Referral Of Adolescents Research Articles

Adolescent Use of the Emergency Department Instead of the Primary Care Provider: Who, Why, and How Urgent?

Adolescents frequently rely on emergency medical care, rather than using primary care providers (PCPs). Our objectives were to characterize a population of adolescents presenting to a large, urban emergency department (ED) and to examine the reasons why they present to the ED, rather than to their PCP's office. Adolescents ages 12 to 21 years and their parents/guardians were invited to participate and asked to complete a brief online survey. Demographic data and triage information were collected from electronic medical records. Of 203 participants, 66% (n = 134) had public insurance, and 40% (n = 82) were triaged as nonurgent. Nearly all (93%, n = 189) reported having a PCP or primary clinic. The most common reasons given for presenting to the ED were participant perception of illness requiring immediate care (34%), followed by PCP referral to the ED (21%). Those with public insurance (odds ratio = 4.44; 95% CI 2.01 to 9.81) or no insurance/unknown insurance status (odds ratio = 4.77; 95% CI 1.34 to 17.01) were more likely to be triaged as nonurgent than those with private insurance. Many adolescents in this study were triaged as nonurgent, with several participants perceiving they were acutely ill requiring immediate physician care. Further analyses revealed that private insurance was significantly associated with urgent triage status. Future studies could educate adolescents and families about appropriate use of the ED or examine PCP offices directly to determine practices for phone triage and ED referrals of adolescents.

Two Cases of Adolescents with Paratesticular Rhabdomyosarcoma Inadequately Treated: The Problem of Referral

This paper reports on two cases of adolescents with paratesticular embryonal rhabdomyosarcoma completely resected at diagnosis (a pediatric disease potentially curable in more than 90% of cases) and treated at adult facilities with a strategy used for adult soft tissue sarcomas. The final outcome of the two patients was dismal after they received a treatment inconsistent with pediatric protocols. The cases reported here give us a chance to turn the spotlight on a crucial issue-the referral of adolescents with pediatric-type tumors and their access to experienced centers and clinical trials.

3. Web-Based Screening and Referral of Adolescents' Health-Related Social Problems

3. Web-Based Screening and Referral of Adolescents' Health-Related Social Problems

A brief intervention is sufficient for many adolescents seeking help from low threshold adolescent psychiatric services

BackgroundThere has been a considerable increase in the need for psychiatric services for adolescents. Primary health care practitioners have a major role in detecting, screening and helping these adolescents. An intervention entitled SCREEN is described in this article. The SCREEN intervention was developed to help practitioners to detect and screen adolescent needs, to care for adolescents at the primary health care level and to facilitate the referral of adolescents to secondary care services in collaboration between primary and secondary health care. Secondly, the article presents the background and clinical characteristics of youths seeking help from the SCREEN services, and compares the background factors and clinical characteristics of those patients referred and not referred to secondary care services.MethodsThe SCREEN intervention consisted of 1 to 5 sessions, including assessment by a semi-structured anamnesis interview, the structured Global Assessment Scale, and by a structured priority rating scale, as well as a brief intervention for each adolescent's chosen problem. Parents took part in the assessment in 39% of cases involving girls and 50% involving boys. During 34 months, 2071 adolescents (69% females) entered the intervention and 70% completed it. The mean age was 17.1 years for boys and 17.3 years for girls.ResultsFor 69% of adolescents, this was the first contact with psychiatric services. The most common reasons for seeking services were depressive symptoms (31%). Self-harming behaviour had occurred in 25% of girls and 16% of boys. The intervention was sufficient for 37% of those who completed it. Psychosocial functioning improved during the intervention. Factors associated with referral for further treatment were female gender, anxiety as the main complaint, previous psychiatric treatment, self-harming behaviour, a previous need for child welfare services, poor psychosocial functioning and a high score in the priority rating scale.ConclusionsA brief intervention carried out by a team including professionals from both primary and secondary level services was sufficient for a considerable proportion of adolescents seeking help for their psychiatric problems. Referral practices and counselling in special level services can be standardized. In the future, it will be important to develop and assess psychiatric services for adolescents using randomised controlled trials.

