| ||||||||||||||||||||||||||||||||||||||||||||||||||
Adolescence and associated behavioural problems
GPST1, East Midlands deanery
E-mail: jamini81{at}hotmail.com
 |
Abstract |
|---|
 TOP Abstract What does the GP...Physical changesEmotional and psychological...Social changesReferences |
|---|
Adolescence is a time of physical, emotional and social change, marking the transition from child to adult. This usually begins at the age of 11 in girls and 13 years in boys and typically concludes by the age of 17.
|
During this period, conflict can result in problems at home, school or in the community. If these problems are managed poorly, it can have a profoundly devastating impact on their future adult development.
As a general practitioner, your opinion may be sought by the individual themselves or by a parent or guardian. Hence, it is important to be able to differentiate between that of normal physical and emotional changes against those that indicate an underlying medical or psychological disorder. This article aims to cover some of the behavioural problems that can arise during this complex period of time.
|
Physical changes |
|---|
|
TOPAbstractWhat does the GP...Physical changesEmotional and psychological...Social changesReferences |
|---|
The physical changes that characterize adolescent development can reflect a time of great activity (Table 1). There is usually a desire to fit in with their friends, so anything that differentiates them from this is likely to be unwelcome and potentially can be a source of bullying.
|
You may be consulted in general practice as to why the changes have not occurred or not as rapidly as the adolescent may wish. Here, it is important to provide reassurance, but exclude delayed puberty first. Delayed puberty is defined as no pubertal changes in a girl aged 13 years or a boy aged 14 years or the failure of developmental progression over a two-year period. Most cases of delayed puberty are due to constitutional delay which tends to run in families. However, it is important to consider other causes listed in Table 2.
|
Appearance becomes increasingly important during adolescence. Peer pressure can lead to the adolescent dressing a certain way in order to be accepted by their friends and to avoid rejection. They are exposed to media images in magazines and television promoting a uniform type of beauty and thus the adolescent may feel pressure to conform to this. Adolescents may start to worry about their weight especially due to the physical pubertal changes they are undergoing. Anorexia nervosa is rare but this age group is particularly vulnerable. Conversely, junk food consumption is high among adolescents. Obesity is increasing amongst this age group which is leading to earlier presentations of diabetes.
Acne is a common skin complaint occurring in up to 85% of adolescents due to rising androgen hormone levels. Characterized by comedones, inflammation and pustules, it commonly affects the face and trunk. Clinical depression, social phobia and certain anxiety disorders have been associated with acne. The severity of acne has been shown to determine the extent of the embarrassment to the individual. Their perception of their body image can lead to lack of self-confidence resulting in withdrawal from their social activities such as going swimming with friends. Adolescent girls are more vulnerable than boys to the negative psychological effects. Hence, it is important not to belittle the importance of acne to the individual and aim to treat acne appropriately to the level of severity.
|
Emotional and psychological changes |
|---|
|
TOPAbstractWhat does the GP...Physical changesEmotional and psychological...Social changesReferences |
|---|
Adolescence marks a period of emotional and psychological variability and development. Most adolescents are noted to have ‘mood swings’ which is simply a rapid change in mood. These are attributed to hormonal changes and settle once hormones normalize.
This may be the first time in their lives that they will value the opinions of their peers rather than their parents. They will start to form their own views on life which may not necessarily be shared by their parents and there are likely to be disagreements because of this. Parents may feel rejected by their child's growing independence. Parents need to be reassured that an important part of adolescence is finding one's identity. Adolescents may demonstrate reckless behaviour and parents should be advised to set appropriate boundaries and rules.
It is important to differentiate between normal adolescent behaviour and possible psychiatric illness. One should consider the possibility of a psychiatric illness if moods are not noted to change that is mood is persistently low or there is a sudden deterioration in family relations, friendships or schoolwork. Overeating, excessive sleepiness and a persistent overconcern with appearance may be signs of emotional distress. Anxiety may produce phobias and panic attacks. If symptoms have continued for a few weeks, this is less likely to be normal adolescent behaviour. Some common psychiatric illness are explained below.
