How to approach and take care of minor adolescents whose situations raise ethical dilemmas? a position paper of the European academy of pediatrics.

In the care of adolescents, health care providers often face situations raising ethical concerns or dilemmas, such as refusal of a treatment or hospitalization, or request of confidentiality while engaging in risky behaviors or facing unplanned pregnancy. This position paper provides concrete avenues as how to assess the adolescent's capacity for autonomous decision making, e.g. the patient's competence in a specific situation, and how to elicit informed choice or consent. To do so, professionals need to be sensitized and trained as how to assess the cognitive and socio-psychological development of the young patient. Another challenge for the health professionals is to balance the needs to support patient's autonomy while offering secure guidance and protection if needed. To optimize such a process, they establish a climate of trust and empathy that will allow the patient to participate freely in the decision. In addition, especially when the decisions have potentially important consequences on the health and life, the professionals include, with the adolescent's permission, parents, caregivers or other significant adults, as well as they may request the opinion of other members of the health care team or expert colleagues such as ethicists.

Adolescent pregnancy: An important issue for paediatricians and primary care providers-A position paper from the European academy of paediatrics.

Adolescent pregnancy and childbearing, remain a widespread health-related problem with potential short and long-term consequences. Comprehensive social, economic, environmental, structural, and cultural factors heavily impact on adolescents' sexual and reproductive health and early pregnancy. Health professionals can play a pivotal role in the prevention of unplanned pregnancy. Improved access to family planning, sexuality education in schools, community-based interventions, and policies contribute greatly to reduce the risk of adolescent pregnancy and the adoption of respectful and responsible sexual behaviour. Additionally, health care professionals can support pregnant adolescents in making decisions under these circumstances and provide adequate health care. This review highlights actions that can guide healthcare professionals in empowering young adolescents to become more aware and capable of making informed decisions about their sexual life, health, and future.

The state of adolescent medicine as a specific field: an international exploratory survey.

OBJECTIVES: The emergence of adolescent medicine (AM) as a specific area of training and health care delivery is progressing at various pace around the world. The objective of this exploratory survey was to inquire about the existence of official bodies and institutions offering recognition of the discipline as a specific field and on the status of related training initiatives. METHODS: A questionnaire was spread among a convenience sample of 21 colleagues involved in adolescent health care around the world, and answers were collected and analysed manually. RESULTS: All 21 colleagues from the North and South American, African, Asian and European regions have responded. Only seven countries report the existence of adolescent inpatient wards in some hospitals, while 16 have specialized outpatient clinics; in only eight countries is formal mandatory training in AM required for paediatricians; in seven others, such a stay is available but optional. Six countries have implemented a systematic assessment tackling AM in the certification process of paediatricians and just four recognize AM as a sub-specialty. Only two countries mention compulsory training in AM for family doctors. Fourteen countries report on the existence of an AM association. CONCLUSIONS: Despite an encouraging number of initiatives testifying the growing place of AM in the practice of medicine, our data bring a worrisome portray of the status of AM in the involved countries and call for the development of appropriate health care and training centres.

Adolescents With Eating Disorders in Pediatric Practice - The European Academy of Paediatrics Recommendations.

In the face of the growing number of adolescents suffering from eating disorders (EDs) and access to psychiatric care limited by the epidemiological and demographic situation, the primary care pediatrician's role in diagnosing and treating EDs is growing. The European Academy of Paediatrics (EAP) decided to summarize knowledge about EDs and formulate recommendations to support European pediatricians and improve care for adolescents with EDs.

The impact of the Ebola epidemics on children's rights: a scoping review.

BACKGROUND: The Ebola virus is known as one of the deadliest pathogens to infect humans. Children represent a minority of Ebola Virus Disease cases globally. Yet, the different Ebola outbreaks in Africa had a wide impact on children's lives and children' rights. OBJECTIVE: Review the published literature to date on Children's rights during Ebola outbreaks. Outcomes shall contribute to get a better understanding of the main limitations or violations of children's rights, identify potential gaps in the literature and support the promotion and protection of children's rights for current and future health crisis. METHODS: A scoping review from PubMed, Medline, Cochrane Library and Web of Science was performed using PRISMA-ScR guidelines. Articles, reports and editorial, published on Ebola Outbreaks between 1976 and 2020 were retrieved. The UNCRC clusters of rights and treaty specific guidelines were used as a framework. Documents were found through a targeted search of websites from international or regional organisations involved in Ebola crises and children's protection. RESULTS: 48 articles and reports were reviewed. Few documents focused solely on children's rights. Several articles covered the topic of children and Ebola outbreaks. Most of the data are linked to basic health, education, discrimination of orphans and survivors. 31% of the reviewed articles underline the violence against the children (rape, abuse, Female genital mutilations), while 21% focus on the right to education. 23% cover the topic of orphans. Impact on mental health and SRH were amongst the other covered topics. CONCLUSION: A lack of data on children's rights and their violations during epidemics is observed. Regional and international collaboration is needed to document the situation of children in health emergencies. Health measures and strategies based on children's opinions and raising awareness of their crucial role in society is key. Child-centred guidelines should be developed based on these elements.

