Challenges in general practice in consultations with youths

1. Challenges in general practice in consultations with youths Seminar in youth medicine for 9th semester medical students by Ole Rikard Haavet

2. How are ethe relation??

3. Case study – part I A 15 year-old boy arrives for a consultation at the local doctor’s office. The boy’s mother made the appointment earlier that same day: the boy is often sick and during the past two weeks he has been increasingly dizzy and pale. His records show 14 consultations during the last two years; 5 from emergency room attendings and 9 from visits to your office. Diagnoses included: muscle pain, eczema, 6 streptococcal throat infections and a serious pneumonia.

4. Biopsychosocial model Predisposing factors Children Biological (sex, age, heredity) Psychological Family Parent-related Childhood Surroundings Physical health Mental stress Place of residence Triggering factors BiologicalPsychosocial Infections Dramatic incidents Trauma Chronic difficulties General practitioner First outbreak of ill-health Subsequent morbidity Moderating factors Preventative measures Inner spirit (Løvetannfaktorer) Treatment

5. Most common disease groups (SN 2000) • 39% respiratory tract infections, allergies and asthma • 22% headaches and migraines • 10-20% anxiety and depression • 12% muscle-skeletal problems

6. We need dynamical ways of thinking concerning adolescents

7. Common consultations:What is normal – what is healthy? • Body appearance (nose, ears, thin/thick, breasts development and size, extern genitalia etc.) • Relation problems (family/friends, lovers etc.) • School problems

8. What is normal – what is healthy? • Problems in job • Healthy food/eating disorders • Sport problems • Drug addiction/ dope/smoking • Sexuality

9. How often do young people with health problems seek help? Norway: • evidence suggests that adolescents visit a general practitioner approx. 3.3 times a year on average • 20 % of the total populations 15 000 000 consultations • 77% of all school aged children have consulted a general practitioner during the last 12 months (psychologists 3%, for comparison). (SSB 2002)

10. Main constituents • Statistisk sentralbyrå’s (SSB) study on standard of living showed that approx. 1 in 10 – corresponding to 90 000 young people – are the main constituents of consultations with a general practitioner. • SSB defines these main constituents as those who have more than 5 consultations yearly, meaning one consultation every other month. • The silent numbers? – Are there, for example, depressed youths who do not ask for help? • What is the physicians reaction to repeated consultations by youths?

11. The Oslo Youth Survey. Health services used last 12 mounth in % of all answered; >1(red), >3(blue) times and sex.

12. Biopsychosocial model Predisposing factors Children Biological (sex, age, heredity) Psychological Family Parent-related Childhood Surroundings Physical health Mental stress Place of residence Triggering factors BiologicalPsychosocial Infections Dramatic incidents Trauma Chronic difficulties First outbreak of ill-health Subsequent morbidity Moderating factors Preventative measures Inner spirit (Løvetannfaktorer) Treatment

13. Negative life events with impact on health(Coddington, Youth-Hubro) • pressure to achieve • longstanding negative daily surroundings • separation/divorce of parents • death of a close family member • bullying • violence • sexual violation

14. Adolescents’ health treats seems to be some of the same everywhere

15. Most common diseases - and diseases related to negative life experiences • Eczema, skin problems and asthma (SSB et al.) • Respiratory tract infections (SSB et al.) • Streptococcal throat infections (Meyer) • Anxiety • Depression • Fibromyalgia and arthritis (Vandvik) Most common causes of encounter: • 39% respiratory tract infections, allergies and asthma • 22% headaches and migraines • 10-20% anxiety and depression • 12% muscle-skeletal problems

16. Violence epidemiology • New studies indicate that a substantial number of youths have been exposed to violence (boys 29%, girls16% last year). • Girls are more vulnerable to violent acts from adults than are boys • Boys are more vulnerable to violent acts committed by other youths • This strongly predisposes for anxiety and depression for those affected - for some the so-called Posttraumatic stress disorder (PTSD)

17. 15- and 16-year old adolescents’ (n=7343) different negative life experiences correlated to health care seeking behaviour in real numbers (SHS = School Health Clinic, YHC = Youth Health Clinic, FP = Family Physician, ES = Emergency Service, POP = Psychologist or Psychiatrist)

18. 15-20% of all youths struggle with psychological problems daily (tidsskr 25/2001)

19. Treatment possibilities of depression • 15-20% of all youths struggle with psychological and somatic problems daily • Of those HSCL-10 positive for anxiety and depression (unpublished data).. • 66.5% consult a general practitioner • 7.9% consult a psychologist/psychiatrist • 1 % are admitted to the hospital • approx. 40-70 % represent a silent number ?

