The Forgotten Tribe

Author: Lauren Fraser, Michelle Jacobs / Editor: Charlotte Davies / Reviewer: Lauren Williams /  Codes: SaC3, SaP1, SaP2, SLO5 / Published: 23/03/2021 / Reviewed: 19/11/2024

Here is a whistle stop tour of adolescent medicine as it applies to the ED and 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 18^th 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.

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”

 

When used, the HEEADSSS assessment found 30% of young people to have a health or wellbeing 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. There are some excellent voluntary organisations in place to specifically support young people, many of which the young person can refer themselves to. This Young Person’s Wellbeing Guide is one example that was co-designed with for a 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 challenging. A parent or carer of adolescents under the age of sixteen should be involved in their care, however You should aim to spend at least some time with the young 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.

There is some excellent e-learning available on the We Can Talk website, including a one hour e-learning module on the fundamentals of compassionate care training. This training has been co-produced by young people, hospital staff and mental health professionals and provides 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.

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.

If you have any concerns regarding the safeguarding of young people and adolescents, 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.”

Where possible, try to have these sensitive and personal conversations with young people in a private space surrounded by walls and not just ‘magic NHS curtains’.

How can I further support adolescents and young people to feel more at ease in our emergency department?

A survey into the experiences of adolescents in the emergency department reported that only 62% felt safe. In this study, 82% of adolescents stated that listening to music would help alleviate the stress they experienced in the ED. As we are all aware, many young people now present with their own phones and devices to listen to music on but does your department have Wi-Fi, spare chargers or even headphones they can use? Is there the possibility to have a separate section in the waiting area, away from the tantruming toddlers, which has some different reading materials, games or a TV which isn’t showing Mr Tumble on repeat? The RCEM blog on ‘play’ has some specific tips for adolescents and young people – including the potential use of virtual reality!

Finally, in March 2023, a Paediatric Emergency Medicine Advisory Group produced an official RCEM document outlining optimal ‘Management of Adolescent/Young Adult (AYA) Patients in the Emergency Department’. The full document can be found here. The summary of recommendations¹:

1. The clinical area where adolescents are assessed should be appropriate for their needs.
2. Staff assessing and caring for AYA patients should have specific training in how to undertake this task. This training should include communication, managing issues specific to the adolescent population and the importance of psycho-social assessment.
3. If a patient needs to be admitted to hospital, there should be a clear policy of where and under which clinical team adolescent patients should be admitted.
4. Assessment of adolescent patients should always include consideration of a form of psychosocial assessment.
5. There should be close cooperation and communication between emergency departments and CAMHS/psychiatric liaison services to ensure effective mental health care for this population. 
6. AYA patients are a vulnerable group and clear procedures for reporting concerns to safeguarding teams, social services and the police should be in place. In areas where violence is endemic violence reduction programs should be in place.
7. The management of AYA patients who refuse medical treatment is complex. Senior clinical staff should be consulted in this scenario.
8. There should be a senior member of medical staff identified to lead the design and development of emergency department services for adolescent patients.
9. The design and configuration of services should involve consultation with AYA patients.