Schizophrenia
Although rare before the age of 18, schizophrenia can manifest in the adolescent years. Features that should alert a practitioner to the possibility of schizophrenia in an adolescent are
- extreme moodiness
- trouble telling dreams from reality
- confusing television with reality
- problems in making and keeping friends
- severe anxiety and fearfulness
- behaving like a younger child
- self-neglect
- vivid and bizarre thoughts and ideas
- thought withdrawal, insertion and broadcasting
- paranoia: ideas that people are ‘out to get them’
- visual and auditory hallucinations
An urgent referral should be made to the Child and Adolescent Mental Health Service (CAMHS) if a diagnosis of schizophrenia is suspected. A specialist from this service will carry out a detailed psychiatric assessment and arrange admission. Patients are likely to require hospital admission especially if the adolescent is acutely disturbed or they are at risk of harming themselves or others. Treatment of schizophrenia is initiated within the specialist mental health service setting and is usually a combination of antipsychotic medications and psychological therapies. Psychological therapies including cognitive behavioural therapy (CBT) and family interventions are available within CAMHS and the adolescent will be referred to these if appropriate by their specialist. The adolescent and their family will require education about the illness and the importance of medication compliance.
A community psychiatric nurse will be assigned to the patient once they are discharged from hospital and they will follow their progress at home. Details regarding rapid access to CAMHS if relapse occurs should be provided to the patient and family on discharge from hospital. The outcome of any medications initiated will be reviewed with the outpatient setting by a consultant child psychiatrist.
As a general practitioner, it is important to have regular reviews with the patient. The frequency of these should be agreed with the adolescent. These reviews should include:
- An assessment of medication compliance
- An assessment for side effects of their medication
- Routine physical examination including monitoring weight
- Routine urine/blood screen for diabetes if patient on antipsychotic such as olanzapine which is associated with hyperglycaemia
- Selective tests for other endocrine disorders depending on medication—certain antipsychotics are associated with hyperprolactinemia
- Promotion of a healthy lifestyle: diet, exercise and smoking cessation
- Assessment of support network. If it is felt the family structure is poor, consider referral to social services
Depression
The Royal College of Psychiatrists states more than one in five adolescents think so little of themselves that life does not seem worth living. Depression in adolescents can be difficult to diagnose due to the normal variant of adolescent emotional highs and lows. Girls are twice as likely to suffer from depression as boys; other risk factors are listed in Box 1.
| Box 1. Risk factors of depression Life events—divorce, death of a parent Family history of depression Chronic illness Abuse Unstable family environment
|
The patient may not state they are feeling ‘sad’. They may use the words ‘grumpy’ or ‘irritable’ instead. Their mood is persistently low. They will have low self-esteem and will not be able to foresee a future for themselves. The patient will have low levels of energy and lack motivation. Anhedonia is also present. They may have feelings of guilt. For example, adolescents are likely to feel responsible for a parental divorce. There may be weight gain or loss attributing to changes in eating patterns and sleep is often disturbed. Early morning wakening is usually characteristic of depression. Some patients may have suicidal ideation. Hallucinations and delusions are rare. Some young people may present in the surgery with general aches and pains such as headaches or musculoskeletal pain which may be masking an underlying depressive illness.
Take a thorough history identifying which symptoms are present and for how long. Identify risk factors, assess suicide risk and the support network the patient has. The WHO ICD 10 criteria (Table 3) provide information to assess severity.
|
There are four possible management options within the primary care setting as advised by NICE:
- General advice and watchful waiting
- Active treatment within primary care setting
- Referral to mental health professionals CAMHS
- Urgent referral to psychiatrist
If mild depression is present or the patient declines any intervention, watchful waiting is advised. You should arrange a further appointment to assess the situation within 2 weeks. It is important to follow-up patients who fail to attend appointments. If after 4 weeks their symptoms have not improved, then consider offering individual non-directive supportive therapy or group CBT for 2–3 months. These services should be available within the CAMHS setting. If they do not respond referral should be made to CAMHS for assessment by a consultant child psychiatrist.
