The teenage years are not the easiest: testing boundaries, asserting your independence and taking risks - and this age group often falls between child and adult healthcare. Claire Laurent reports on moves to target services for young people's needs
Teenagers get a bad press. Often vilified and misunderstood, as a group they are sometimes feared and stigmatised. While children can generally be guided and adults know the rules, teenagers often do not and won't conform to a world designed for and by adults.
The world's teenage generation is now the biggest ever known. According to a 2003 UN report, one in five people on the planet is aged between 10-19 (2006 figures show around a third of the world's 6.5 billion population is under 18). In England alone there are 6.5 million 10 to 19-year-olds and 600,000 new young people join their ranks every year. It is an age when there are important, often life-long decisions, to make. Social pressures are increasing, there are conflicting demands from parents, teachers and friends and on top of all of that there are physical and emotional changes happening almost daily.
Yet healthcare at this time can be overlooked. This age group is notoriously uncommunicative and parents can be caught between caring for a child and respecting the independence of a burgeoning adult. But the effects of poor health in adolescence can last a lifetime: alcohol, smoking and drug addiction often begin in the teenage years and there are many youngsters with life-long conditions such as diabetes that begin in childhood or at birth and need ongoing support and treatment. It is also estimated that one in 10 young people have a diagnosable mental health disorder, often later resulting in serious mental ill health in adulthood.
Teenage health can fare badly. Cancer rates for teenagers and young adults are higher than for children and teenagers have a poorer than average cancer survival rate than either children or older adults. One reason for this may be delayed diagnosis with symptoms dismissed as growing pains or sports injuries.
The growth spurt around puberty can have a knock-on effect on conditions such as diabetes: what chief medical officer Sir Liam Donaldson calls "double jeopardy". As well as having an illness, "they are also coping with the turbulence of adolescence and the frustration with the actual and perceived barriers that the illness creates".
In his latest annual report Sir Liam called for health service action for teenagers. In a chapter devoted to the issue, he highlighted specific problems: "Adolescents are vulnerable to many harms and their health can suffer significantly from inappropriate risk-taking behaviour".
But, he added, they are less likely than other age groups to visit their GP.
Sir Liam called for new approaches to make healthcare more teen centred, recommended more research and development of teaching provision for health professionals to understand their needs and for young people to be included in the design of teen-friendly services.
Adolescents often find they fall between adult and child services.
If admitted to hospital they may be cared for on an adult ward or a children's ward, neither of which is suitable.
"Children's wards with pictures of Snow White and cartoon characters make teenagers feel unwanted. Similarly, if they're on an adult ward and people are much older they can feel no one is interested in their needs. I think all people need health services appropriate to their needs and teenagers are no different," says Leeds University professor of child and adolescent psychiatry David Cottrell.
There is a particular difficulty in moving from paediatric to adult services for adolescents with long term conditions. "Potentially, there are lots of problems. We are well aware that if the transition (from paediatric to adult services) is not handled well, we lose these children to follow up," says Diabetes UK care adviser Libby Dowling. And those who are lost "are more likely to develop complications in the future".
She says: "Paediatric diabetes services are very family centred and nurturing but the adult model is based around the individual. Paediatric services are proactive and will check up on a young person, so they are well supported. But with adult clinics you are on your own. They won't ring you but instead rely on you to contact them if there's a problem.
"We need to think about transition early: make service users aware that their care will move from paediatric to adult and prepare them to develop the confidence to manage their condition."
Ms Dowling reflects the views of others when she says the age of transfer from child to adult services should be individual and based on "emotional readiness, cognitive maturity and also on what the young person wants".
Her words are echoed by Professor Cottrell, who says the move to adult services should depend on the developmental needs of young people and not be an arbitrary cut-off point according to date of birth.
Dedicated transition clinics that operate with a mix of paediatric and adult staff have been shown to be the most effective aid to transfer, adds Ms Dowling. "We are well aware that resources are strapped in the health service but you don't necessarily need extra if you can shuffle resources around a bit."
Dedicated secondary healthcare clinics and units for teenagers are rare in the UK. There are currently about 20 wards for teenagers around the country for long term and some acute health problems and nine teenage cancer units. The latter are funded by the Teenage Cancer Trust and are regarded as pioneering, compared with a lack of provision for this age group in Europe. The units provide medical care in a centre of excellence and within dedicated facilities, which the charity describes as "providing teenagers with an environment where they can get on with being teenagers". The units include day rooms, chill-out rooms and access to the internet, games consoles, satellite TV and musical instruments. The units aim to make it easy for family and friends to visit and for the young person with cancer to mix with others of the same age who are going through a similar experience.
The first teenage cancer unit opened at London's Middlesex Hospital in 1990 and moved to a new home at University College Hospital in 2006.
"We have a large 40-bed adolescent floor, of which around half the beds are for a general/multispecialty ward and half for a teenage cancer ward," says Russell Viner, consultant in adolescent health at University College London's institute of child health.
Dr Viner has long campaigned for dedicated services for teenagers, who, he says, have particular issues about confidentiality.
"They don't use services that are not young people friendly. They are not used to negotiating the health service and do not have the skills to get on and use them if they're not seen as being friendly," he says.
