Family Health – Discussion
Areas of concern
An important area of concern for this 16-year-old patient is to find out why she is having difficulties concentrating in school. As the practitioner, I would want to inquire in more details about the child’s life. What are some stressors in the child’s life that are making it difficult to focus in school? How is her family life? How are her friends? Additionally, seeing that this patient already looks thin and frail in appearance, I would wonder what her diet consists of. Why would a thin and frail teenager inquire about diet pills? What is the reason for her wanting to lose weight?
It seems that this patient could be experiencing depression, as well as body dysmorphic disorder, and an investigation of her lifestyle is a must. There are six categories to discuss with a teenager that can help the practitioner understand the health-related behaviors leading to death and disability. The topics include behaviors contributing to unintentional injuries and violence, risky sexual behaviors that can lead to unintended pregnancy and sexually transmitted diseases, the use of alcohol or any drug use, tobacco use, unhealthy dietary behaviors, as well as physical activity that can be inadequate (Youth Risk, 2020).
An important screening tool to be used at the beginning of the visit is using the HEADSSS assessment. This acronym stands for Home, Education, Activities, Drugs and alcohol, Sports, Sex, Suicide as well as Safety. Asking these questions can help the practitioner understand the patient a bit more in order to better help them. When inquiring about the home, it is important to note who the patient lives with and if they feel safe. Questions related to the education includes grades, interests, and career aspirations. Activities questions may include extracurricular involvements, and favorite pass times. When covering the topic of drugs and alcohol, many screens can be performed, such as the CRAFFT assessment tool. This specific tool includes questions regarding driving a car while being under the influence of alcohol or drugs, the need to take drugs or alcohol to be able to relax, if the patient ever uses any substances when they are alone, if the patient ever forgets things when using substances, if family or friends ever think they should cut down on drugs, and finally, if the patient has ever gotten in trouble while using mind alternating substances (Adolescent Medicine, 2020).
The next step of the HEADSSS assessment includes asking questions about sports. Such questions may be related to what types of concussions, palpitations, or any history of cardiac issues in the family. Sexual questions may include their age at their first sexual encounters, number of partners, and sexual orientation. Suicide questions may revolve around anxiety and/or depression the teenager may be feeling. An assessment tool that can be used at this point is the Patient Health Questionnaire-9 (PHQ-9), modified for teens. This tool allows the patient to understand questions about their moods and feelings in the last two weeks. The patient answers these questions with “not at all”, “several days”, “more than half the days”, and “nearly every day”. Depending on the score, depression may be better assessed, and additional help provided, whether it includes referral to psychiatry, therapy, or low-dose medications. The last portion of the HEADSSS assessment includes inquiring about safety. These questions can include physical and sexual abuse, bullies, gang involvement, seatbelt usage, helmet, etc. (Adolescent Medicine, 2020).
For this patient, it would be important to focus on “nutrition and the relationship between good nutrition, health, and a positive body image” (Burns et al., 2019). Because the patient is asking about diet pills when she is already looking thin and frail, it is important to emphasize on healthy eating habits, limiting the sugar intake as well as caffeinated drinks, and lastly to not skip any meals. This patient should be encouraged to following healthy paths to weight management. Body dysmorphic disorder (BDD) is described as “a preoccupation with perceived defects in physical appearance, as well as avoidance and repetitive behaviors, causing distress and impairment (Rautio et al., 2022). This condition can severely impact the teenager’s education as well as social development, and it can be associated with severe levels of psychiatric comorbidities, poor insight, psychiatric treatment refusal, as well as suicidal behaviors. It seems that this patient is experiencing these symptoms on top of her depression.
Social media is an enormous component to BDD. In the last couple decades, bullying has been very prevailing, and many children and teenagers are affected. Different types of bullying exist, such as body shaming and fat shaming, and can have a great negative influence on one’s own perception of their body image, leading to low self-esteem and BDD. Social media may be a trigger to the teenagers who already are predisposed to the disorder, and could therefore worsen the symptoms (Body Dysmorphic, 2022).
At this point, I would not feel comfortable prescribing this patient any diet pills. Once I have evaluated the patient and I am more informed on her situation from the questions I will be asking her, I believe a referral to therapy is advised so that she can receive the proper care. During therapy, a deeper understanding can be communicated through the use of cognitive behavioral therapy (CBT). This type of therapy added to an antidepressant, such as SSRI, can greatly increase outcomes. Additionally, the patient should be encouraged to continue participating in family activities and social gatherings, encourage the parent to show their child unconditional love, to be patient and supportive, to maintain a positive and close relationship, to be a good role model and a good listener. The main advice to the parent of a child with BDD is to not be critical of their child, but rather to encourage them to receive professional help (Body Dysmorphic, 2022).
Additionally to referring the child to psychiatry and therapy, I would also refer the child to a nutritionist. Sometimes patients, especially teenagers, may be falsely informed on foods and food groups and they do not necessarily know the right foods to eat. Focusing on protein and vegetables, while limiting portions and not skipping meals is of great importance and the patient should be thoroughly educated on it. Lastly, education about incorporating a light workout routine may be complementary to the healthy diet.
Adolescent medicine: Routine screening [The University of Chicago]. (2020).
Body dysmorphic disorder (BDD) and youth. (2022). Mental Health America. https://www.mhanational.org/body-dysmorphic-disorder-bdd-and-youth
Burns, C., Dunn, A., Brady, M., Starr, N., & Blosser, C. (2019). Burns’ pediatric primary care (7th ed.). Elsevier.
Rautio, D., Gumpert, M., Jassi, A., Krebs, G., Flygare, O., & Monzani, B. (2022). Effectiveness of multimodal treatment for young people with body dysmorphic disorder in two specialist clinics, Behavior Therapy, 53, 1037-1049.
Youth risk behavior surveillance system (YRBSS). (2022). Centers for Disease Control and Prevention. https://www.cdc.gov/healthyyouth/data/yrbs/index.htm