Urgent referral is required if there is high risk of self-harm or suicide and/or if there is significant ongoing self-neglect such as anorexia which could be detrimental to their physical well-being or lack of personal hygiene. Admission may be required and a care plan can be developed by the specialist in CAMHS.
Antidepressant therapy should not be used as first-line treatment of young people with mild depression. In children with moderate to severe depression, psychological therapies such as CBT, interpersonal therapy or shorter term family therapy is offered as first line. These therapies are available through CAMHS after review by a specialist. Antidepressant therapy is used in conjunction with this if required and is also commenced by a specialist. Once commenced on medication, the general practitioner should monitor the adolescent for compliance and adverse effects of medication. The adolescent should have their mental status reviewed initially on a weekly basis for the first month and then at regular intervals depending on the patient and their clinical need. The patient should be reviewed by a specialist before medication is changed or stopped.
Hyperkinetic disorder
Hyperkinetic disorder or attention deficit hyperactivity disorder (ADHD) is classed as a developmental disorder. Its incidence is approximately 3–5% among school children. It is 10 times more likely to occur in boys than girls. Diagnosis is made using the WHO ICD 10 criteria for hyperkinetic disorders which encompass three main symptoms of impulsivity, hyperactivity and inattention (Box 2). These symptoms need to be present for at least 6 months and a diagnosis of ADHD is usually made before the age of seven. However, more and more young adults are being diagnosed with ADHD.
| Box 2. ICD 10 criteria for hyperkinetic disorders Lack of persistence in activities that require cognitive involvement Tendency to move from one activity to another without completion of either one Disorganized, ill-regulated and excessive activity They are often reckless and impulsive and therefore more prone to accidents They find themselves in trouble usually due to not thinking before acting rather than deliberate disobedience Relationships with adults are often disinhibited They are unpopular with other peers and may become isolated Impairment of cognitive functions is common and specific delays in motor and language development are disproportionately frequent. Secondary complications include dissocial behaviour and low self-esteem
|
The assessment of the behaviour must take into consideration the age and developmental maturity of the patient. The same behaviour that is acceptable in a 5 year old may not be appropriate in a 10 year old. If one suspects a diagnosis of ADHD, referral to a specialist in the field is required such as a child psychiatrist or a paediatrician with relevant expertise. Diagnosis is based on assessing the patient's behaviour in their normal environment. Ideally, additional information should be obtained from the patient's parents, teachers and other appropriate health-care staff to aid diagnosis. Consent will be required from the patient and family to discuss medical issues with non-medical staff such as the patient's teachers.
Management should provide education, counselling and family support. Cognitive behavioural therapy can be beneficial. Central nervous system (CNS) stimulants have been shown to be very effective. Methylphenidate, atomoxetine and dexamfetamine are all used. These should be commenced by the specialist but monitoring of the drug therapy can be done by general practitioners under shared care arrangements. Emphasis needs to be made on the importance of compliance to the family. Individuals involved with the adolescent such as teachers should ideally be made aware of the diagnosis, but this should be left at the discretion of the patient and their family. Signs of ADHD may continue into late adolescence and adulthood. Patients with ADHD are more likely to have further problems in later life such as unemployment, substance misuse and participation in criminal activities.
|
Social changes |
|---|
|
TOPAbstractWhat does the GP...Physical changesEmotional and psychological...Social changesReferences |
|---|
A period of social change usually involves the development of an important social circle to the adolescent where they will highly value the opinions of their peers. This may lead to peer pressure and risk-taking behaviours.
School problems
School is an important part of an adolescent's life and problems can occur around this. The pressure of exams and fear of not performing well can result in anxiety. Parents need to be advised to be supportive and not add to the stress of exams.