The Impact of COVID on Adolescent Mental Health, Self-Harm and Suicide: How Can Primary Care Provider Respond? A Position Paper of the European Academy of Pediatrics.

Adolescents aged 10 to 19 live a period of their life marked by opportunities and vulnerabilities during which the issue of mental health is of prime importance. Since several decades, and especially since the start of the COVID pandemic, mental health problems and disorders among adolescents have increased around the world. Depression, self-harm and suicidal behavior are common during this period of life, and pediatricians can play a pivotal role in identifying affected or vulnerable youngsters. This article describes risk factors for self-harm and suicidal behavior and reviews how primary care pediatricians and health professionals can respond to such situations. This scoping review is based on existing evidences as well as the authors clinical experience. It suggests concrete actions that can be taken to secure the life of at risk teenagers, and discusses how to organize the transfer to mental health professionals when needed.

E-Cigarettes as a Growing Threat for Children and Adolescents: Position Statement From the European Academy of Paediatrics.

As the tobacco epidemic has waned, it has been followed by the advent of electronic nicotine delivery devices (ENDS) primarily manufactured by the tobacco industry to try to recruit replacements for deceased tobacco addicts. This document sets out the ten recommendations of the European Academy of Paediatrics (EAP) with regard to e-cigarettes and children and young people (CYP). The EAP notes that nicotine is itself a drug of addiction, with toxicity to the foetus, child and adult, and were ENDS only to contain nicotine, their use to create a new generation of addicts would be rigorously opposed. However, e-cigarettes include numerous unregulated chemicals, including known carcinogens, whose acute and long term toxicities are unknown. The EAP asserts that there is incontrovertible evidence that the acute toxicity of e-cigarettes is greater than that of "traditional" tobacco smoking, and a variety of acute pulmonary toxicities, including acute lung injuries, have been recorded due to e-cigarettes usage. The chronic toxicity of e-cigarettes is unknown, but given the greater acute toxicity compared to tobacco, the EAP cannot assume that e-cigarettes are safer in the long term. The high uptake of e-cigarettes by CYP, including under-age children, is partly fuelled by deceitful marketing and internet exposure, which is also unregulated. Although proposed as aids to smoking cessation, there is no evidence that e-cigarettes add anything to standard smoking cessation strategies. In summary, the EAP regards these devices and liquids as very dangerous, and ineluctably opposed to their use, and their direct or indirect marketing.

Organization and activities of school health services among EU countries.

BACKGROUND: School health services (SHS) can be defined as health services provided to enrol pupils by health professionals and/or allied professions. The aim of this study was to explore the current state of the governance, organization and workforce of SHS and their provision of preventive activities in European countries. METHODS: Observational study. Data were collected as part of the Horizon 2020-funded project 'Models of Child Health Appraised'. Only 1 expert from each of the 30 included European countries answered a closed-items questionnaire during the years 2017 and 2018. RESULTS: All countries (except Spain and the Czech Republic, which do not have formal SHS) provided school-based individual screening and health-enhancing measures. The majority performed height, weight, vision and hearing checks; some integrated other assessments of limited evidence-based effectiveness. Most countries also delivered health education and promotion activities in areas, such as sexual health, substance use and healthy nutrition. Almost all countries seemed to suffer from a shortage of school health professionals; moreover, many of these professionals had no specific training in the area of school health and prevention. CONCLUSIONS: Many EU countries need better administrative and legal support. They should promote evidence-based screening procedures and should hire and train more school health professionals. Overall, they need to adapt to the evolving health priorities of pupils, adopt a more holistic paradigm and extend their activities beyond traditional screening or vaccination procedures.

[Impact of the COVID-19 pandemic on adolescent health and development: a role to play for physicians]. / Impact de la pandémie de Covid-19 sur la santé et le développement des jeunes en Suisse - Quel rôle pour les médecins ?

