Pediatric Primary Care Case Studies (56 page)

   Explain your process to arrange for a mental health specialist to see Tom for therapy and your intention to call the therapist to work out a plan to coordinate management as specialist and primary care provider.

Once his mood is stable, follow-up appointments can be changed to meeting every 4–6 weeks to continue to assess response to medications and to support the patient and his parents. In our case example, Tom begins to feel better after 4 weeks on Prozac. He has started to see a therapist and is starting to work on viewing situations in his life more positively. After 6 months of therapy and medications, he is enjoying high school, his grades have improved, and he is more motivated and has his sense of humor back. He has started to play baseball again and is hanging out with more positive peers. No suspicions of drug use are noted.

Key Points from the Case

1. Guidelines can help to simplify the care of depression, such as how to choose a medication or therapy technique, but often the individual’s situation and variables of biology, environment, cognition, and events leading to depression all need to be factored into treatment planning.

2. Treatment of depression with a teen includes understanding his or her pathophysiology, cognitive development, family history, family environment, school environment, social environment, and life experiences.

REFERENCES

Beck, A. (1976).
Cognitive therapy and emotional disorders
. New York: International Universities Press.

Centers for Disease Control and Prevention. (2005). Mental health in the United States: Health care and well being of children with chronic emotional, behavioral, or developmental problems—United States, 2001.
Morbidity and Mortality Weekly Report, 54
(39), 985–989.

Centers for Disease Control and Prevention. (2008). Youth risk behavioral surveillance—United States, 2007.
Morbidity and Mortality Weekly Report, 57
(SS-4).

Compton, S., March, J., Brent, D., Albano, A., Weersing, R., & Curry, J. (2004). Cognitive-behavioral psychotherapy for anxiety and depressive disorders in children and adolescents: An evidence-based medicine review.
Journal of the American Academy of Child and Adolescent Psychiatry, 43
(8), 930–959.

Flavell, J. H., Green, F., & Flavell, E. R. (2000).
Young children’s knowledge about thinking: Monographs of the Society for Research in Child Development
. Malden, MA: Blackwell.

Hankin, B. (2006). Adolescent depression: Description, causes, and interventions.
Epilepsy and Behavior, 8
, 102–114.

Hazell, P. (2004). Depression in children and adolescents.
Clinical Evidence, 12
, 427–442.

Kaye, D. L., Montgomery, M. E., & Munson, S. (2002).
Child and adolescent mental health
. Philadelphia: Lippincott Williams & Wilkins.

Kovaks, M. (2003).
Children’s Depression Inventory: Technical manual
. Toronto: Multi-Health Systems.

March, J., Silva, S., Petrycki, S., Curry, J., Wells, K., Fairbank, J., et al. (2004). Fluoxetine, cognitive behavioral therapy, and their combination for adolescents with depression: Treatment for Adolescents with Depression Study (TADS) randomized controlled trial.
Journal of the American Medical Association, 292
, 807–820.

Mesquita, P. B., & Gilliam, W. S. (1994). Differential diagnosis of childhood depression: Using comorbidity and symptom overlap to generate multiple hypotheses.
Child Psychiatry and Human Development, 24
(3), 157–172.

Pearlin, L. I., Lieberman, M. A., Menaghan, E. G., & Mullan, J. T. (1981). The stress process.
Journal of Health and Social Behavior, 22
, 337–356.

Powers, S., Jones, J., & Jones, B. (2005). Behavioral and cognitive-behavioral interventions with pediatric populations.
Clinical Child Psychology and Psychiatry, 10
, 65–77.

Quakley, S., Coker, S., Palmer, K., & Reynolds, S. (2003). Can children distinguish between thoughts and behaviors?
Behavioural and Cognitive Psychotherapy, 31
, 159–168.

Rice, F., Harold, G., & Tharper, A. (2002). The genetic aetiology of childhood depression: A review.
Journal of Child Psychology and Psychiatry, 43
(1), 65–79.

