Asthma Management Handbook

General considerations when providing health care for adolescents and young adults

Recommendations

By mid-adolescence (around 14–16 years), provide medical management of asthma as for adults (e.g. medication options, doses).

Note: Whether the individual is considered to be a child or adult for the purposes of prescribing will depend on the individual’s size and clinical factors, TGA-approved product information for medicines, and PBS subsidisation criteria.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

If parents or carers are present, arrange to see adolescents alone for part of the consultation so that you can confidentially discuss sensitive issues like adherence to asthma medicines and exposure to smoke from tobacco or other drugs.

How this recommendation was developed

Adapted from existing guidance

Based on reliable clinical practice guideline(s) or position statement(s):

  • The Royal Australasian College of Physicians, 20081

Discuss confidentiality with the patient and agree on which of their personal information will not be shared with anyone else and which can be discussed with parents or passed on to other healthcare professionals.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

Assess psychosocial status so that you can identify and manage any factors that could affect their asthma management and ensure that self-management advice is appropriate to the individual’s stage of psychosocial development.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available), with particular reference to the following source(s):

  • Bender, 20062
  • Sawyer et al. 20123
  • The Royal Australasian College of Physicians, 20081
  • Van de Ven et al. 20094

Consider the person’s health beliefs, cultural perspective and family circumstances that may affect asthma management.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

More information

Confidentiality issues for adolescents

Adolescents’ concerns about confidentiality prevent them using health care services, especially if substance use is likely to be raised. Adolescents are more likely to disclose information about health risk behaviours, and are more likely to return for review, if they know that confidential information will not be revealed to their parents or others.5

When adolescents are accompanied by parents or carers, health care providers should consider seeing the adolescent alone for part of each consultation.5

Health professionals should discuss confidentiality and its limits with adolescents.5, 6 Adolescents are more willing to communicate honestly with healthcare professionals who discuss confidentiality with them.1

Health professionals need to clearly explain which personal health information can be confidential and which must be shared with parents, and keep parents informed.

Health care providers should advise adolescents that they can obtain their own Medicare card once they turn 15.5

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Psychosocial factors affecting adolescent health

Adolescence is a time of rapid growth and physical, cognitive, emotional and social development. An adolescent’s age is not a reliable indicator of maturity in each of these areas.1

Mental health disorders (e.g. depression, anxiety, eating disorders) are common and clinically important among young people.1 A significant proportion of adult mental health problems emerge during adolescence.1

Adolescence is also a time when people can begin risky behaviours (e.g. smoking, poor eating habits, physical inactivity, and drug and alcohol use), which can continue into adulthood.1, 3 Although smoking rates among adolescents and young people are declining,7 approximately 6% of adolescents aged 15–17 years smoke, and 4% smoke at least daily.8 Smoking rates are higher among Aboriginal and Torres Strait Islander young people, young people living in rural and remote communities, and young people of lower socioeconomic status.97

Adolescents with chronic disease show higher rates of health risk behaviours than healthy adolescents.110 Some risk behaviours are based on incorrect health beliefs (e.g. the myth that smoking cannabis is good for asthma).

Risk-taking behaviour – as well as poor understanding of their health condition – may contribute to the higher rate of food-induced fatal anaphylaxis among adolescents and young adults, compared with other age groups.11

Depression, risk behaviours and poor adherence to medicines are interrelated.2 Adolescents with asthma who adhere poorly to asthma treatment and hide their asthma are more likely to start smoking than other adolescents with asthma.4 Among adolescent boys, those with lower quality of life are most likely to start smoking.4

Adolescents often wish to discuss their health concerns with health professionals but are reluctant to discuss sensitive issues unless asked directly and confidentially.1

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Psychosocial assessment in adolescents

The Royal Australasian College of Physicians recommends that all primary care health professionals should routinely assess psychosocial health of people aged 10–24 years.1

Routine psychosocial health assessment helps the health professional identify mental health states that may affect chronic disease management, identify and understand risk behaviours and strengths, take psychosocial circumstances into account when managing chronic disease, and promotes engagement between the health professional and patient.1

The Royal Australasian College of General Practitioners12 and Royal Australasian College of Physicians suggest that health professionals can use the HEADSS framework (Home, Education and Employment, [Eating and exercise], Activities and peers, Drugs, Sexuality, Suicide and depression, Safety, Spirituality).1314