This article summarizes the conclusion of a two-days interprofessional online workshop held under the auspices of the Brocher Foundation. The objectives were to review the impact of COVID on adolescent health and development and to generate some key responses to the situation. The pandemic has severely affected the mental health of a large proportion of adolescents and has significantly reduced access to health care. It has as well disturbed the school education of vulnerable youngsters and decreased social contacts with adults and peers. In the future, authorities should better consider the rights of young people and request their opinion and participation in decision making. Physicians should systematically explore their young patients' opinions and queries regarding the COVID and address problematic situations such as family conflicts, misuse of internet or risky behaviour.

Cet article résume le contenu d'un colloque participatif interprofessionnel en ligne de 2 jours visant à faire un état des lieux et à élaborer des réponses à la situation des adolescent·e·s à l'ère du Covid. La pandémie affecte leur santé en réduisant l'accès aux soins (confinement) et en induisant des problèmes psychologiques chez certains d'entre eux. Elle affecte la formation et la scolarité des plus démunis, réduit les contacts sociaux avec les adultes et les pairs. À l'avenir, les autorités devraient mieux respecter les droits des jeunes en sollicitant leur avis et leur participation et en adaptant leurs messages. Les médecins doivent, lors des consultations avec eux, offrir systématiquement un dialogue et des informations, et repérer des problématiques telles que conflits familiaux, abus d'internet ou prise de risque sanitaire.

Transition to postgraduate practice: perceptions of preparedness and experience of the daily work of junior residents.

BACKGROUND: The transition from undergraduate to postgraduate training is a crucial career step for physicians. Several international studies have shown that graduates feel insufficiently prepared to perform various aspects of clinical practice. The publication of a national framework for undergraduate medical education triggered major curricular reforms at our institution. Through this study, we explored the perceptions of preparedness for practice of junior residents who graduated from the new curriculum. METHODS: This was a cross-sectional, triangulation mixed-methods quantitative and qualitative study among junior residents and senior physicians of 13 hospitals in western Switzerland. We administered two online questionnaires aimed at exploring perceptions in five areas of clinical competence (knowledge, clinical skills, clinical reasoning, communication and collaboration), as well in self-confidence and coping with the daily work. The qualitative part consisted of six semi-structured focus groups with junior residents, aimed at further clarifying the perceptions and circumstances of their preparedness. Verbatim transcriptions were analysed through thematic analysis. RESULTS: Fifty-nine (43.3%) junior residents and 68 (26.5%) senior physicians completed the questionnaire. Among residents, 54.2% considered the curriculum to have adequately prepared them for practice. However, residents felt they were underperforming particularly in developing therapeutic strategies, in communicating with patients’ relatives, and in writing discharge letters. 50.8% (95% confidence interval 37.5-64.1) of them felt overwhelmed by the workload and 39% felt unfulfilled at work. Perceptions of senior physicians about residents’ clinical competences most often agreed with those of their young colleagues. Nineteen residents volunteered to participate in six focus groups. Thematic analysis allowed us to highlight six areas associated with perceptions of underpreparedness: (1) the adequacy of undergraduate instruction; (2) the ability to work efficiently within an interprofessional team; (3) the ability to communicate with patients and colleagues; (4) the effect of the curriculum on the development of critical inquiry and their approach to learning; (5) difficulties in managing their daily clinical work; (6) the negative emotions experienced at the beginning of postgraduate training. CONCLUSIONS: Several important aspects of daily clinical practice appear to be insufficiently mastered in the first few months of residency. The resulting stress and anxiety negatively affect job satisfaction. This study provides concrete examples and guidance for program directors and educators on how to better prepare students for postgraduate training.

Including adolescents of childbearing potential in clinical trials with possible exposure to teratogenic medication: a challenge for paediatricians and researchers.

The issue of contraception and pregnancy tests among minor adolescent women participating in clinical trials, whether healthy or suffering from a disease, represents a challenging issue for paediatricians and researchers, given the potential harmful effect of various therapeutic procedures being tested. First, they need to gauge at what age or developmental stage they need to impose pregnancy tests and contraception. Second, if the adolescent denies any sexual activity, it may be ethically questionable to impose such procedures. Third, these professionals must deal with the issue of confidentiality, taking into account the fact that some adolescents engage in penetrative sexual intercourse without their parents or caregivers knowing. Fourth, in such cases, they must assess the extent to which a minor adolescent can be considered as competent (capable of making autonomous decisions) and deserves privacy and confidentiality. There is indeed a legal obligation for the provider to check that sexual experiences and intercourse take place within a safe relationship. Fifth, if the prescription of contraception is warranted, they have to decide who should assist the adolescent in choosing the method. Finally, with the occurrence of a positive pregnancy test, they may face the rare instance of a competent minor adolescent who refuses to inform her parents. This article has been developed by a group of experts under the auspices of swissethics, the Swiss Association of Research Ethics Committees and SwissPedNet, the umbrella organisation that coordinates the paediatric research in Switzerland. The paper reviews how to address practical and ethical questions regarding minor adolescents of childbearing potential enrolled in a clinical trial that may involve teratogenic medication and offers a series of concrete advice and tools for dealing with problematic situations. Most paediatric protocols stipulate that adolescents included in clinical trials involving potentially teratogenic drugs should undergo pregnancy tests and use contraception. The circumstances in which such requirements are undertaken, however, has not been sufficiently addressed. The recommendations presented in this article will assist researchers in assessing which circumstances apply when considering minor adolescents as individuals with childbearing potentials. It also offers concrete suggestions for tackling such situations.

