Slide Note
0 likes | 20 Views
Adolescence is a crucial period of transition marked by physical, cognitive, social, and emotional changes. Defined by the World Health Organization as ages 10-19, this stage encompasses pubertal developments and shifts in thinking patterns. It is divided into early, middle, and late phases, each with distinct characteristics and challenges. Adolescent health encompasses issues like medical diseases, risky behaviors, nutritional problems, reproductive health issues, mental health concerns, and more. Prioritizing adolescent health problems can help address key issues affecting this age group.
E N D
Chapter 5 Adolescent Health
Definition and Importance of Adolescent Health • Adolescence is a period of transition between childhood and adulthood • A time of rapid physical, cognitive, social, and emotional maturing. Definition of adolescence • WHO defines “adolescence” as age between 10 and 19 years • Government of India (National Youth Policy) defines adolescence as 13–19 years • “Youth” refers to ages 15–24 years. Government of India defines this as 15–35 years • “Young people” refers to ages 10–24 years • “Young adults” refers to ages 20–24 years • Early adolescence refers to age 10–13 years, middle adolescence refers to age 14– 16 years and late adolescence refers to age 17–19 years.
Pubertal Changes Girls • Girls develop breast buds as the first sign of puberty • Approximately 1 year after breast budding, girls reach their peak height velocity, and 1 year later menarche ensues. After menarche, a girl usually grows only an additional 4–5 cm. Boys • Onset is heralded by an increase in testicular volume, followed by pubic hair growth, then enlargement of the penis. • Peak height velocity occurs 2 years after the onset of testicular enlargement. Adolescents gain about 15–25% of their final adult height during their pubertal growth spurt. Important • Pubertal development starts 1–2 years earlier in girls as compared to boys. • Appearance of secondary sexual characters before the age of 8 years in girls and 9 years in boys, and nonappearance of secondary sexual characters by the age of 13 years in girls and 14 years in boys is considered abnormal. • A girl who does not menstruate by 16 years should be thoroughly evaluated.
Cognitive and Developmental Changes 1. Bodily changes cause emotional stress and strain as well as abrupt and rapid mood swings. 2. Sexual attraction leads to a desire to mix freely and interact with each other. 3. Adolescence is characterized by an emerging capacity to reason in an increasingly more sophisticated manner. 4. Adolescents have a sense of uniqueness and personal invulnerability. 5. This sense of personal invulnerability, coupled with a desire to test and master and their newly emerging physical and mental capabilities, may also explain the risk- taking behaviors observed during this age.
PHASES OF ADOLESCENCE Adolescence is customarily divided into the stages: (1) Early (age 11–14 years), • Characterized by a focus on the physical changes that accompany puberty and by concrete thinking. Separation from parents and the rise in peer group influence begins during this stage but is not prominent. (2) Middle (age 14–17 years) and • Peer group influence and conflicts with parents peak. Risk-taking behaviors, become common. Concerns about one’s developing sense of self and autonomy become increasingly important. (3) Late (age 17–21 years) (Table 5.4). • The focus shifts to developing the capacity for intimacy in relationships and defining one’s career goals and place in society.
IN A NUTSHELL Changes in Adolescence 1. Adolescence is accompanied by physical, cognitive, emotional, social and behavioral changes due to interplay of various hormones during puberty. 2. Physically, an individual gains the final 15–20% of adult height; 50% of the adult body weight; and 40% of the adult skeletal mass in adolescence. 3. Marshall and Tanner have described the appearance of secondary sexual characteristics as sexual maturity ratings (SMR). 4. Adolescence is customarily divided into the three stages: early (11 to 14 years), middle (14 to 17 years) and late (17 to 21 years).
