The adolescent years can be a time of major changes and challenges, both for the young people concerned and the GPs who treat them. We undertook research to investigate the frequency and reasons for the attendance of teenagers at our practice in Ballymun, Co Dublin. The results showed that there was a marked difference in attendance depending on the person’s gender and whether or not they had a valid medical card. 

Even in the younger age group, we found that males were found to attend much less frequently and this difference became more marked in the older age group. Our results also show that those with medical cards attended more frequently.

The proportion of those attending with psychological issues was also examined and compared with published research elsewhere. It was found that although teenagers have a much higher prevalence of psychological problems than other subsets of the population, the proportion of attendances where psychological problems were brought up, was approximately 5%,¹ which is in line with findings elsewhere.

Practice in a deprived area

Our practice, Ballymun Family Practice, has 2,665 registered patients, of whom 1,999 have a valid medical card;  382 are aged from 12-18 years, with 188 males and 194 females. This number of teenagers was further subdivided into those aged 12-15 years, and those aged 16-18 years. The area surrounding the practice is one with high levels of socio-economic deprivation.

Using the practice software, HealthOne, all patients in the 12-18-year age group were identified. Each patient record in this category was opened and reviewed, to see whether they had attended in the period between June 2011 and August 2012, if they had attended, the number of attendances and reasons for those attendances were identified and recorded in an Excel spreadsheet. Using simple statistical tools in Excel, this information was then examined. The difference in attendance rate between the younger and slightly older age group, and the difference between males and females were compared.

When all attendances from June 2011 to August 2012 were examined, the findings were as follows: 

• 121 consultations for respiratory problems
• 81 consultations for skin problems
• 49 consultations for musculoskeletal problems
• 22 consultations for prescribed contraception
• 14 consultations where reference was made to psychological issues, mostly anxiety
• 6 consultations where reference was made to bullying problems. 

It was notable that in none of the consultations was there any record of exam stress being a factor in this population; this may not be typical of the general teenage population and reflective of the Ballymun teenage population coming from a community where there is not a lot of emphasis placed on academic achievement.

Substance misuse and recording of this issue was also reviewed. In general, it was noted that whether or not the person attending used alcohol, smoked cigarettes or used other substances was not recorded. No reference was made to alcohol in any of the 380 teenagers’ records; that this was not recorded does not in our view indicate that none of these 380 teenagers drinks alcohol. 

Seven teenagers were noted to be smokers of cigarettes, seven were noted to be smokers of hash, and there was no mention in the clinical records of other drugs being used. This low level of recorded drug and alcohol use appears very low and is reflective of our tendency as GPs not to ask these questions. It was also very interesting that in this small number of people where drug use was recorded, it was not recorded as the reason for the attendance or even as a problem. 

In the period reviewed, 22 girls attended seeking contraception. It was sometimes unclear in cases where acne was also noted to be a problem, whether skin problems or prevention of pregnancy prompted the need for contraception. There was no record of any terminations of pregnancy and there were five new babies born to the girls in this cohort – all of these five pregnancies were unplanned.

Attendance rate varied hugely between genders and age groups. The total number of visits for the entire group of 382 people was 578 visits. The average number of attendances in the whole group was 1.51 visits per person, but if only the younger age group – 12-15-year-olds – was looked at, the attendance rate was 1.24 visits per person, while in the older age group of 16-18-year-olds, the rate was 1.96 visits per person.

The gender difference was very marked and showed that this difference starts at an early age. In the overall group, the average number of visits per male patient was 1.04, which was markedly different to the average number of visits per female patient, at 1.97 visits per female. Even in the younger age group, this finding was apparent: average number of visits per male was 1.0 and per female was 1.49 visits for the 12-15-year-olds. For the older age group, the males had an average number of visits of 1.12 and for the females this rose to 2.73 visits per year. 

As in many previous studies, it was very clear that teenagers who had a medical card were more likely to attend. The average number of visits per person with a GMS card was 1.97, whereas for those without one this was 0.47. The practice population was not reflective of the general Irish population, where the number of medical card holders would be lower than in the Ballymun area.

Psychological issues

A literature review of recent articles on this subject found several published in the British Journal of General Practice. It appears that we are not too dissimilar from our British counterparts. Extensive research on the adolescent population in the UK estimates that between 10-20% of the adolescent population have mental health problems.² It is also widely accepted that in half of the adults with serious mental illness diagnoses, their problems began in their adolescent years.³

Psychological issues were mentioned to be a factor for 16 of the 382 adolescents who attended in our practice; approximately 5% of our teenage population. This would not be out of step with the British experience, but the Royal College of General Practitioners in the UK is taking steps to heighten awareness among GPs that this is just the tip of the iceberg as regards mental health issues.

Transition from child to adolescent care

Interestingly, whereas with most patient groups, long associations and relationships with patients greatly helps in interactions with patients and the ability of a GP to provide quality care, qualitative research with GPs treating the adolescent proportion of our population shows that this may be a hindrance, as GPs are likely to view these young adults as children simply because they have known them since they were very young.⁴

The adolescent years are a time of huge transition for the young people. GPs themselves need to take care that treating adolescents as though they were young children is going to lead to the young person in the GP surgery failing to disclose the real reason for their attendance. 

Strategies to improve GPs’ engagement with teenagers may include undertaking GP education in this area, policymaking, and reaching out to adolescents who do not enter into GP practices at all by letter. 

In Norway, contacting adolescents by letter advising them of health issues that the GP may be able to help with and also advising them of their health rights, especially to privacy, resulted in a marked improvement in attendance rates,especially among males.⁵

Taking more time to consider the person in front of us, whose competencies and capabilities may have changed hugely even in the short period of time since they last attended, is something that GPs should make an effort to be more aware of. 

References

1. Roberts J, Crosland A, Fulton J. Patterns of engagement between GPs and adolescents presenting with psychological difficulties: a qualitative study. British Journal of General Practice  May 2014  64: e246 - e254
2. Martinez R, Reynolds S, Howe A. Factors that influence the detection of psychological problems in adolescents attending general practice. British Journal of General Practice, 2006; 56: 594-599
3. Dawlatly S. Why bother talking to teenagers? British Journal of General Practice  Feb 2012
4. Roberts J, Crosland A, Fulton J. GPs’ responses to adolescents presenting with psychological difficulties: a conceptual model of fixers, future planners, and collaborators. British Journal of General Practice, 2014; 64: e254-e261
5. Aarseth S, Dalen I, Haavet OR. Encouraging adolescents to contact their GP: a community based trial. British Journal of General Practice May 2014  64: e262- e26