Availability and accessibility of primary mental health services for adolescents: an overview of national recommendations and services in EU.

BACKGROUND: Mental health problems in adolescence can profoundly jeopardize adolescent current and future health and functioning. We aimed to describe existing recommendations and services regarding the delivery of primary mental health care for adolescents in 31 European countries. METHODS: Data on the availability and accessibility of primary mental health services were collected, as part of the Horizon 2020-funded project Models of Child Health Appraised. One expert from each country answered a closed items questionnaire during years 2017-18. RESULTS: All 31 participating countries had some policy or recommendations regarding the availability and accessibility of primary mental health services for adolescents, but their focus and implementation varied largely between and within countries. Only half of the participating countries had recommendations on screening adolescents for mental health issues and burdens. Merely a quarter of the countries had ambulatory facilities targeting specifically adolescents throughout the whole country. Just over half had some kind of suicide prevention programs. Same-day access to primary care in case of -health emergencies was possible in 21 countries, but often not throughout the whole country. Nineteen countries had strategies securing accessible mental health care for vulnerable adolescents. CONCLUSIONS: Overall, around half of European countries had strategies securing access to various primary mental health care for adolescents. They frequently did not guarantee care over the whole country and often tackled a limited number of situations. EU countries should widen the range of policies and recommendations governing the delivery of mental health care to adolescents and monitor their implementation.

Correction to: How can primary care practitioners address substance use by adolescents? A position paper of the EUROPEAN academy of PAEDIATRICS.

The authors of the published version of this article inadvertently omitted the table note of the Table 2 under the Appendix section. The complete Table 2 is shown in this article].

Correction to: how can primary care practitioners address substance use by adolescents? A position paper of the EUROPEAN academy of PEDIATRICS.

The authors of the published version of this article inadvertently omitted the table note of the Table 2 under the Appendix section. The complete Table 2 is shown in this article].

How can primary care practitioners address substance use by adolescents? A position paper of the EUROPEAN academy of PAEDIATRICS.

The objective of this article is to review how primary care providers - paediatricians, family practitioners, nurse practitioners - could address the use of substances by adolescents and respond to problematic behaviours and situations. Given the highly addictive properties of nicotine, adolescents should be supported in avoiding any consumption of tobacco or quitting if they already do so. Screening and investigation of substance use is usually not difficult, provided that it is processed in a neutral and empathetic atmosphere and securing confidentiality if the adolescent asks for it. Any type of substance use is potentially linked with adverse events such as injuries, violence, unplanned and unsafe sexual experience, alcoholic coma, 'bad trips' or unpleasant psychological experiences. As such, substance use should be identified and openly discussed with the adolescent. Moderate intermittent recreational use of legal and illegal substances (mainly alcohol and cannabis) should be carefully monitored over time, as it can lead to problematic use. Problematic use and substance use disorder require various interventions, including motivational interviewing, family counselling and psychotherapy, especially when substance use is linked with mental health disorders. Despite the importance of confidential care, parents or caregivers should be involved in problematic situations as much as possible. What is known: • While problematic use of substances is transient amongst many adolescents, it may be a threat to health and school/professional functioning • Primary care providers (PCPs) can address queries or offer preventive interventions to adolescents who use substances What is new: • Some interview tools can assist PCPs efficiently to identify problematic users of substances • There are effective approaches that PCPs can use to address problematic use by adolescent patients.

Do European Union countries adequately address the healthcare needs of adolescents in the area of sexual reproductive health and rights?