Dr Viner believes that although all doctors and nurses need some skills in dealing with adolescents, there is no need for more than "a small cadre of specialists in adolescent health to support and train the generalists and to run specialist services".
In an attempt to address the knowledge gap, the Department of Health has funded an e-learning module - the Adolescent Health Project - designed by the Royal College of Paediatrics and Child Health, the Royal College of Nursing and the Royal College of GPs.
Speaking at the launch of the module in July, health secretary Alan Johnson said it provided "clear recognition of the increased profile of adolescent health we will see reflected in our forthcoming children and young people's health strategy".
The strategy is due out this month. NHS Confederation deputy policy director Jo Webber says it is likely to focus on the environment in which adolescent services are provided. "It's one area where you really have to involve local teenagers in designing the service they want," she says.
She adds that although there are some good services around the country, it is still a "work in progress" and that local commissioning skills will need to be developed further if they are to design teenage-appropriate services.
The DH's You're Welcome initiative, published in 2005, sets out quality criteria to help ensure services are young people friendly, including implementing local strategies for easier access to services. Areas such as confidentiality and consent, sexual and reproductive health and child and adolescent mental health services are covered, as well as developing staff skills.
Dr Viner says it is time to move on from focusing on single health issues like teenage pregnancy and to develop a more holistic approach to adolescent health, taking in wider services such as education, social services and the justice system.
A DH spokesperson says: "We recognise that to make information, advice and guidance accessible to young people, we need to go to where they are. This is why we have a strong focus on working with non-traditional as well as traditional health settings and have commissioned the National Youth Agency to embed health knowledge and skills within youth work."
The DH has also funded four teenage health demonstration sites in London, Portsmouth, Northumberland and Bolton.
The Parallel young people's health centre in Bolton provides a holistic health service and works in partnership with schools, youth and Connexions workers, third sector organisations and social care to meet the needs of young people.
Bolton primary care trust and council lead on teenage pregnancy and sexual health Jayne Littler says: "We are developing local working in community settings in a range of different ways, of which the Parallel is the hub. Youth services have developed a health curriculum to support adolescent health. They issue condoms and are starting to do chlamydia screening. Youth offending team nurses address the health needs of their client group on site so they don't have to go to another appointment and young people's substance misuse services provide similar support."
She adds: "Adolescents need more support than adults. It often takes longer to gain their trust and confidence and they worry greatly about confidentiality. They tell us they want staff who smile and who are interested. What they don't want is trendy staff using their language and trying to be their 'mate', but they do want someone who understands young people and is professional."
Those working with teenagers feel the time has come for adolescent health to have a new focus.
"There's a real sense that things are changing," says Dr Viner. "There is a sense of progress being made; there is commitment from the DH and from the royal colleges and a growing interest in this area among NHS staff."
A place of sanctuary
Markers for good practice in the national service framework for children, young people and maternity services include providing age-appropriate services for everyone up to the age of 18 years, including 16 and 17-year-olds (who can fall between the services for children and those for adults) and ensuring those who require admission to acute care receive it in an appropriate setting for their age and development. This can be lacking in mental healthcare provision.
Leeds University Professor of child and adolescent psychiatry David Cottrell would like to see more specialist beds for teenagers with mental health problems. He says acute mental health wards for adults are no more appropriate for teenagers than children's wards.
"Acute mental health ward service users have severe mental health problems and are often extremely unwell, which can be unnerving and scary for a young person. We want admission to be a sanctuary for the young person. For many adults their mental illness started in the teenage years. Treatment approaches need to take into account family involvement and education."
Although children and adolescent mental health services are moving to include social services and education, service structure varies regionally, says Young Minds policy and knowledge manager Paula Lavis. This can make it hard to assess what is working effectively and to see who is falling through the gaps. Some areas provide teenage advice and counselling services that include support with mental health problems. Services that do not look like NHS facilities (which carry a stigma for users) are more likely to be accessed.
Obesity levels are rising among young people and physical inactivity is an issue in the 11-15 age group, especially girls.
It is thought around 9 per cent of 11 to 15-year-olds smoke cigarettes. Someone who starts smoking at age 15 is three times more likely to die of smoking-related cancer than someone who has smoked from their mid-twenties. And while the number of 11 to 15-year-olds who drink has decreased in recent years, those who drink do so more frequently and choose high-alcohol drinks. Alcohol-related admissions to hospital for children under 16 increased by a third to 5,280 in the decade up to 2006. Binge drinking is particularly harmful in adolescence and is associated with violence and sexual behaviour risks.
Teenage pregnancy rates in England remain the highest in western Europe and rates of sexually transmitted infections continue to rise overall and among young people.
It is also estimated around 770,000 11 to 15-year-olds have tried drugs - 170,000 of them class A drugs. Substance misuse in young people has been linked to suicide, depression, conduct disorders, educational problems and long term effects on mental health.
Young people aged 15-24 are twice as likely as any other age group to die in a transport accident and young people, particularly young men, are most at risk of being a victim of violent crime.
Find out more
Royal College of Paediatrics and Child Health, Royal College of GPs and Royal College of Nursing Adolescent Health Project, www.rcpch.ac.uk
Department of Health You're Welcome guidance, www.dh.gov.uk