Sadock, B. J., & Sadock, V. A. (2007).
Kaplan and Sadock’s synopsis of psychiatry
(10th ed.). Philadelphia: Lippincott Williams & Wilkins.

Chapter 15

The Teen Who Thinks She Might Be Gay

Sheran M. Simo

Things aren’t always the way they appear. Judgments are made on a daily basis regarding every aspect of a person’s life, including lifestyle, religious beliefs, and sexual orientation. As is often the case in the primary healthcare setting, the initial reason that brings an individual in for a health visit may evolve into something completely different as the visit progresses.

Educational Objectives

1.   Identify lesbian, gay, bisexual, and transgendered (LGBT)–sensitive questions to ask your patients.

2.   Identify and become familiar with health issues specific to adolescent LGBT youth.

3.   Identify risk factors such as sexually transmitted diseases (STDs), mental health disorders, and violence that LGBT youth may experience.

4.   Become familiar with resources available in the community specific to LGBT youth.

   Case Presentation and Discussion

Fifteen-year-old Cassandra Stanley is brought to your office by her mother. According to Mrs. Stanley, she would like you to initiate birth control for her daughter. As the story unfolds, you learn that Cassandra is the youngest of three daughters, 8 years younger than her next older sibling. Mom states that she had initiated birth control for Cassandra’s sisters and neither of them became pregnant prior to finishing school and getting married. She hopes to provide the same means of protection for Cassandra. As you look to Cassandra to initiate the conversation, you notice that Cassandra appears very upset. She expresses to her mother that she’s already told her that she doesn’t want to be on birth control so this visit is pointless!

You realize very quickly that you have a stressful situation on your hands and ask Mom to step out of the room to allow you to get to know Cassandra a little better and talk with her in private as you do with all your teen patients. During the course of your conversation, Cassandra blurts out, “My mom wants me to take birth control because she thinks I want to have sex with boys.” As you question her further, she relates, “I’m in love with my best friend, and
she
can’t get me pregnant!” Cassandra reveals that she has “always known I liked girls” and “can’t imagine ever being with a boy.”

What information do you need to recall for this situation?

Because of the delicate nature of this situation, it is important for the healthcare provider (HCP) to be sensitive to the teen’s feelings and concerns. In order to promote this type of communication, the provider is encouraged to ask open-ended questions. Asking open-ended questions promotes conversation more readily and helps the teen to think more clearly about what it is that they want to discuss or what questions they need answered, such as, “What questions about being with your partner have come to mind as you’ve begun to think about being sexually active?” or “What questions would you like to ask me as you begin your sexual relationship?” Asking adolescents closed-ended questions such as “Do you understand?” or “Do you have any questions?” will limit the discussion.

It is also important for the practitioner to be aware of what it means when a female describes herself as a woman-loving woman or lesbian, or a male describes himself as a male-loving male or gay. Sexual orientation describes the direction a person’s emotional connections, attractions, and sexual activity lean toward. Attractions may be toward the same sex (homosexual, gay, lesbian), the opposite sex (heterosexual), or toward both sexes (bisexual).
Table 15-1
defines these different sexual orientations.

It is important for the HCP to consider several factors when working with adolescents who are deliberating about their own sexual orientation, especially when they believe they are or may be homosexual.

•   Adolescents usually establish their sexual identity by the time they reach adolescence, even if they have not had an opportunity to act on it.

•   Sexual orientation cannot be changed; it is deeply ingrained within children’s makeup. Very often the fact that children or adolescents are gay remains hidden from family and friends, and is often denied by the teens themselves.

•   Sexual orientation appears to be a biological phenomenon. Only rarely, if ever, is sexual orientation caused by personal experiences and environment (American Academy of Pediatrics, 1999), although heredity seems to also have a place.

•   Despite increased knowledge and information about being gay or lesbian, teens still have many concerns. These include (American Academy of Child and Adolescent Psychiatry, 1997):

   Feeling different from peers