The Adolescent
Case 5.5 Mother ’ s Concern
152 The Adolescent
Allergies: No known drug allergies (NKDA).
Following the interview, the clinician speaks to the mother again and comments, “ Nathan sounds like he was very helpful taking you to physical therapy and picking up your prescriptions. How are you feeling? ” His mother replies that “ it wasn ’ t as bad as I thought. I did have some pain but got over it quick. I only used pain medication for a few days. ”
CRITICAL THINKING
Which diagnostic or imaging studies should be considered to assist with or confi rm the diagnosis?
___Toxicology screen ___CBC
___CMP ___TSH
What is the most likely differential diagnosis and why?
__Substance use/abuse __Alcohol use/abuse __Depression
__Hypothyroidism __Sleep disorder
How would you proceed with the visit?
Nathan asks, “ If I tell you the truth, will you tell my mother? ” How do you respond?
Are there any elements of the history that concern you as the clinician regarding substance use?
After your discussion with Nathan ’ s mother, you ask Nathan if he has ever tried any other drugs. He asks, “ Like what? ” What would you ask about?
What is your next step?
Can minors seek substance abuse counseling without parental consent?
Under what circumstances would you break the confi dentiality agreement?
What other questions would you ask regarding his tiredness?
What aspects of the physical exam to which would you want to pay particular attention?
RESOLUTION
Diagnostic t ests: If the patient has not had a CBC or CMP in more than 1 year, then these could also be performed. Consider a TSH if concerned about hypothyroidism. Also consider a toxicology screen with consent from Nathan.
What is the most likely differential diagnosis and why?
Prescription pain medication abuse:
Nathan has had access to his mother ’ s pain medication, and the history points to the likelihood that he has been taking her medicine.
How would you proceed with the visit?
Separate Nathan from his mother. Review the confi dentiality agreement and when and how it may need to be broken. Ask Nathan why his mother is concerned and whether her concerns are legitimate.
Inquire if they have discussed her concerns at home and how the conversation started.
Mother’s Concern 153
Nathan asks, “ If I tell you the truth, will you tell my mother? ” How do you respond?
Consult the local consent laws. Most states allow minors to consent for care related to alcohol and drugs; however, age and service restrictions vary. Adolescent services are confi dential unless there is a concern that the teen is hurting himself or another or a concern of abuse. As the clinician you can respond that your role is to assist adolescents to remain healthy and to get the help they need.
Reiterate the confi dentiality agreement and provide examples for him.
Are there any elements of the history that concern you as the clinician regarding substance use?
The inconsistency in the mother ’ s version of her history regarding her postoperative course, recovery, and experience with pain and Nathan ’ s version differ dramatically. In addition, Nathan admits to alcohol use, binge drinking, tobacco use, and marijuana use.
After your discussion with Nathan ’ s mother, you ask Nathan if he has ever tried any other drugs. He asks, “ Like what? ” What would you ask about?
It may be helpful to ask fi rst about his peers ’ drug use and then ask him about what he has tried and used. Ask directly about his past and current use of alcohol, marijuana, and prescription drugs and whether there has been anything else. Take cues from what Nathan reports regarding his friends and what you, as the clinician, know about the prevalence of alcohol and drug use in the community.
What is your next step?
Ask Nathan if he has been taking his mother ’ s pain medication. Determine the frequency and amount and whether there have been any adverse effects. It is also important to ask why he has been taking his mother ’ s pain medications. Ask him what was it like for him while is mother was ill.
Anticipatory guidance regarding substance use should be given in adolescent - friendly and sup- portive manner. Determine whether he is concerned about his substance use, what happens if he does not use the medication, as well as why and when he takes it. Is he interested in seeking treatment?
Why or why not? It is essential to consult with a substance abuse expert to determine the best course of action. Further questioning about anxiety; depression; suicidal ideation, safety, and past attempts need exploration.
Can minors seek substance abuse counseling without parental consent?
Consult local health law to determine the answer to this. Determine adolescent resources within the community and the types of insurance they accept.
Under what circumstances would you break the confi dentiality agreement?
The confi dentiality agreement made with an adolescent needs to be broken if the clinician determines he is at risk of harming himself or others. This needs to be clearly discussed with him prior to break- ing the agreement.
What other questions would you ask regarding his tiredness?
• “ What time do you go to bed at night? ” • “ Do you feel rested in the morning? ”
• “ How often do you nap? How long does the nap last? Are you able to go to sleep that night? ” • “ Are you able to return to sleep? ”
• “ Do you have diffi culty falling asleep? ”
• “ Do you use anything to help you fall or stay asleep? ” • “ Do you have nightmares? ”
• “ Do you go to bed at a similar time each night? ” • “ Where do you sleep? ”
• “ Is the TV, radio, computer, or phone on when you are asleep?
• “ How often are you awakened by a phone call or a text message? ”
• “ Does anyone report you snoring or having long pauses between breaths as you sleep? ” • If his sleep pattern has changed, ask when he fi rst noticed this and any related circumstances.
What aspects of the physical exam would you want to pay particular attention to?
A complete physical examination is indicated to look for organic causes of tiredness.
154 The Adolescent
REFERENCES AND RESOURCES
Boyd , C. J. , McCabe , S. E. , Cranford , J. A. , & Young , A. ( 2006 ). Adolescent ’ s motivations to abuse prescription medications . Retrieved from http://www.pediatrics.org/cgi/doi/10.1542/peds.2006 - 1644
English , A. , Bass , L. , Boyle , A. D. , & Eshragh , F. ( 2010 ). State minor consent laws: A summary . Chapel Hill, NC : Center for Adolescent Health and the Law .
Patton , G. , Patton , G. C. , McMorris , B. J. , Toumbourou , J. W. , Hemphill , S. A. , Donath , S. , & Catalano , R. F. ( 2004 ).
Puberty and the onset of substance use and abuse . Pediatrics , 114 , e300 – e306 .
Schiffman , R. ( 2004 ). Drug & substance use in adolescents . The American Journal of Maternal Child Nursing , 29 , 21 – 27 .