Adolescent Health Problems 1. Medical diseases: Asthma, respiratory infections, tuberculosis, precocious or delayed puberty short stature, and chronic disorders such as diabetes, celiac diseases, heart diseases, etc. 2. Consequences of risk-taking behavior: Accidents and injuries, violence, homicide, suicide, substance abuse 3. Nutritional problems: Undernutrition, iron deficiency, obesity, and eating disorders—anorexia nervosa, bulimia 4. Reproductive health problems: Teenage pregnancy, abortion, menstrual problems, and reproductive tract infections 5. Mental health problems: Substance abuse, violence, depression and suicide, learning disorders, and other psychiatric disorders
Priority Health Problems Affecting Adolescents 1. Nutritional problems 2. Sexual and reproductive health problems (including HIV/AIDS) 3. Noncommunicable diseases 4. Mental health problems 5. Substance use and abuse (tobacco, alcohol, and other substances) 6. Injuries and violence (including gender-based violence) 7. Endemic and chronic diseases: TB, malaria, asthma
Priority Health-risk Behaviors in Adolescents 1. 2. 3. 4. 5. 6. Behavior contributing to unintentional violent injuries Tobacco use Alcohol and other drug use Sexual behaviors contributing to unintended pregnancy, STD and HIV Unhealthy dietary behavior Physical inactivity
PROTECTIVE FACTORS These factors increase the likelihood of adolescents making decisions that contribute positively to their health and development and decrease the likelihood of engaging in risky behavior. 1) caring and meaningful relationships; 2) positive school environment; 3) structure and boundaries for behaviors; 4) having spiritual beliefs; 5) encouragement of self-expression; and 6) opportunities for participation and contribution.
IN A NUTSHELL Health Issues in Adolescence 1. Though adolescence is considered relatively a healthy period, but many health risk behaviors such as smoking, alcohol consumption, sedentary lifestyle are formed in this age, which are responsible for significant morbidity and mortality in the adult life. 2. Health problems encountered in adolescence can be broadly grouped as medical and nonmedical. 3. Apart from medical issues, mental health issues, drugs, and injuries and violence are the major causes of morbidity and mortality in adolescents. 4. Protective factors increase the likelihood of adolescents making decisions that contribute positively to their health and development, and decrease the likelihood of engaging in risky behavior
Adolescent Sexuality A. Sex • The terms sex and sexuality often confuse the adolescents. • The term sex is often used for the intercourse whereas it denotes the biological difference between women and men. • The goal of sex drive is biological sexual maturity, i.e., capacity to love, mate, reproduce and care for the young ones. B. Sexuality • It includes the sum of person’s personality, thinking and behavior toward sex. • It includes the identity, emotions, thoughts, actions, relationships, affection, love, feelings, caring, sharing, and the intimacy the person has and displays. • The negative aspect of sexuality includes sexual coercion, eve teasing, sexual harassment, rape, and prostitution.
Adolescent Sexuality • Adolescents develop and become aware of their sexual drives and feelings. • They also tend to explore the various aspects/ dimensions of being sexual. • They are likely to be curious and try to experiment. • Many adolescents adopt high-risk behavior due to the numerous myths and lack of skills—especially the ability to negotiate and to deal with peer pressure effectively. • Consequences of unsafe sexual behaviors include adolescent pregnancy, unsafe abortions, and sexually transmitted infections (STIs).
Adolescent Pregnancy • Globally, 15% of all births are to women 15–19 years old. • Nineteen percent of total fertility in India is contributed by girls in the 15–19 age group. Adverse effects ˗ ↑morbidity and mortality. ˗ Malnutrition in fetus and mother. ˗ Premature labor, spontaneous abortion, and stillbirths. ˗ Pregnancy-related hypertension and anemia. ˗ Young mothers are also likely to have a higher incidence of poor childcare and poor child feeding practices.
Unsafe Abortion in Adolescents • Can result in complications such as hemorrhage, septicemia, injuries, infertility, and death. • Abortion also has psychological consequences such as depression. • Adolescent abortions are estimated globally at 2.5 million per year, representing 14% of all unsafe abortions. Most of them are performed illegally or under hazardous circumstances. Sexually Transmitted Infections • Each year, >1 out of 20 adolescents contract a curable STI. • At least one-third of total estimated new STI cases occur in young people. • More than half of all new HIV infections reported globally are from the age group of 15–24 years.
PROMOTING THE SEXUAL AND REPRODUCTIVE HEALTH Adolescents need to have clear, accurate and precise information to understand the various aspects of human sexuality, sexual roles and responsibilities. Promoting the sexual and reproductive health of adolescents involves the implementation of the following: Proper information that will help adolescents understand how their bodies work and what the consequences of their actions are likely to be. Social skills that will enable them to say no to sex with confidence and to negotiate safer sex. Counseling to make informed choices. Health services can help adolescents to stay well, and ill adolescents get back to good health.