School refusal
School refusal is a term used to identify children who fail to attend school due to attendance causing extreme anxiety or emotional distress. It is not a psychiatric diagnosis but rather a term to define behaviour. It was formerly known as school phobia and has been present since the early 1940s. School refusal is a difficult problem and is one that you are likely to encounter in general practice. It is estimated that 2% of children will have an ongoing problem with school refusal. Although it can occur at any school age, it peaks at key transition times 5–6 years (school entry), 10–11 years (transfer to secondary school) and 14 years (adolescence),
Possible of causes of school refusal are
- Difficulties in separating from parents
- Family event: death, divorce, financial problems and move
- Difficulty with academic workload
- Bullying—at school or on the way to school
- Difficulty to adjusting to school routine environment after a period of absence due to illness
The symptoms of school refusal are gradual. They are likely to occur following a period away from school that is a weekend or school holiday. The following symptoms may occur:
- Crying episodes
- Fearfulness
- Temper tantrums
- Panic symptoms
- Threat of self-harm
- Somatic symptoms: gastrointestinal—abdominal pain, nausea, vomiting and diarrhoea; autonomic—palpitations, chest pain, dizziness and headaches; muscular—aches, back and joint pains
The symptoms classically improve if the adolescent is allowed to stay at home.
The main aim of management is to achieve early return to school through gradual exposure. The longer an adolescent is away from school, the more difficult it is for the adolescent to return.
When the adolescent first presents in the GP setting, it is important to talk to the adolescent and parents together and then if possible separately. Talking to the adolescent in private depends on his or her willingness to do so and an assessment of Gillick competence. The consent of the adolescent is required to discuss the problem with his or her parents separately. This provides an opportunity to ascertain any underlying reason for the school refusal such as social, financial or recent traumatic events. It is important to liaise with the school which may provide some further insight into underlying problems.
If the adolescent is presenting with physical symptoms, it is important to exclude other causes before attributing this to psychological distress. If a reason is identified such as bullying or family problems, an appropriate solution can be found such as liaison with school or family support counselling. However, if the problem persists or there is suspected associated anxiety and depression, a referral to a child psychiatrist is appropriate.
Truancy
Truancy is a term used to describe any intentional unauthorized absence from compulsory schooling. It is estimated that 63 000 pupils truant every day resulting in a truancy rate of 1.42%. The rate is steadily rising in the UK. In contrast to school refusal, there is no associated fear or anxiety in attending the school itself. Other features suggestive of truancy rather than school refusal are
- The adolescent will hide his school absence from parents
- They often truant with other antisocial peers
- They do not stay at home while truanting
- There is a lack of interest in their academic studies
- They may demonstrate antisocial behaviours such as lying or stealing
|
As a general practitioner, identify any reasons that may be a cause of the truancy. Adolescents that truant are likely to have family problems at home such as an absent father. They tend to come from poorer backgrounds. Parents may report that the adolescent has shown disruptive behaviour towards them or other members of the family. Offer counselling and support services if family issues are the cause of the problem. If possible, liaise with the school to identify other reasons for absence such as difficulty with the schoolwork or problems with particular teachers. It is important that the school and parents work together to reintroduce the adolescent back into school. Truants are unlikely to respond to psychiatric therapies and therefore referral may not always be appropriate.
Drug abuse
Many adolescents will experiment with drugs, alcohol and smoke cigarettes. Alcohol is the most common drug that is abused. Cannabis is also used and this can worsen mental health problems and double the risk of developing schizophrenia. However, solvent abuse is particularly relevant to this age group due to low cost, availability and the ease of use. It is estimated that 10% of secondary school children have tried solvents at least once. Solvent abuse is the inhalation of vapours emitted from various products such as glues, paints, propellant gases in aerosols and nail varnish removers. These products are carbon based and emit either a vapour or are gases at room temperature which on inhalation via the mouth or nose can provide effects similar to alcohol. The effects upon inhalation begin immediately and can last up to 45 minutes. They include:
- initial feeling of euphoria
- disorientation
- slurred speech
- dizziness
- blackouts
- hallucination
Cardiac arrhythmias or bronchoconstriction may occur. The after effects of the drug are lack of concentration and fatigue. Long-term inhalation may result in CNS damage such as loss of cognitive functions, gait disturbances, and loss of coordination. It has been suggested that 2% of all deaths among adolescent males may be due to recreational solvent abuse.
