It's true; I say this about about every age, but I really, really love caring for the #adolescent client. I think it's because they are so misunderstood and so often neglected in healthcare. Did you know that medical residency programs only require one month of adolescent training from an adolescent specialist for all pediatric residency programs? I think most of healthcare, and our culture as a whole, is starting to realize that we need to get serious about addressing the unique needs of our adolescents.
I've talked about the average primary care visit being only 6 minutes, which includes your sharing and your clinician's time making decisions, prescribing and getting you out the door. This is largely why I chose to create own practice nearly twenty years ago now, because I want to spend time with clients and make connections. It's important especially that adolescents feel safe and that they can trust they will be respected and can make decisions in the healthcare that will impact them, but also, I love teaching people about their health and wellness. This is really fascinating stuff we do, but not just physical health, also emotional regulation and even building a relationship with nature and empowering every client I meet to step into being their own healer.
Adolescence is defined as those between the ages of 11 years and 21 years (Alderman & Breuner, 2019). It's interesting to me that most of us don't think of the 18 to 21 year olds as adolescents, but in fact these are the later adolescent years because medically speaking, there is still a lot of maturing happening during these years. This is also the time kids start to become more autonomous and begin making more decisions for themselves. A significant concern for the adolescent is that they start to become exposed to scenarios that they are not often well prepared. They are also taking more risks. In fact, most visits to their primary care visit is for seeking treatment for conditions or injuries that could have been prevented if screened and addressed earlier in wellness visits.
Certainly some of this risk-taking behavior is a normal part of their development, engaging of some of these activities can be quite dangerous and have life long impact. Most adolescent morbidity and mortality is preventable and unintentional. Approximately 72% of deaths among this age group is related to an injury from motor vehicle crashes, other unintentional and intentional injuries, injuries caused by firearms, alcohol or illicit substances, or even homicide or suicide (Alderman & Breuner, 2019). These causes of death far exceed those from cancer, HIV infections, and heart disease.
One of the great travesties in healthcare is that clinicians simply haven't the time to really counsel and educate their clients, or even listen to them if I am honest. Seventy-one percent of adolescents report having at least one high risk factor for serious morbidity or mortality, but this is only even discussed in about 37 percent of visits (Alderman & Breuner, 2019). Chronic medical conditions are becoming much more common among adolescents as well. It's really very alarming to me even, how often I am diagnosing hypertension, elevated cholesterol, diabetes, mental health disease and even liver disease in my adolescent clients. A third of all adolescents have at least one moderate to severe chronic illness. One in four adolescents have at least one unmet health need that may affect their physical growth and development into adulthood.
Having a smaller private practice with minimal overhead, and admittedly, not having to jump all the hoops required for third party reimbursement, I have the freedom to just sit and listen and connect with my clients. I can get into good conversation and explore some of the areas of their life that as parents, sometimes we just don't think about among all the other demands we juggle. Sometimes as parents too, we are just too close to see well. For example, ethnic identity is especially important for enabling adolescents to develop into successful and contributing adults. Minority youth are prone to depression because of isolation and discrimination faced during adolescence while navigating neighborhood and school environments, even when they have educated and supportive parents. African American male adolescents have the highest rates of mortality, then American Indian adolescents (Alderman & Breuner, 2019). However, there is also great disparity among specific groups of adolescents, such as lesbian, gay, bisexual, and transgender youth and those in the juvenile justice system, foster care, or the military. These issues are hard to discuss sometimes with people so close, people you want to reassure you're okay.
Brain Development
It's pretty well known that adolescents have quite a bit of physical growth to endure, and #puberty is the hallmark of progression from the child to adult body, but what's happening in the brain is truly fascinating. Impulse control, abstract thought, the reward system, awareness that there is an entire world outside their own reality, empathy, identity - all of it - is really evolving at this time of their lives. There is also a "pruning" of gray matter and synapses during adolescents which makes the brain more efficient. White matter increases throughout adolescence, which allows the older adolescent and adult brain to conduct more-complex cognitive tasks and adaptive behavior. And in spite of this, it is often the understanding of the adult that because our teens are so smart and starting to make really great decisions, that their not-so-good decisions are a reflection of their character when in fact, this is more the consequence of some of their brain being mature and some of it being much like a child. It isn't always logical and adolescent brains are not often thinking about consequences or the future; they're impulsive and risky.