Parental relations and referral of adolescents to Norwegian mental health clinics

Objective: Many youngsters with mental health problems are not referred to mental health clinics. Parents play an important role in the referral process of youngster to mental health clinics. The main aim of this study was to explore the role of the parent–child relation for referral of adolescents to outpatient psychiatric clinics. Method: Employing a cross-sectional design, we compared a referred sample of 39 adolescents in outpatient psychiatric treatment with a non-referred matched control sample of 39 adolescents. The Parental Bonding Instrument and Youth Self-Report were employed to assess the characteristics of these two population groups. Results: Adolescents referred to Norwegian mental health clinics for mental health problems report more perceived care from mothers and a trend of more care from fathers compared with non-referred controls matched on level of mental health problems, age and gender. Implications of the finding for the role of parents on referral of adolescents to mental health clinics and for treatment compliance are discussed.

Gender identity disorder in adolescents

At a recent conference in London the problems and possibilities of clinical management in gender identity disorder (GID) of adolescents were addressed. The number of referrals of adolescents with GID has tripled in recent years. With the uncertainties of the DSM classification and the lack of reliable criteria diagnosis remains controversial. Atypical gender behaviour is rather common in children but persistent GID in adolescence is only seen in 25% of the referred children. The role of pubertal hormones in brain development is the subject of studies but no clear answers are (yet) available. Prenatal hormone exposure is clearly linked to child play behaviour but does not appear to be the most important factor for gender identity. An option for adolescents with persistent GID and an increase of distress at puberty is puberty-delaying treatment with GnRH analogues. This treatment relieves distress and no detrimental physical effects have been observed, but follow up is limited. From an ethical point of view, the developing autonomy of the adolescent with GID should receive more attention and a practical approach should underscore the experimental nature of the intervention and the possibility of withdrawal from treatment. In dealing with adolescents with GID puberty-delaying treatment is a valuable option with encouraging preliminary results, but long term outcome studies and more research are necessary.

A window of opportunity: Referral of adolescents to the hospital Child Protection Team

The arrival of an adolescent at the hospital provides a window of opportunity to help those exposed to abuse or neglect, by looking beyond the presenting symptom. The Child Protection Team (CPT) assesses cases of suspected abuse or neglect (SCAN) referred by hospital staff. As adolescents pose a particular array of presentations, this study assessed their socio-demographic features and characteristics of hospitalization in order to improve procedures for identifying SCAN. The study group included all 674 referrals of 10-17-year-olds to the CPT from 1991-2007. Their files were abstracted and demographics compared to similarly-aged Emergency Department (ED) admissions. Different patterns were found by gender and age group. The youngest group (10-13 years) included a higher rate of boys than girls (47.9% vs. 27.6%), and among the oldest (16-17 years) the rate of girls was higher (31.9% vs 15.8%). Comparison with all ED admissions indicated a lower rate of younger girls and a higher rate of 14-15-year-old girls in the study group. The study group also had a higher rate of immigrants (12.8% vs. 4.7%). The most frequent reason for arrival at the hospital was suicidal behavior (30.9%). Older age was related to fewer arrivals for trauma/burn and more suicidal behavior. In 83.1% of the referrals, reports were made to welfare authorities and/or police. The suspicion in 64.2% of the referrals was emotional abuse or physical/emotional neglect; in 18.8%, physical and/or sexual abuse was suspected. The older groups had lower rates of physical and/or sexual abuse and higher rates of emotional abuse or physical/emotional neglect. This study highlights the importance of age-by-gender analysis and understanding of the differential susceptibility of early, middle and late adolescence to SCAN.

Site of Oncologic Specialty Care for Older Adolescents in Utah

Adolescents with cancer may access oncologic care from pediatric or adult medical centers, given overlapping age eligibility. However, some recent data suggest a benefit to adolescents with certain cancers when treated at pediatric centers or on pediatric protocols. We used a population-based registry to determine the site of care of children, adolescents, and young adults (age 0 to 24 years) with newly diagnosed cancer. From the Utah Cancer Registry 1994 to 2000, new malignant cases in patients aged 0 to 24 years were chosen; data including diagnosis, home ZIP code and sites of oncologic care were abstracted. Distance between home ZIP code and Primary Children's Medical Center (PCMC; Salt Lake City, Utah), the state's sole site of pediatric oncology care, was determined. Sixty-six percent of Utah 15- to 19-year-olds with cancer were never seen by a PCMC oncologist. Even among this narrow age range, utilization of the pediatric center dropped with each additional year of age. Not unexpectedly, few of those with epithelial malignancies in this age group were seen at PCMC. But surprisingly, 47% of the older adolescents with leukemia, 66% with brain tumors, and 71% with lymphoma never saw a pediatric oncologist. After consideration of age and diagnosis, distance the patient lived from PCMC had a negligible effect on the likelihood of an adolescent being seen there. The referral of adolescents with cancer to a pediatric oncology center diminishes greatly with age, and is moderately influenced by diagnosis and minimally by distance from center. Further study should investigate reasons for referral patterns, and impact on outcomes.