20. Posttraumatic stress disorder 2 - 7 % of school children (18-63000. School studies) • importunate flashbacks of events (e.g.. disturbing thoughts, sensations, nightmares, strong reactions to similar situations). • avoidance of stimuli associated with the event (e.g.. not wanting to remember, discuss or visit the place of occurrence, as well as avoiding other individuals involved, social isolation). • lasting psychological affection (e.g. disrupted sleep, aggression, difficulties in concentrating, abnormal alertness).

21. Depression results in compromised immunity Studies show that in cases of depression the right frontal lobe of the cortex becomes dominant. Corresponding serious life events seem to result in a weakened immune response. Cellular defense dominates at the expense of humoral. Additionally, cellular defense mechanisms are weakened. T-cell lymph proliferation and killer cells (Natural Killer cells) seem to be reduced by up to 40%. (Liang, S-W 1997).

22. Case study - part II The boy managed to produce work well above average at school up until around Easter a year and a half ago, after which his schoolwork has declined substantially. His parents are not aware of any mobbing. They, themselves have been very busy lately. i The family has almost no time together during the week. Nor do they eat together. The boy has quit his soccer team and sits, for the most part, in front of the computer or the television. His grandfather, which he describes as his only good friend, died during the Christmas holiday nearly two years ago.

23. What is the boys problem?3 minutes of summing with your neighbour

24. Case study part III first possibility During an extensive consultation the doctor gets the impression that the patient has had a high score indicative of depression over many years. This, however, becomes overshadowed by a clinical finding of an enlarged liver and spleen. Blood tests show a low blood percent. A blood smear gives the impression of many immature cells. The patient is therefore admitted to the hospital.

25. Biopsychosocial model Predisposing factors Children Biological (sex, age, heredity) Psychological Family Parent-related Childhood Surroundings Physical health Mental stress Place of residence Triggering factors BiologicalPsychosocial Infections Dramatic incidents Trauma Chronic difficulties First outbreak of ill-health Subsequent morbidity Moderating factors Preventative measures Inner spirit (Løvetannfaktorer) Treatment

26. What can we learn from survivors?

27. Three main characteristics of survivors(Kauai-study) • sought and found emotional support with at least one adult outside of the family • had at least one good friend • participated in an extracurricular club

29. The teenagers welcome health promotion in general practice consultations (Walker, 2002, Murdoch, 1996)

30. How to facilitate the admission to the GPs office? {Kisker, 1996, Jacobson, 2001, Akinbami, 2003} The teenagers report: • lack of knowledge of the services available from primary care • a feeling of little respect for teenage health concerns • poor communication skills • inaccurate information about confidentiality policies • lack of resources • logistical barriers

31. How to facilitate the admission to GPs in office? Logistic: • Easy to get the first appointment • Training god communications skills both in the staff and among the doctors • Consultations free of charge

32. Possible strategies of the GP • Listen, listen and listen ... to the young person • Follow up, and when needed, suggest new consultations at regular intervals • Participate in interdisciplinary teamwork • Write doctors certificate to teachers, schools i.e. in adolescents with different needs, e.g.depression • Adequate treatment

33. Diagnosis and treatment of depression • Supplies for the diagnoses of anxiety and depression in youths • Hopkins Symptom Checklist (HSCL 10) • Montgomery and Åsbergs Depression Rating Scale (MADRS) • Cognitive therapy with homework in 6 - 8 consultations • Therapy with antidepressive medication if needed

34. Diagnosis: depression and anxietyHopkins Symptom Checklist (HSCL-10)

36. Case study part IIIsecond possibility During an extensive consultation the doctor gets the impression that the boy is depressed. He is assessed using a test for depression, which results in a high score. The boy is prescribed Fontex, a medication for depression. Additionally, he comes to weekly consultations following guidelines for cognitive therapy. An attest is written to the school. After a few months time, he begins to renew contact with old friends and focuses his energy toward school and other activities.

37. The GPs’ role in society? • Make it more easy to take care of the health • Generally make visible unhealthy environmental conditions? • Trace schools and classes with high prevalence of health problems (bullying, violence etc.)?

38. Adolescents’ health problems seems to be some of the same everywhere

39. Conclusions/challenges • Adolescents in Norway are amongst the healthiest in the world. Many manage to do well, despite bad odds. Good health is however quite unevenly distributed. • There is most probably a societal health problem that affects a substantial and increasingly large group of youth (> 90 000). • As it stands today, help often comes too late. • Children and adolescents are the future: It is therefore important to view the problem in an ecological perspective.