When you appreciate that the adolescent brain really doesn't reach maturity until about 24 years of age, imagine adding alcohol and illicit drugs to it at about 14 years of age. They respond much differently to these toxins than an adult would, and even adults are exceedingly challenged under the influence. Adolescents are at greater risk for binge drinking and greater untoward cognitive effects of alcohol and marijuana.
Developing Identity
The adolescent period is when we start thinking about the world around us and how we might fit into that world rather than just assuming we are the world and everything revolves around us, as we can do as children. Relationships, our roles, and even our identity is part of the evolution of child to adult, and as you can probably identify, much of this we are still really grappling with into adulthood, even into those middle decades of our lives.
We pretend, we perform, we mask. Some of us never give that up and ultimately create a life that is all about what others might think, or serving the needs of others, and we never really check in with self, honoring ourselves, or even identifying what is authentic to ourselves. We don't identify healthy boundaries, understanding our rights and what we deserve. The adolescent period is such an important time in each person's life, a time of identity formation, a time for developing self-love.
There is strong evidence that many adolescents do not feel they can express their true selves, so they hide or deny who they are to others. They have higher rates of mental health problems, including depression and suicidality, altered body image, self harm, and substance abuse. When this is combined with parental rejection or bullying then teens will internalize this and their self-esteem plummets, and ultimately depression and suicide become real risks.
Mental & Emotional Health
Healthcare can often be perceived as a science about the body, and I get this because our country really has not placed much value on mental health or even health itself. We have a sick-care system so unless there is overt disease, there is very little concern, certainly no attention towards health preserving or even optimizing behaviors. But, about 20% of adolescents have a diagnosable mental health condition and many of these present for the first time in adolescence. Suicide is the second leading cause of death in adolescents. Since I've opened my practice, suicide in children between the ages of 10 and 19 has increased by 56% (Alderman & Bruener, 2019). Here's the real shocker though, 7.4% of high school students have attempted suicide in the last 12 months - not thought about it, but attempted it and not while in high school, but in the last 12 months. One or two of every ten students has a suicide plan.
Eating disorders is an issue too, anorexia and bulemia, even overeating and binge eating, but these don't even compare to the incidence of anxiety, depression, and mood disorders. Emotional regulation in general has never been spoken to me in any one of my primary care visits and we have six children, all of them on the spectrum. This is the absolute core of autism and ADHD, so to have never had that discussion with my child's care providers is really, really disconcerting for me. In fact, my third son got into a little trouble at school so he met with a therapist there; when my son shared some of his anxieties and concerns, and asked me about some family experiences I used the term gaslighting - the word of the year - and she had never heard that concept before. How does this even happen? How does a therapist advocate for their client who is unaware of various forms of abuse, manipulation, and personality disorder? I was dumbfounded.
Conventional medicine has become a focus entirely in jumping hoops to master diagnostic reimbursement codes and not about actually learning to understand our client's experiences and helping them create a more healthy reality for themselves. Emotional regulation is a huge part of this rewiring of our brain and a huge part of my efforts even prior to the adolescent period. In fact, I've wrote courses about it and encourage my clients to participate in these opportunities. We have discussions on these matters and connect, without judgment. If you're looking for a safe place to be authentic, to be seen and heard, and if you want your adolescent to develop a mutually respectful and trusting relationship with their provider, reach out. Email me at Doctor@EdenFamilyPractice.com. Call the office at 765-335-2171. Let's connect.
References
Alderman, E. M. & Breuner, C. C. (2019). Unique needs of the adolescent. Pediatrics, 144(6).