IN A NUTSHELL Adolescent Sexuality 1. Sexuality is broad term, which includes the sum of person’s personality, thinking and behavior toward sex. 2. Nineteen percent of total fertility in India is contributed by girls in the 15–19 age group. 3. Adolescent pregnancy and breastfeeding puts both mother and child at higher risks of morbidity and mortality. 4. To function as effective and well-adjusted adults, adolescents need to have clear, accurate and precise information to understand the various aspects of human sexuality, sexual roles, and responsibilities.
Recommended Diet for Adolescents • Increased demand of calories and proteins • The “growth spurt” results in a 50% increase in calcium and 15% increase in iron requirements.
Factors Influencing Adolescent Nutrition • Conditioning factors: Worm infestations, diarrhea, poor environmental sanitation, and menstruation in girls contribute to malnutrition. • Cultural factors: Food habits custom, beliefs, tradition, attitudes, religion, food fads, cooking practices, and social custom. • Socioeconomic factors: Poverty, ignorance, insufficient education, lack of knowledge regarding nutritive value of foods, large family. • Gender issues: Girls are discriminated against in both quantity and quality of food. • Eating pattern: Dependance on JUNCS, negative influence of media, and availability of fast food on a click.
ADOLESCENT UNDERNUTRITION • Adolescent girls are at particularly high risk of anemia (upto 66%) and malnutrition. • Even boys are found anemic up to 45%. • Stunting is prevalent in 37.2% boys and 41.0% girls in India. • Two-thirds suffer from chronic energy deficiency of the third degree, with body mass index below 16. • Almost half of the adolescents are not getting even 70% of their daily requirements of energy. • Almost 25% are getting <70% of RDA of proteins.
• Deficiencies of iodine, iron, and vitamin B12 are common among adolescents, causing delayed growth spurt, stunted height, delayed/retarded intellectual development, anemia, and increased risks in childbirth. • Intake of most foods, except cereals, millets, roots and tubers, is below the reference daily intake (RDI) in adolescents. • Consumption of green leafy vegetables, fruits, pulses and milk is grossly inadequate. • Prevalence of overweight and obesity is also high because of sedentary lifestyle.
Eating Disorders: Anorexia and Bulimia • Eating preadolescence or adolescence and are often due to extreme disturbance in eating behavior. • Three most prevalent disorders are: ˗ Anorexia nervosa, ˗ Bulimia nervosa, and ˗ Binge eating disorder. • Symptoms of eating disorders include the following: a distorted body image, skipping most meals, unusual eating habits, frequent weighing, extreme weight change, insomnia, constipation, skin rash, dental cavities, loss of hair or nail quality, hyperactivity, and high interest in exercise. disorders are psychological disorders that typically start during
ANOREXIA NERVOSA • Occurs more commonly in adolescent girls shortly after completion of puberty. • Characterized by deliberate weight loss induced by the adolescent by reducing food intake, in relentless pursuit of thinness. Etiology • Common in girls with excessive dependence, low self-esteem, high anxiety, and affective disorder. Their families are overprotective. • Now thought to be a disorder of mood or problem in identity development. • A complex interaction between sociocultural, biological and psychological factors contributes.
Diagnostic Criteria 1. Persistent restriction of energy intake leading to significantly low body weight. 2. Either an intense fear of gaining weight or of becoming fat, or persistent behavior that interferes with weight gain. 3. Disturbance in the way one’s body weight or shape is experienced.
Clinical Manifestations of Anorexia Nervosa Young females begin to eat less and less food, leading to profound weight loss and emaciation. Associated with self-induced vomiting or purging. There may be a history of excessive exercise, use of appetite suppressants, or diuretics. Complain of abdominal pain and bloating of abdomen even with ingestion of small amounts of food. Weight loss >30% leads to lethargy, cachexia, and generalized weakness. There is undernutrition of varying severity, with resulting secondary endocrine and metabolic changes and disturbance of bodily functions including amenorrhea. The mortality is 10% and is due to electrolyte imbalance, cardiac arrhythmias or congestive heart failure, hypothermia, and hypotension. Bone marrow hypoplasia, constipation, esophagitis, hypophosphatemia, potassium depletion, hypochloremic alkalosis, and elevation of BUN may also be present.