BACKGROUND AND OBJECTIVES: Adolescent sexual and reproductive health and rights (SRHR) are of particular relevance given their potential short-term or long-term health consequences. This study evaluates recommendations and policies regarding access to care in this area in 31 European countries (European Union (EU) plus Iceland, Norway and Switzerland). METHODS: As part of the EU funded Models of Child Health Appraised project, data were gathered using a 43-item questionnaire sent to experts responsible for collecting information in each country. RESULTS: Ten countries have not developed any formal policy or recommendation that guarantee the respect of confidentiality and the possibility of consulting a physician without parents knowing. Nearly half of the countries do not have centres specialised in adolescent healthcare, tackling comprehensive health issues or focusing specifically on SRH. Access to emergency contraception and information regarding pregnancy, including testing, is easy in most countries. However, oral contraception is delivered free of charge in only 10 countries. Twenty-three countries do not meet current standards in terms of providing policy-based pregnancy care, and only 13 have set up special programmes for pregnant adolescents. In only seven countries can adolescents definitely have their pregnancy terminated without their parents knowing (and in another seven countries in selected situations). CONCLUSION: The provision and availability of adolescent-friendly SRHR care are far from optimal in around half of the surveyed countries. These results call for the review and implementation of policies, specialised healthcare centres and training initiatives for primary care providers.

An exploratory survey on the state of training in adolescent medicine and health in 36 European countries.

The development of adolescent health and medicine as a medical discipline lags behind in Europe compared with other regions of the world. This study aims to evaluate the structure and content of adolescent medicine and health training curricula for medical students, paediatricians, and other primary care physicians in the European region. A questionnaire survey was sent by e-mail to experts in the field from 36 European countries, addressing the content of adolescent health issues. Data was obtained from all 36 countries. At the undergraduate level, seven countries reported some mandatory stand-alone teaching (sessions dealing specifically with adolescents), while seven countries reported optional stand-alone teaching. In only 7 out of 36 countries were issues critical to adolescents covered as stand-alone sessions. At the postgraduate level, 15 countries delivered stand-alone mandatory training sessions to primary, secondary, or tertiary care paediatricians, covering most of the five critical areas listed in the questionnaire. In another 13 countries, such sessions were not mandatory and were inexistent in eight of them. The coverage among school physicians was similar but was much lower among general practitioners.Conclusion: Paediatric associations and academic institutions should advocate for a better coverage of adolescent health and medicine in the training curricula of health care providers. What is known: • In most European countries, adolescent medicine is still poorly represented as a discipline. • Experts have recently published recommendations regarding what form the structure and content of a training curriculum in this field should take. What is new: • This paper gives information on the extent and content of training in adolescent medicine and health as currently offered within under- and postgraduate European training curricula, in terms of stand-alone mandatory (versus optional) sessions. • In many European countries, both medical students and residents are poorly exposed to the basic knowledge and skills pertaining to adolescent health care.

Child trafficking in Europe: what is the paediatrician's role? : A statement by the European Academy of Paediatrics.

Child trafficking is among the most lucrative criminal activities in the world and growing rapidly. Poverty, natural disasters, armed conflicts and, in particular, migration put vulnerable children at high risk of trafficking. Accurate statistics on child trafficking are not available due to its illegal nature. Moreover, trafficking may not be consistently recorded and reported by European countries, mainly because of different perceptions as to who is considered a victim of trafficking. Around 4000-5000 children were identified as presumed victims of trafficking in European Union countries from 2013 to 2014; this is an underestimate of the problem because many victims go unrecognised. Trafficking is linked with issues, such as forced marriage, begging, labour or domestic servitude, slavery and prostitution as well as sexual abuse and child pornography. It may also involve the use of children as soldiers or for criminal activities, such as theft and drug smuggling. Child trafficking also involves the removal of organs and the selling neonates, infants, and children for adoption. Child victims of trafficking should be promptly identified in order to provide them with the necessary care as well as to prosecute the traffickers and stop their illegal activity. Healthcare professionals should be appropriately trained to keep a careful eye out for any signs of trafficking in children. CONCLUSION: The European Academy of Paediatrics calls on our governments, intergovernmental organisations, paediatricians, and healthcare professionals to collaborate so as to improve the identification and healthcare of victims and to contribute to the disbanding and prosecution of child traffickers by reporting such situations. What is Known: • Child trafficking is a fast growing and among the most lucrative criminal activities in the world. • Poverty, natural disasters, armed conflicts and in particular migration put vulnerable children at high risk of trafficking. What is New: • Child trafficking is an underestimated and often ignored issue, with around 4000-500children identified as presumed victims in European Union countries from 2013 to 2014. • The European Academy of Paediatrics strongly encourages Paediatricians to identify victims as well as provide them with adequate health care and support; it calls on governments, intergovernmental organisations, and fellow compatriots to act within the full extent of the law to identify, disband, and prosecute child traffickers.