55: Providers’ experiences with identification, management and referral of adolescents with depression

55: Providers’ experiences with identification, management and referral of adolescents with depression

Chest pain in the adolescent and young adult.

Pediatric cardiologists and cardiologists who examine adults frequently receive referrals of adolescents and young adults with chest pain. Chest pain in this age group is most likely noncardiac in origin, which often creates a diagnostic dilemma for the consultant in terms of the etiology and extent of evaluation. This review presents the noncardiac and cardiac etiologies of chest pain in adolescents and young adults, as well as the key features of a patient's history and physical examination that help delineate cardiac from noncardiac chest pain. In addition, we present recommendations for the cardiac consultant regarding the evaluation and management of adolescents and young adults referred with the complaint of chest pain.

Parenting adolescents with ADHD: evaluation of a psychoeducation group

ADHD and disruptive behaviour disorders are the most common reasons for referrals of adolescents to children's mental health services. Psychosocial treatments for parents and adolescents, though routinely recommended, have not been well evaluated. This paper reports an evaluation of a clinic based, parent skills training and education group for parents of adolescents with ADHD. The parent education group is a manual based program which provides information about ADHD and training in problem solving and parenting skills. Using a pre–post design, we collected evaluation data from 163 parents of 103 adolescents before and after participation in the group. The outcome measures were two parent self-report measures, the conflict behaviour questionnaire, the issues checklist and an investigator-designed evaluation questionnaire. There was a statistically significant decrease in frequency and intensity of self-reported parent–adolescent conflict and in parent-reported problem behaviour. Parent reports of problem behaviour were not related to kin relationship or child age. There was a trend for parents of daughters to report more problem behaviours and more conflict in the parent–adolescent relationship. Participants reported positive effects on their parenting skills and confidence. They tended to evaluate the program as very helpful.

New challenges, new answers: Pediatric nurse practitioners and the care of adolescents

Introduction: Since the 1950s, patterns of morbidity and mortality among adolescents have shifted to social and environmental causes. This study examines pediatric nurse practitioners' (PNPs') self-assessed competencies in addressing the common health concerns of adolescents. Method: The analysis used a sample of 257 PNPs drawn from a larger national data set of 637 nurses randomly sampled from 3 nursing organizations. Factors associated with self-perceived knowledge or skill and interest in training for 28 common health concerns of adolescents were analyzed using Chi square, t test, and Pearson's correlation. Barriers and attractions to working with adolescents were also investigated. Results: The greatest deficits in selfperceived knowledge or skill, as well as low interest in training and low perceived relevance to practice, were around issues of gangs, gay/lesbian/bisexual/transgender youth, HIV/AIDS, and counseling about a positive pregnancy test. Also, PNPs identified the lack of resources appropriate for adolescent referrals as the greates barrier to working with this population. Discussion: PNPs assessed their lowest competencies in some of the areas that present the greatest threats to adolescents' health and well-being. These deficits suggest needed curricular shifts in entry-level and advanced-level preparation of PNPs, as well as new priorities for continuing education.

Effect of Co-Occurrence on the Referability of Internalizing and Externalizing Problem Behavior in Adolescents

Assessed the effect of co-occurring versus not co-occurring internalizing and externalizing behavior problems on the reasons parents reported for clinical referral of their adolescent child. Reasons for referral were coded for 181 inpatient adolescents, and parent ratings of internalizing and externalizing behavior were obtained for a general population sample of 500 adolescents. Parents concurrently reported internalizing and externalizing behavior as reasons for referral less frequently (p < .0001) than would be expected given the correlation between these two domains in the general population sample. This suggests that the presence of externalizing problems may decrease parents' concern or awareness of internalizing problems, the presence of internalizing problems may decrease parents' concern or awareness of externalizing problems, or both Implications for the clinical referral of adolescents and for informal parental efforts at helping their children with externalizing and internalizing problems are discussed.

