Authors: Michelle Jacobs, Trudie Kee / Editor: Charlotte Davies / Codes: SaC1, SaC2, SaP1, SaP2, SLO5 / Published: 29/06/2021 / Reviewed: 08/10/2024
This blog is a splicing of some thoughts from Redthread, and some thoughts from the EMJ supplement. Redthread is a charity that runs a number of hospital-based Youth Violence Intervention Programmes, Young Women’s and IDVA services in hospital EDs throughout London and the Midlands. This blog was prepared by Michelle Jacobs, PEM Consultant at Northwick Park, a very busy DGH in Northwest London, who has a specialist interest in adolescent Emergency medicine and the delivery of developmentally appropriate healthcare to this age group, and Trudie Kee, Programme Coordinator for the Redthread team based in Queen Elizabeth Hospital ED in Woolwich, a busy local hospital in South East London.
Introduction
Whether you see them in your children’s Emergency Department (ED) or in adults, in minors or resus, teenagers form an important and much-overlooked group of patients. They may be on their own, presenting with an adult-type complaint but feeling very much like a child and wishing their mum or dad was there. When young people attend ED, they sometimes have professionals who are already in their lives, for example teachers, social workers, or mental health professionals. In some cases, it could be that the trusted adults in their life have let them down, and that has created a barrier of skepticism when approached with support in the future. In this blog we will talk about how to overcome these barriers, which will help you build trust with, and get the information you need from the patient to treat them and keep them safe.
Beware of adultification – treating a teenager as an adult or attributing adult-like characteristics or attitudes to them because they are seen in the adult side of ED or present with an adult-type complaint. They may look physically like an adult, but their brains are very much still developing and they have a different way of thinking from an adult.
There may be safeguarding issues (children’s safeguarding, like CAMHS, covers children and young people up to the age of 18), drug or alcohol use and/or mental health issues which may not be an obvious part of the reason they are attending your ED.
Teens are often surprisingly open and trusting of healthcare professionals and may reveal important information which they have told no-one else, especially if you have established a rapport with them.
Examples from my practice are:
- A 14-year-old girl who came to ED with an earring butterfly stuck in her earlobe. The ACP who was going to remove it went through a HEEADSSS assessment with her, and the teenager told her that she had been stockpiling paracetamol and was planning to take an overdose because she had been feeling so upset with issues at school.
- A 15-year-old boy attended an ED far from home late one evening with a hand injury. He was referred to the plastics team at his local hospital to be seen the next day. At the local hospital he was asked about why he was so far from home the night before and how he sustained the injury and he disclosed that he was involved in a County Lines operation and needed help.
- A 16-year-old was stretchered off the rugby pitch with a suspected neck injury. As he was waiting for imaging to be done, with his C-spine immobilized, I started chatting to him about his life and asked how he was doing. I was surprised when he started telling me how depressed he had been because his girlfriend had left him for his best friend. We were later able to discuss how this was affecting him and I signposted him to some local and online support.
- A 17-year-old presented with DKA. He was being treated in our adult resus room and shortly after he arrived, a patient was brought into the bay next to him in cardiac arrest. After the sadly unsuccessful resuscitation attempt I went to the 17 year old who obviously would have heard what was going on. He was very upset and scared and was alone (it was during the covid pandemic). I was able to spend some time with him explaining what had happened and reassuring him. I went to see him the next day on the ward to check that he was OK and carried out a psychosocial assessment. I received a lovely thank you letter which didn’t mention the DKA treatment but expressed his appreciation of having someone there to support him in a very upsetting situation.
Picture the Scene
A young person is sitting on the bed, we know that they have been a victim of an assault, their face is swollen and they are clearly in pain. They are refusing treatment and being verbally aggressive with staff.
What do you do in this situation?
There are many ways this could go – some clinicians might give them time to calm down before attempting treatment and some may refuse treatment due to their behaviour. Whatever you do, Redthread advises every clinician to step back and think: what brought this young person here? Who is supporting them during their distress? In this situation it is clear that the young person needs treatment they are refusing, so the priority here is to get them to engage with you through de-escalation and emotional containment.
Use the tools you already have:
The familiar AIDET acronym is a great foundation to develop your interaction with young people. In a blog by Charlotte Davies in November 2020 on communicating with patients in the emergency department, she writes:
“Patient communication in the ED serves several purposes. You want to get information from the patient, which needs rapport and skill, but you also want to give the patient information whilst maybe using your words to treat.
“AIDET” is one framework that might help. Many of you will complete components of this subconsciously and intuitively”
Using this familiar acronym as a foundation can help you develop your interaction.
In addition to this, the HEEADSSS assessment (or other psychosocial assessment) offers a useful framework for exploring a young person’s circumstances and, though you may not want to undertake a full HEEADSSS assessment when a young person is in crisis, you can select parts of the assessment that can be used to talk with the young person, to build rapport and put them at ease. HEEADSSS takes just a few minutes but can uncover some really important healthcare issues which you can support with or signpost to appropriate services. Or, if unsure, ask a colleague for help. Don’t just save HEEADSSS assessments for adolescents who have self-harmed or in whom you suspect there may be issues.