TREATMENT: Anorexia Nervosa Treatment involves a combined approach of (1) individual and family psychotherapy, (2) behavioral modification, and (3) nutritional rehabilitation. Those with associated depression may require antidepressants. Role of parents: They should be fully involved in their child’s therapy. Psychotherapy helps children improve their self-esteem, peer relationship, and resolving parental conflicts.
BULIMIA NERVOSA • Predominantly seen in adolescent females • Characterized by recurrent episodes of binge eating accompanied by purging through vomiting, overuse of laxatives, enemas, diuretics, fasting, or excessive exercise. • Eating binges may occur as often as several times a day but are most common in the evening and night hours.
Clinical Features These episodes must occur at least once a week for 3 months to meet the diagnostic criteria for DSM-V classification. Some of the salient features of this condition are as follows: • Rapid consumption of large amounts of high calorie food with no apparent change in weight. • Binging is often followed by purging, which is often done secretly. • Evidence of binge eating: Hiding food or discarded food containers and wrappers, stealing, hoarding food. • Evidence of purging: Frequent trips to bathroom, especially after meals, signs and/or smells of vomiting, presence of empty containers or packages of drugs such as laxatives or diuretics. • Excessive exercise or fasting, frequent weighing, peculiar eating habits or rituals, preoccupation with food, body weight and image. • Overachieving and impulsive behaviors. Physical signs of bulimia nervosa include dental enamel erosion, odor on the breath, skin changes such as calluses/ scarring on the dorsum of hands caused by self-inducing vomiting, enlargement of salivary glands, and edema.
Treatment: Bulimia Nervosa • Early diagnosis and management are the mainstay • Requires a multidisciplinary team approach comprising of physician, therapist and a nutritionist medical and nutritional intervention with the • Aim of restoring weight, nutritional rehabilitation, and treatment of complications. • Family-based treatment is often the mainstay of psychological intervention. • Coexisting mental illness such as anxiety and depression are also treated. • Selective serotonin uptake inhibitors (fluoxetine, sertraline, etc.) are used in resistant cases.
Mental Health Problems PREVALENCE • As per WHO “globally, one in seven 10–19-year-old experiences a mental disorder, accounting for 13% of the global burden of disease in this age group” and is considered most common non-communicable disease (NCD) in this age group. • In any given year, about 20% of adolescents will experience a mental health problem, most commonly depression, anxiety, or behavioral disorders. • In India, the prevalence of psychiatric disorders among adolescents under 16 years is 12.5%. In addition, • Almost half of the mental illnesses diagnosed in adults have their onset in the adolescent. ETIOLOGY Risky behavior (such as unsafe sex, hazardous/drunk driving, smoking), self-harm, physical inactivity, educational failure, and school dropout are associated with mental health problems.
ASSESSMENT • Mental illness can present in a variety of ways. • Changes in mood and behaviors are important indicators of mental well-being. • Unexplained aches and pains, inability to concentrate, disruptions in sleep habits, changes in appetite and eating, heightened irritability, agitation, and moodiness should alert to presence of a mental illness. • Persistence of symptoms for >2 weeks are important “Red flags” for depression. The HEEADSSS approach (Table 5.7) can help the clinicians assess whether an adolescent is mentally well or ill and, if they are ill, to assess the severity of the illness.
Areas of Stress in Adolescents 1. Body image 2. Sexuality conflicts 3. Scholastic pressures 4. Competitive pressures 5. Relationship with parents 6. Relationship with siblings and peers 7. Finances 8. Decision about present and future roles 9. Career planning 10. Ideological conflicts Common psychosomatic symptoms include recurrent abdominal pain, headaches, chest pain, and chronic fatigue. Nonspecific symptoms include dizziness, syncope and/or tiredness
Suicidal Behavior • Ask this directly without any hesitation, e.g., “Have you ever felt so bad that you felt like committing a suicide?” • Asking about suicidal behavior does not precipitate or trigger it. • Any suicidal ideation should prompt a more careful assessment of the patient’s suicide risk and must include a referral to a mental health expert. • Previous suicide attempts are often a strong risk factor for future attempts. • Ensure that adolescents have access to quality and affordable mental health services.
