Author: Lauren Fraser, Michelle Jacobs / Editor: Charlotte Davies / Codes: PAP6, SaP2, SLO5 / Published: 23/03/2021
This week marks the annual International Adolescent Health Week and in celebration we present a whistle stop tour of adolescent medicine as it applies to the ED and discuss some hints and tips on how to improve the ED experience for adolescents whilst also increasing your confidence in supporting the needs of this sometimes tricky age group.
Why all the fuss about teenagers…? What’s the case for young people’s health?
Despite having specific and defined needs, young people often find that they fall into the gap between the current provision of paediatric and adult healthcare services. In England, legally a child is defined as “anyone who has not yet reached their 18th birthday”. However, there is no consistency across the country with regards to the upper age limit of Paediatric EDs and, once admitted, whether 16 and 17 year olds (or sometimes older) go to paediatric or adult wards.
The health of our adolescents is vitally important as getting this right will lead to a healthy adult population. Emergency presentations for those aged 16-19 years old in England have increased three-fold over the past decade. Adolescents and young adults (AYA), those aged 16-24, have high levels of mental and sexual health problems, alcohol and substance misuse as well as injuries. Those with long-term conditions are more likely to exhibit risky behaviours.
As we are all very aware the Coronavirus pandemic has provided many challenges for healthcare services across the world. Fortunately, we have seen very few children or young people physically affected by the virus itself; however, this age group has been significantly impacted in many other ways, often in relation to the social determinants of health, and this has influenced the type of presentations we are now seeing of adolescents in our EDs.
How do I know what the “biopsychosocial developmental needs” of each individual young person I see are?
The simplest approach is to follow the HEEADSSS assessment. This is something RCEM advocates for as part of the 2019/20 Care of Children National Quality Improvement Project. This infographic from EM3 covers all the basics:
“If you don’t ask, they won’t tell”
This phrase is taken from the RCP Acute Care for Adolescents and Young Adults Toolkit. When used, the HEEADSSS assessment found 30% of AYAs to have a health need requiring intervention. That’s not a bad yield!
This HEEADSSS app, created by the team in Southampton, provides a selection of questions to enable you to address each of the relevant topics. If you identify any issues through these questions they provide a number of relevant organisations that you can text or email the details of to the young person.
And how do I offer health education and promotion within the time constraints of a busy ED?
You may want to think about collating links to resources relevant to your local area, and then ensure they are easy to access by young people, whether for themselves or to enable them to support a friend in need. This Young Person’s Wellbeing Guide is one example that was co-designed with our local young population.
What if they won’t talk to me?
Knowing how best to communicate with young people when they are unwell or distressed can be very daunting. You should aim to see the person alone and somewhere private.
Explain who you are and what your role is. Explain what is going to happen and be frank about the limits of confidentiality (covered in this RCEMLearning blog – the 3cs of paediatrics).
Above all be friendly, open and calm.
This short We Can Talk e-learning module, which works brilliantly on a mobile, is created with young people and has some simple, yet effective, pointers on how you can become more confident in your approach to talking with young people.
They also have a fantastic online bank of top tips.
There’s even a national training league table so you can challenge your colleagues to get your Trust to the top!
You may find that using the HEEADSSS structure to chat with a young person in the ED highlights some harmful influences and risks which exist outside of the family environment and over which the young person’s parents and/or carers can exert limited, or no, control. This is becomingly increasingly recognised by agencies that safeguard children and young people.
Contextual Safeguarding is an approach to “understanding, and responding to, young people’s experiences of significant harm beyond their families”. The concept was developed by Dr Carlene Firmin at the University of Bedfordshire and is described by her in this great TED Talk.
The risk of criminal or sexual exploitation, often as part of “county lines” activity, may be one such risk that can present to the ED in many different guises, e.g. following recreational drug ingestion, as a result of an injury, as abdominal pain related to a STI or even a mental health crisis.
Remember, not every young person presenting with a seeming “mental health crisis” has an underlying mental health disorder. There may be many other factors at play that need addressing, as covered in this blog.
For those under the 18 it is likely to be appropriate to make a referral to Children’s Social Care (aka social services) to safeguard the young person and ensure they have appropriate support once it is safe for them to be discharged. Follow your local safeguarding processes and policies.
I can see the importance of asking the right questions next time I see a young person but I’m not sure my department has anywhere that is particularly “adolescent friendly” to see them in. What can we do to make an improvement on this?
Don’t worry, you’re not alone as Michelle Jacobs explains…
“It came to me as I was standing in the bay in our Children’s ED taking a sexual history from a 14 year old girl who had presented with abdominal pain.
On one side of us in the bay was a couple and their grizzly baby in a cot, on the other side was a young boy on a trolley who had injured his leg and was waiting with his dad for an X-ray and review.
Around us were those “magic sound proof NHS curtains” which we all have in our departments.
It suddenly felt very wrong to be asking these sensitive questions from a teenager in this environment.
Later, working on the adult side of our ED, I saw an older teenager who had self-harmed looking anxious and uncomfortable in our Majors area, populated by several elderly patients, one of whom was confused and calling out for help.
This might be considered a normal day in the ED, but it made me think that we should be doing things differently for this group of patients and better addressing their particular needs.”
In my research 32 EDs out of 50 had separate Children’s EDs but only 5 had specific provision for teenagers. This included separate cubicles with neutral décor, age appropriate healthcare info leaflets, DVDs, and Wi-Fi access.
In my hospital we have formed a special interest group specifically looking at the needs of Teenagers and Young People (TYPSI). This group is made up of healthcare professionals (doctors, nurses, community nurses and play therapists) as well as volunteer services and our Trust Comms team. Our successes so far include:
- using charitable funds to buy a mobile trolley stocked with age appropriate books, games and puzzles
- training youth volunteers to go to the wards and spend time chatting/playing games with teenagers and young people who are inpatients
- development of a TYP logo which is added to badges for volunteers to wear so they are a distinct group and on white board magnets for patient lists so that staff have a visual reminder
We are also trying to find a space within the hospitals for Teenagers and Young People to be able to sit and relax/access devices etc away from ward based and clinical areas. This is proving very difficult in our old and overstretched hospital (we are getting a new one soon, apparently!)
We have lots of other ideas – many of these do not cost large amounts of money and are simple to bring about. The key is having a group of people who can champion and publicise the work (I have spoken at divisional clinical governance and other departmental and local meetings to spread the word).
Right, now we’ve captured your attention, use the resources below to find out more about Adolescent Health and start thinking about how you will influence, for the better, provision of developmentally appropriate healthcare in your ED!
- Wear lime green and follow the events occurring on social media as part of International Adolescent Health Week @IAHW2021
- Sign up for the College’s informative “The forgotten tribe: adolescents in the emergency department” study day on 08/06/21
- Join RCPCH’s Young People’s Health Special Interest Group
- Read WHO’s Adolescent and young adult health factsheet