Consider childhood trauma or mental trauma:
It’s useful to understand here the mental state of a young person following a traumatic injury or crisis in a new environment. They may be fearful of the negative consequences of speaking to professionals, including doctors and nurses. These negative consequences could involve further physical or emotional violence, something that anyone would want to avoid. This fear can create conditions that activate the amygdala, the threat-response centre of the brain, causing young people to behave in ways that seem challenging or disruptive to professionals who are offering care. For more information on the trauma-informed approach Redthread use, check out this article in the RCPCH’s Milestone Magazine (pages 18-19).
Communicate on a person to person, not clinician to patient level:
Redthread sometimes see clinicians engaging first, or even exclusively interact with the older adult (i.e. a parent, or police officer, perhaps) in the room. Acknowledging the young person directly can help in some way to build rapport, even if that leads to them directing you to the parent or guardian in the room.
Introduce yourself
Explain your role (avoiding hospital jargon if possible), make eye contact, be patient and aware that you may need to repeat yourself. Ask yourself: are their basic needs being adequately met? Is there more that can be (reasonably) done to make this young person feel as safe and comfortable as possible?
Be Inclusive
It’s also important that the young person is part of the discussion about their treatment plan, and is able to give consent to procedures. Alongside this, making sure that they understand what treatment they will be having and how long they are likely to be in the emergency department empowers the young person to take control of a stressful situation, which could help rebuild their trust in professionals. Involving the patient by letting them ask questions of you is a simple yet effective way to give them space to process their ordeal.
Breaking down barriers can help to create an appropriate plan of care with a patient. At Redthread, safety planning is an immediate priority, and we often provide emotional containment for young people at the bedside, which helps support clinicians to build rapport and open up to both the YVIP service and further treatment.
Be curious and stay curious:
As humans, each of us have our unique experiences of the world. Young people are exactly the same, and it’s important not to assume an understanding of any one situation. Be curious, asking open-ended questions like “Tell me about being in school these days?” in, for example, the context of a school-based assault. Connecting over our differences can be just as important as finding common ground.
It’s very important to listen to young people and their wishes. Where you have a legal obligation to report your concerns, be honest about the reasons for this with them to show them that this is something that you must do in order to better safeguard them. In the case below, as this young adult was 18 at the time, they had a choice to report to the police or not – a decision which should have been respected.
Multi-Agency Working
Communication and Multi-agency working in such complex situations is key. We can’t expect a busy emergency department to perform the same function as an inpatient ward, however, what clinicians should do is refer to your safeguarding team and make the appropriate referral to children’s social services or CAMHS. Where Redthread or another Hospital Youth Violence Intervention Programme is available, you can utilise our holistic support (if needed). In the cases above, referrals were made and the Redthread team were able to provide immediate emotional and practical support which helped progress these cases towards discharge and led to follow-up support in the community.
Here are Michelle’s 10 top tips for communicating with teens:
1 Talk directly to them, not to parents or others, though others can obviously be included where relevant. (Psychosocial assessments are usually best done without parents/carers present). Communicate clearly about what is going on and what the plan is so they are fully aware.
2. Try to convey information at an appropriate level – some teens will be more like children in their reaction to a situation and others will be able to understand more like an adult. Start off simple and check understanding, then give more detail as needed.
3. Think carefully about what you say and how you speak to teens. They do not want to be in your ED and attitudes about time wasters or trivialising their issues are unhelpful and damaging. This may be the only contact they have with a healthcare professional, and you may be the only person they share this information with.
4. Trust them to be telling you the truth about how they are feeling and what is going on. They also have to be able to trust you, and you should explain that your conversation will remain confidential if they don’t want information shared, unless you feel that they or someone else is in danger.
5. Translate: listen to what they have to say and don’t be afraid to ask for explanations if they use terms or expressions you are not familiar with. Teens know that many of us older people may not speak their language and are usually more than happy to explain what they mean!
6. Toggle: feel able to jump between different areas of the psychosocial assessment, don’t feel you have to follow in order. They may want to speak about some aspect in particular which is important to them or causing them difficulty.
7. Thorough: do include all aspects of the psychosocial assessment, focusing on those where help may be needed.
8. Be Truthful: don’t promise things you cannot deliver but assure them that you will support and assist them as much as you are able.
9. Terminate the conversation if you are upsetting them or if they just do not want to talk. Explain that you will come back later to discuss further if wanted (and make sure you do that).
10. Thank them for sharing information: tell them that you really appreciate them being so open and trusting of you.
Want to know more about the work we do?
Website: http://www.redthread.org.uk
Email: [email protected]
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Further Links
- Cappelli M, Gray C, Zemek R, et al., The HEADS-ED: A rapid mental health screening tool for pediatric patients in the emergency department. Pediatrics. 2012; 130(2):e321–7.
- RCEMLearning, The Forgotten Tribe – adolescents in ED. 2021.
- RCEMLearning, Communication in ED. 2020.
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