A list of screening and assessment tools appropriate for adolescents and young adults is included in beyondblue’s Clinical practice guidelines: Depression in adolescents and young adults (2010).15

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Impact of puberty on asthma

In the past, it was thought that children typically 'outgrew' asthma due to maturation of the autonomic and central nervous systems under the effect of sex steroids during puberty.16 However, there is little evidence to support this assumption.16 Puberty does not predict remission of asthma. Almost two-thirds of children with chronic asthma have persistent symptoms throughout puberty.16

Early puberty has been reported to be an independent risk factor for the persistence of asthma into adolescence, and for the severity of asthma in adulthood.16 The mechanism for this association is unclear, and might involve the effects of hormonal changes on reactivity of airways or risk factors that are common to both asthma and early puberty.16

Increased BMI in girls has been associated with both early puberty and increased asthma risk.

Australian data show that more boys than girls experience remission of asthma during adolescence (based on 2007–2008 data):17

  • the prevalence of current asthma is higher for boys than girls among children aged 0–14 years, and higher for women among people aged 15 years and over
  • the prevalence of current asthma in children aged 10–14 years is approximately 12% for boys and 7% for girls
  • the prevalence of current asthma in adolescents and young adults aged 15–24 years is approximately 11% in both sexes.

Asthma can worsen or improve during adolescence; close monitoring is necessary so that medicines can be adjusted to maintain good asthma control at the lowest effective doses. If attempted back-titration of an adolescent’s preventer dose or step-down in the treatment regimen results in worsening of asthma symptoms, this experience can help the person understand why it is necessary to take these medicines regularly. Health professionals can make unsuccessful back-titration an opportunity to reinforce self-management education.

Asthma can occur for the first time during adolescence, more commonly in girls than boys.18 The true prevalence of asthma in adolescents is difficult to estimate because of under- and over-diagnosis.

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Adherence to preventer treatment: adults and adolescents

Most patients do not take their preventer medication as often as prescribed, particularly when symptoms improve, or are mild or infrequent. Whenever asthma control is poor despite apparently adequate treatment, poor adherence, as well as poor inhaler technique, are probable reasons to consider.

Poor adherence may be intentional and/or unintentional. Intentional poor adherence may be due to the person’s belief that the medicine is not necessary, or to perceived or actual adverse effects. Unintentional poor adherence may be due to forgetting or cost barriers.

Common barriers to the correct use of preventers include:

  • being unable to afford the cost of medicines or consultations to adjust the regimen
  • concerns about side effects
  • interference of the regimen with the person’s lifestyle
  • forgetting to take medicines
  • lack of understanding of the reason for taking the medicines
  • inability to use the inhaler device correctly due to physical or cognitive factors
  • health beliefs that are in conflict with the belief that the prescribed medicines are effective, necessary or safe (e.g. a belief that the prescribed preventer dose is ‘too strong’ or only for flare-ups, a belief that asthma can be overcome by psychological effort, a belief that complementary and alternative therapies are more effective or appropriate than prescribed medicines, mistrust of the health professional).

Adherence to preventers is significantly improved when patients are given the opportunity to negotiate the treatment regimen based on their goals and preferences.19

Assessment of adherence requires an open, non-judgemental approach.

Accredited pharmacists who undertake Home Medicines Reviews can assess adherence while conducting a review.

Table. Suggested questions to ask adults and older adolescents when assessing adherence to treatment

  1. Many people don’t take their medication as prescribed. In the last four weeks:
    • how many days a week would you have taken your preventer medication? None at all? One? Two? (etc).
    • ​how many times a day would you take it? Morning only? Evening only? Morning and evening? (or other)
    • each time, how many puffs would you take? One? Two? (etc).
  2. Do you find it easier to remember your medication in the morning, or the evening?