Solvent abuse may be difficult to identify in the general practice setting. Features of abuse include:
- sudden behavioural change
- breaking curfew or other rules assigned to them
- lying
- isolating themselves—that is always staying in their room
- mood swings—verbally or physically abusive to others
- poor performance at school
- solvent smell
- stealing
- recent change in friends
If solvent abuse is suspected refer to the appropriate youth drug services.
Trouble with the law
Most adolescents do not break the law and if they do, it is usually only once. Males are more likely to commit an offence. Recurrent offenders are likely to either come from a background where family members or friends also commit crime. Unhappiness may lead to behaviours that get them into trouble. Other common reasons why an adolescent may commit crime are peer pressure, drug and alcohol abuse and mental health problems such as ADHD. They may often be truant from school and lack education. It is important to ask repeat offenders about their feelings to assess for any distress that is resulting in law-breaking behaviour.
Key points
|
|
References |
|---|
|
TOPAbstractWhat does the GP...Physical changesEmotional and psychological...Social changesReferences |
|---|
-
Department of Health publication. The mental health and psychological well-being of children and young people. National Service Framework (2004) Accessed via www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4089114 [date last accessed 01.09.2008].
Fremont W. School refusal in children and adolescents. American Family Physician (2003) 68:1555–64.[Medline]
Krowchuk DP, Stancin T, Keskinen R, Walker R, Bass J, Anglin TM. The psychosocial effects of acne on adolescents. Paediatric Dermatology (1991) 8(4):332–8.
National Foundation for Educational Research. Provision for pupils who are regarded as school phobics. Accessed via www.nfer.ac.uk/research-areas/pims-data/summaries/provision-for-pupils-who-are-regarded-as-school-phobics.cfm [date last accessed 05.07.2008].
NICE Guidance. Schizophrenia: core interventions in the treatment and management of schizophrenia in primary and secondary care (2002) Accessed via www.nice.org.uk/nicemedia/pdf/CG1NICEguideline.pdf[date last accessed 30.08.2008].
NICE Guidance. Depression in children and young people: identification and management in primary, community and secondary care (2005) Accessed via www.nice.org.uk/nicemedia/pdf/cg028fullguideline.pdf[date last accessed 07.07.2008].
NICE Guidance. Methylphenidate, atomoxetine and dexamfetamine for attention deficit hyperactivity disorder (ADHD) in children and adolescents (2006) Accessed via www.nice.org.uk/nicemedia/pdf/TA098guidance.pdf [date last accessed 07.07.2008].
RCGP. Curriculum Statement 8: Care of children and young people. Accessed via www.rcgp-curriculum.org.uk/PDF/curr_8_Care_of_Children_and_Young_People.pdf [date last accessed 01.09.2008].
Thambirajah M. Case studies in child and adolescent mental health (2007) Oxford: Radcliffe Publishing. ISBN: 1857756983.
The Royal College of Psychiatrists. Adolescent behaviour. Accessed via www.rcpsych.ac.uk/mentalhealthinformation/youngpeople.aspx [date last accessed 23.09.2008].
The Society for the Prevention of Solvent and Volatile Substance Abuse. Accessed via www.re-solv.org.
World Health Organisation. Mental and behavioural disorders. Accessed via www.who.int/classifications/apps/icd/icd10online/ [date last accessed].
CiteULike 
Connotea 
Del.icio.us What's this?
| ||||||||||||||||||||||||||||||||||||||||||||||||||