultation patterns and provision of contraception in general practice before teenage pregnancy: case control study. BMJ 2000; 321: 486d489. 12. Social Exclusion Unit. Teenage Pregnancy. London: Stationery Office, 1999. 13. Mellanby A R, Phelps F A, Crichton N J, Tripp J H. School sex education: an experimental programme with educational and medical benefit. BMJ 1995; 311: 414d417. 14. Nicoll A, Catchpole M, Cliffe S, Hughes G, Simms I, Thomas D. Sexual health of teenagers in England and Wales: analysis of national data. BMJ 1999; 318: 1321d1323. 15. Viner R, Keane M. Youth Matters. Caring for Children in the Health Service. London, 1998. 16. Boswell K, Finlay F, Jones R, Hill P. Perceived ideal outpatient department, and hospital ward for children, adolescents and their families. Clin Child Psychol Psychiatr 2000; 5: 213d219.
FURTHER READING Coleman J. Key data on Adolescence. Trust for the Study of Adolescence. Brighton, 1997. Rogers A, Popay J, Williams G, Latham M. Inequalities in Health and Health Promotion: Insights from the Qualitative Research Literature. London: HEA, 1997. Meyrick J, Swann C. An overview of effectiveness of interventions and programmes aimed at reducing unintended conceptions in young people. London: HEA, 1998.
HEALTH ISSUES FOR ADOLESCENTS Macfarlane A. Adolescent Medicine. London: Royal College of Physicians, 1996. Audit Commission. Children First: a Study of Hospital Services. London: HMSO, 1993.
125 Jones R, Dennison C, Coleman J. Developing Indicators for Community Approaches to Health Promotion with Young People. Trust for the Study of Adolescence. Brighton: TSA, 2000.