Using Multiple Reporters of Problem Behavior to Predict Clinical Referral of Adolescents with Learning Disabilities

Ratings of behavioral and emotional problems at the start of a school year were used to predict referral for mental health assistance. Participants were 63 11- to 16-year-old adolescents with learning disabilities who attended a residential school. Reports of problem behavior consisted of internalizing and externalizing behavior on the parent and teacher reports of the Child Behavior Checklist, ADHD behaviors on the home and school forms of the Children's Attention and Adjustment Survey, and depressive symptoms on the Children's Depression Inventory (CDI). Students referred for mental health services had higher scores than adolescents not referred on teacher ratings of externalizing behavior, inattention, and conduct problems, as well as self-reports of depressive symptomatology, and were more likely to have scored above clinical cutoff scores on the first two measures as well as on parent reports of internalizing behaviors. There were correlations in the various kinds of problem behavior rated by teachers, parent ratipigs were also intercorrelated, and CDI ratings correlated with both teacher and parent ratings of internalizing behavior. However, situational specificity was demonstrated by an absence of relations between any reports by parents and teachers. Discussion focused on the use of screening measures in learning-disabled populations, as well as unique features of the current setting that may have influenced teacher reports of behavior. Des classements de problèmes comportementals et émotionnels au début de l'année scolaire ont été utilisés pour prédire le recours ultérieur à des soins de santé mentale. Soixante-trois adoles cents entre 11 et 16 ans ayant des problèmes d'apprentissage et qui frequentaient un milieu scolaire residentiel ont participé à cette recherche. Les comptes rendus de comportement consistaient en: comportement intériorisant et extériorisant évalué par les parents et les enseignants (Child Behavior Checklist); une mesure d'inattention, d'impulsivité, and et d'hyperactivité évalué à l'école et à la maison (Children's Attention and Adjustment Survey); et un inventaire de symptômes de depression (Children's Depression Inventory). Les étudiants qui ont été dirigé vers les services de santé mentale avaient des scores plus élevés sur les évaluations des professeurs de comportement extériorisant, inattention, troubles de conduite, et rapports de symptomatologie de dépression que les autres étudiants. Ces étudiants risquaient aussi d'obtenir des scores en haut de la démarcation des scores cliniques sur les deux premiers mesures, aussi que les reportages d'intériorisation des parents. Les résultats obtenus démontrent des corrélations entre les problèmes comportementales et rapports des professeurs. Les rapports des parents étaient aussi en corrélation, et les classements CDI étaient reliés avec les classements d'intériorisation des parents et professeurs. La présence d'une spécificíté situationelle a été démontré, étant donnée l'absence de relations entre aucun des rapports de parents et d'enseignants. La discussion porte sur l'emploi des mesures d'évaluation chez les enfants qui présentent des difficultés d'apprentissage ainsi que sur les facettes uniques du présent contexte qui ont pu avoir influencé les rapports de comportement des enseignants.

Reliability of psychiatric diagnosis in referred adolescents.

The authors report a reliability study of the DSM-III diagnostic system in a series of 393 adolescent referrals diagnosed by two clinicians over a period of 3 years. Overall reliability (kappa) was 0.59. However, most of the frequently used diagnoses had reliabilities of 0.7 or higher. Dysthymic, Adjustment, Overanxious and Avoidant Disorders showed poor diagnostic agreement (kappa below 0.4). The patterns of agreement across this and other studies suggest that diagnostic criteria for Affective, Anxiety and Adjustment Disorders are in need of further improvement.

Reliability of the psychosocial axes of DSM-III in an adolescent population.

Three psychosocial variables were rated independently by two clinicians for 140 adolescent referrals to a psychiatric unit. Overall, intraclass correlations for DSM-III Axis IV, Axis V and a psychosocial adversity index (PSAI) were respectively 0.44, 0.58 and 0.68. The main source of unreliability is probably the operational definitions, rather than their application by clinicians; indices similar to the PSAI may be preferable.