SUBSTANCE ABUSE • Illiteracy, economic background, unemployment, and family disharmony increase vulnerability to drug abuse. • Consumption of tobacco, alcohol, and illicit substances by adolescents is rising. Tobacco • Globally, 300 million young people (10–24 years) smoke. 50% of these to die of tobacco-related diseases. • Some begin as 10-year-old. The earlier adolescents start using tobacco, the more likely that they will get addicted.
SUBSTANCE ABUSE Alcohol • Most common cause of substance use related death of young people. • Associated with poor scholastic attainment, increased drop out from school, drink and drug driving delinquency, early pregnancy and family difficulties. Associated with greater likelihood of early sexual initiation. Drugs • Drug abuse must be discussed frankly with the adolescents. • More often they do not admit doing drugs when directly asked tell about their friends. • Use the CRAFT Questionnaire.
CRAFT Questionnaire to Detect Substance Abuse 1. Have you ever ridden in a Car driven by someone who was high or had been using drugs or alcohol? 2. Do you ever use alcohol or drugs to Relax, feel better about yourself, or fit in? 3. Do you ever use drugs or alcohol when you are Alone? 4. Do you Forget things you did while using drugs or alcohol? 5. Do your family or Friends ever tell you that you should cut down your drinking or drug use? 6. Have you ever gotten into Trouble while using drugs or alcohol? Two or more “Yes” answers suggest high risk of a serious substance-use problem or a substance-use disorder .
PROMOTING MENTAL HEALTH Promote positive, caring and supportive relationships with families and peers, teachers, and other adults. Ensure that adolescents’ lives are free from neglect, trauma, excessive stress, violence, abuse, and discrimination. Ensure good living conditions including access to sporting facilities. Accept diversity among adolescents. Help adolescents to develop life skills including communication, decision making, negotiation, critical thinking, stress management skills. Ensure access to educational and vocational training to enhance their abilities and employment opportunities. Integrate mental health promotion and life skills development in the school curriculum.
IN A NUTSHELL Mental Health in Adolescence 1. In India, the prevalence of psychiatric disorders among adolescents under 16 years is 12.5%. 2. Nearly 50% of mental health issues diagnosed in adults have their onset in the adolescent period. 3. HEEADSSS approach related to mental health can help the clinicians to assess mental wellbeing and their severity in adolescents. 4. Some of the common mental health problems prevalent in this age group are substance abuse, violence, depression, suicide, learning disorders, and other psychiatric disorders.
Noncommunicable Diseases in Adolescents 1. Injuries and violence 2. Mental health and substance abuse disorders 3. Chronic respiratory disorders (asthma) 4. Musculoskeletal disorders (low back pain, neck pain) 5. Neurological disorders (epilepsy, migraine) 6. Dermatological disorders (dermatitis, acne vulgaris) 7. Endocrine disorders (diabetes) 8. Hematological disorders including malignancies 9. Urogenital and digestive disorders 10. Nutritional disorders: Iron deficiency anemia), overweight, obesity In 2019, globally, one in five deaths among adolescents were caused by NCDs and estimated to cause over half of the disability- affected life years (DALYs).
IN A NUTSHELL Noncommunicable Diseases in Adolescence 1. Behaviors responsible for the majority of NCDs in adulthood have their origin in adolescence. 2. Physical inactivity, unhealthy diet, tobacco use, harmful use of alcohol, and indicators of metabolic syndrome (high blood pressure, high cholesterol, diabetes) are some of the important behaviors responsible for the majority of NCDs of adult life. 3. Injuries and violence including sexual violence is an important cause of morbidity and mortality among adolescents
COMMUNICATION AND COUNSELING • Integral part of managing adolescent health issues. • Communication is an exchange of information, knowledge, ideas, or feelings. In a face-to-face situation, communication is not just exchange of information. • Conveys one’s feelings, by use of gestures, facial expressions, language, and the manner of tone. • Helps in building bridges with the client • Counseling is not simple advising rather it is helping people to identify problem, make decisions, and giving them confidence to put their decision into practice.
Steps of counseling: “GATHER” Techniques of good communication 1. Creating a good, friendly first impression 2. Rapport building during the first session 3. Nonjudgmental, active listening 4. Providing information in the simple way 5. Ask appropriate and effective question • G: Greet the person • A: Ask how can I help you • T: Tell them any relevant information • H:V Help them to make decisions • E: Explain any misunderstanding • R: Return to follow-up for referral. Maintain confidentiality and involve parents in care of adolescents