Source: Foster JM, Smith L, Bosnic-Anticevich SZ et al. Identifying patient-specific beliefs and behaviours for conversations about adherence in asthma. Intern Med J 2012; 42: e136-e44. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21627747

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Resources for health professionals working with adolescents
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References

  1. The Royal Australasian College of Physicians. Routine adolescent psychosocial health assessment. Position statement. The Royal Australasian College of Physicians, Sydney, 2008. Available from: http://www.racp.edu.au/fellows/resources/paediatric-resources
  2. Bender BG. Risk taking, depression, adherence, and symptom control in adolescents and young adults with asthma. Am J Respir Crit Care Med. 2006; 173: 953-7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/16424441
  3. Sawyer SM, Afifi RA, Bearinger LH, et al. Adolescence: a foundation for future health. Lancet. 2012; 379: 1630-1640. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22538178
  4. Van De Ven MO, Engels RC, Sawyer SM. Asthma-specific predictors of smoking onset in adolescents with asthma: a longitudinal study. J Pediatr Psychol. 2009; 34: 118-28. Available from: http://jpepsy.oxfordjournals.org/content/34/2/118.long
  5. The Royal Australasian College of Physicians Joint Adolescent Health Committee. Confidential Health Care for Adolescents and Young People (12–24 years). The Royal Australasian College of Physicians, 2010. Available from: http://www.racp.edu.au/
  6. British Thoracic Society (BTS), Scottish Intercollegiate Guidelines Network (SIGN). British Guideline on the Management of Asthma. A national clinical guideline. BTS, SIGN, Edinburgh, 2012. Available from: https://www.brit-thoracic.org.uk/guidelines-and-quality-standards/asthma-guideline/
  7. Australian Institute of Health and Welfare. Australia’s health 2010. no. 12 Cat. no. AUS 122. Australian Institute of Health and Welfare, Canberra, 2010. Available from: http://www.aihw.gov.au/publication-detail/?id=6442468376
  8. Australian Bureau of Statistics. 4364.0.55.003 - Australian Health Survey: Updated Results, 2011-2012. Australian Bureau of Statistics, Canberra, 2013. Available from: http://www.abs.gov.au/ausstats/abs@.nsf/Lookup/E3E02505DCAF230CCA257B82001794EB?opendocument
  9. Australian Bureau of Statistics. The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples, Oct 2010. Cat. no. 4704.0. Australian Bureau of Statistics, Canberra, 2011. Available from: http://www.abs.gov.au/AUSSTATS/abs@.nsf/lookup/4704.0Chapter755Oct+2010#currentdailysmokers
  10. Suris JC, Michaud PA, Akre C, Sawyer SM. Health risk behaviors in adolescents with chronic conditions. Pediatrics. 2008; 122: e1113-8. Available from: http://pediatrics.aappublications.org/content/122/5/e1113.long
  11. Australasian Society of Clinical Immunology and Allergy (ASCIA). ASCIA health professional information paper. Nutritional management of food allergy. ASCIA, Sydney, 2013. Available from: http://www.allergy.org.au/health-professionals/hp-information/asthma-and-allergy/nutritional-management-of-food-allergy
  12. Royal Australian College of General Practitioners. The RACGP Curriculum for Australian General Practice 2011. Children and young people's health. Royal Australian College of General Practitioners, Melbourne, 2011. Available from: http://curriculum.racgp.org.au/statements/children-and-young-peoples-health
  13. Goldenring JM, Rosen D. Getting into adolescent heads: an essential update. Contemp Pediatr. 2004; 21: 64-92.
  14. Goldenring JM, Cohen E. Getting into adolescent heads. Contemp Pediatr. 1988; 5: 75-90.
  15. Beyondblue. Clinical practice guidelines: Depression in adolescents and young adults. beyondblue: the national depression initiative, Melbourne, 2010. Available from: http://www.nhmrc.gov.au/guidelines/publications/ext0007
  16. Patton GC, Viner R. Pubertal transitions in health. Lancet. 2007; 369: 1130-1139. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17398312
  17. Australian Centre for Asthma Monitoring. Asthma in Australia 2011: with a focus chapter on chronic obstructive pulmonary disease. Asthma series no. 4. Cat. no ACM 22. Australian Institute of Health and Welfare, Canberra, 2011. Available from: http://www.aihw.gov.au/publication-detail/?id=10737420159
  18. Towns SJ, van Asperen PP. Diagnosis and management of asthma in adolescents. Clin Respir J. 2009; 3: 69-76. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20298380
  19. Wilson SR, Strub P, Buist SA, et al. Shared treatment decision making improves adherence and outcomes in poorly controlled asthma. Am J Respir Crit Care Med. 2010; 181: 566-77. Available from: http://ajrccm.atsjournals.org/content/181/6/566.full