Do family doctors also treat children

Treating teenagers successfully

Young people are unbearable for themselves and often also for those around them. You are no longer a child, but you are not yet an adult either. They are insecure themselves, but their moods also unsettle everyone who has to deal with them - including doctors and their staff. But with a little know-how and empathy, the family doctor can set the course so that the teen will become an adult who trusts his doctor, takes responsibility for his health and works towards the success of the therapy.

Young people are a rather rare clientele in general practitioners' practices. On the one hand, this is due to the fact that they mostly feel healthy, and on the other hand, that you don't really know who is responsible - the pediatrician no longer seems to be. Perhaps this is also one of the reasons that preventive medical check-ups are nowhere near as popular as they are in toddlers.

As in school, people are generally aged 16 and over. In the doctor's office, the following can also apply: Anyone who looks adult obviously wants to be addressed with you. Even with patients who have been cared for since kindergarten age, the change from you to you is usually desirable. An announcement has proven itself here: "At your age, I usually see adolescent patients. If it is okay with you, I will now go over to you with you too." Young people orientate themselves strongly towards their peers. The introduction to Siezen in the future and the reference to their peers usually make the young people react positively - they feel that they are being taken seriously.

But when teenagers come to the practice, the general practitioner has the opportunity to positively influence future relationships with doctors. He can build up a long-term relationship of trust, awaken health awareness, convey personal responsibility in therapy - in short: train him to become a responsible patient, writes Christoph Rutishauser in the journal "Praxis" [1].

Admittedly, dealing with young people is not always pleasant. Anyone who has children of their own and suffers through puberty knows that moods change quickly. You fluctuate between insecurity, fears, a "zero-minded-for-nothing" attitude or even an overestimating, omnipotent behavior. Accordingly, in the doctor's office, too, young people fluctuate between uncertainty about the medical specialist and possibly authority, diagnosis and therapy on the one hand, and the desire for a say and autonomy on the other. The mood swings are due, among other things, to the changing hormone surges, but also to the development of the brain: the limbic system with the impulses for excitement and emotions develops faster than the prefrontal cortex, which is responsible, among other things, for impulse control.

Address young people directly

Not all young people are the same. Puberty spans a period of eight years and more. It is not for nothing that a distinction is made here between early, middle and late adolescence (see Table 1), which are passed through at different speeds. Whereby in early adolescence the question "Am I normal?" in the foreground is the question of identification "Who am I?" drives young people and in late adolescence the path to life is sought ("Where am I going?"). Correspondingly, age-appropriate handling is difficult here. The central point for all age groups and stages of development is to perceive the adolescent as a separate person. This means, for example, addressing the teen directly and not talking to the person accompanying you (usually the mother) about him - possibly even over his head. The reception staff should also greet the young person first and then the mother. He should also answer the questions about the administrative basics himself, such as names, date of birth, previous visits, etc., and the mother is only asked if he does not know.

One-to-one conversation

This concept of "taking it seriously" continues in the consulting room. As a confidence-building measure, it is advisable to explain the process of a consultation to the young person with anamnesis, examination and discussion about the further procedure. Part of the consultation should also take place without the accompanying adult. By pointing out that this is common at this age, the mother's acceptance can also be increased. For this part of the doctor's visit, the young patient should also be assured of confidentiality vis-à-vis the parents - provided the teenager appears capable of judgment and there is no evidence of harm to himself or others. This conversation "off the records" offers several advantages: The doctor can create trust, the patient can ask questions that may be embarrassing to him in the presence of the mother, for example about normal penis size, after prescribing the "pill" etc.

The anamnesis in adolescents not only includes questions related to the medical occasion, but also an orienting psychosocial anamnesis, which should be carried out at least partially in a one-to-one conversation. As a starting point, questions about interests, hobbies, school, friends (peer group), family, etc. are suitable. Only when a certain relationship of trust has been established (possibly also at a later point in time) can more sensitive questions, for example about sexuality, be asked. Standardized questionnaires such as the semi-structured HEEADSSS (Home environment, Education and employment, Eating, peer-related Activities, Drugs, Sexuality, Suicide / depression and Safety from injury and violence) (see Table 2) are helpful in taking a psychosocial anamnesis. Before the parent joins them again, it is decided with the patient which parts of the conversation should be subject to confidentiality.

Examine in stages

The medical history is usually followed by a physical exam. Teens often feel more shame than adults because they feel insecure in their changing bodies. In order to take this into account, the process should be carried out in stages: first undress the upper body, examine it, put it back on, then the lower body. The presence of an accompanying person is recommended at the latest during an examination in the genital area - depending on the patient's wishes, this can be a practice employee or an accompanying parent.

Chronically ill child grows up ...
It is difficult to suddenly see a chronically ill adolescent who has been cared for since infancy as almost an adult. But it is also important for these patients to take them seriously as a person and gradually lead them to take responsibility for their own health - including the constantly updated psychosocial anamnesis. But especially with the chronically ill, who have followed their therapy well so far, one must reckon with setbacks in puberty. The older children realize that they will probably have to deal with their illness for life. This often leads to a negative attitude towards therapy. Furthermore, adolescents often tend to experiment. Does the doctor notice that I have not taken my asthma spray? What happens if i don't inject the insulin? If the doctor notices the incompliance, it is helpful to analyze the reasons for it with the young person - preferably without the parents. Sometimes a temporary therapeutic compromise is better here than state-of-the-art treatment, which is not adhered to.

When discussing how to proceed, the young patient should definitely be included. Young people want their aspirations for autonomy to be respected and therefore want to have an active say in determining the treatment modalities. However, so that the teenager can bear joint responsibility for the success of the therapy, the facts about the disease and the further treatment steps must be explained to him in an understandable manner and possible obstacles to compliance must be addressed. But even if he agrees to a therapy plan, this is still no guarantee that the therapy will be followed. Young people just want to try themselves out and occasionally practice rebellion. Some need several attempts before they become therapy-adherent patients. In spite of all the understanding and courtesy in the therapy of adolescents, it is not possible without the parents. Handing over responsibility for the health of your daughter or son is a step-by-step process that your GP can help you with.

1) Rutishauser C: Adolescent medicine: an enriching challenge in practice, Praxis 2013, 102 (18): 1105 - 1109
2) Goldenring J M et al: Getting into adolescent heads: an essential update, Modern Medicine, January 2004