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Adolescence: An Introduction

Adolescence: An Introduction. William P. Adelman MD Associate Professor of Pediatrics Uniformed Services University. ACCREDITATION COUNCIL FOR GRADUATE MEDICAL EDUCATION. Residency Requirements for Pediatrics Adolescent Medicine

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Adolescence: An Introduction

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  1. Adolescence: An Introduction William P. Adelman MD Associate Professor of Pediatrics Uniformed Services University

  2. ACCREDITATION COUNCIL FOR GRADUATE MEDICAL EDUCATION Residency Requirements for Pediatrics Adolescent Medicine The program must provide all residents with experience in adolescent medicine that will enable them to recognize normal and abnormal growth and development in adolescent patients. The experience must include, as a minimum, a 1-month block rotation to ensure a focused experience in the area of adolescent medicine. This experience must be supervised by faculty qualified to teach adolescent medicine. The program must also provide the resident with an integrated experience that incorporates adolescent issues into ambulatory and inpatient experiences throughout the 3 years (e.g., inpatient unit, community settings, continuity clinic, and subspecialty rotations).

  3. ACCREDITATION COUNCIL FOR GRADUATE MEDICAL EDUCATION Residency Requirements for Pediatrics Adolescent Medicine It must include instruction and experience in at least the following: i) normal pubertal growth and development and the associated physiologic and anatomic changes; ii) health promotion, disease prevention, and anticipatory guidance of adolescents; iii) common adolescent health problems, including chronic illness, sports-related issues, motor vehicle safety, and the effects of violence in conflict resolution; iv) interviewing the adolescent patient with attention to confidentiality, consent, and cultural background; v) psychosocial issues, such as peer and family relations, depression, eating disorders, substance abuse, suicide, and school performance; and vi) male and female reproductive health, including sexuality, pregnancy, contraception, and STDs.

  4. Goal and Objectives • Understand the psychosocial growth and development that occurs during adolescence • Recognize the typical early, middle, and late adolescent • Provide a framework to understand and deal with the adolescent health care visit

  5. We Live in a decadent age. Young people no longer respect their parents. They are rude and impatient. They frequent taverns and have no self respect. Inscription on Egyptian tomb circa 3000 B.C.E.

  6. Routine Physical Exam • You are seeing an 11 year old boy for his routine physical exam. What issues would be important to discuss during the anticipatory guidance portion of the visit? How do you discuss those topics? • 15 year old boy • 18 year old boy

  7. Pregnancy Test • A 14 year old 8th grader presents to the adolescent clinic with CC: “pregnancy test.” What is a developmentally appropriate way to approach this case? • A 20 year old College Junior presents to the health service with the same CC. Do you approach this patient differently?

  8. Stages of Adolescence • Early Adolescence (10-14 years/ SMR 2-4) • Middle Adolescence (15-17 yrs/ SMR 3-5) • Late Adolescence (18-21+)

  9. Concerns of Adolescence • Independence • Body image • Peer Group • Identity

  10. Early Adolescence (10-14 yrs) • Ind: Transition from childhood / Less interest in parental activity/ “Mood swings”/ need for guide • BI: Biologic changes of Puberty/ interest in sexual anatomy and physiology (menses/ wet dreams) “Am I Normal?” • PG: intense same-sex friends --strong desire to conform/ Opposite sex in groups “Blood Brothers” “Friends 4Ever” • Id: concrete/operational thinking/ increased self-interest, fantasy, daydreaming, idealistic; “Feels on stage” Increased need for privacy; Poor impulse control

  11. Early Adolescent Visit: Interview • Introduce private time with the provider to build relationship as child’s advocate • Discussion with parent mandatory as early adolescent lacks insight and has poor history skills • Blunt, clear discussion; euphemism and analogy not understood

  12. Early Adolescent Visit: Exam • Minor blemishes are threats to self-identity • Modesty is the norm/ allow to disrobe in private/ clear instructions/ parent present if prefer • Normalize but do not minimize

  13. Early Adolescent Visit: Anticipatory Guidance • Puberty • Peer Pressure • Experimentation • Health Risk Behaviors • Safety

  14. Middle Adolescence (15-17 ) • Ind: Conflicts may become more prevalent or become quiescent. “Temporary Parental Disablement” • BI: Concern for attractiveness; general acceptance of physical changes “Am I attractive?” • PG: Peak of peers and conformity; Sexual activity and experimentation; clubs/sports/ gangs • Id: Abstract thinking skills, “What if?…” creativity; Omnipotent and immortal--high risk taking and high morbidity and mortality

  15. Wendy Wu homecoming warrior • Part Teenager • Part Warrior • All Hero

  16. Middle Adolescent Visit: Interview • Most of visit should be with the patient alone • Look for the “hidden agenda” • Direct all information to patient, not parent

  17. Middle Adolescent Visit: Anticipatory Guidance • Address specific risks with “propositional” thought, “What happens if you don’t take your insulin?” “If you get pregnant, Then how will your life change? Then what will happen? Then what?…” • Safety, risk taking behaviors, avoidance or refusal skills

  18. Late Adolescence (18 yrs +) • Ind: Final transition to adulthood: College/ Work force; Accept parents; Achievement of Autonomy; adult relations; “Who am I in relation to Society?” • BI: Acceptance • PG: Identify with multiple peer groups; more time in intimate relationships • Id: Formal reasoning with sense of future; • Vocational goals and financial independence • Refine moral, religious and sexual values

  19. Late Adolescent Visit: Interview • All interaction with the patient • Usually a specific agenda • If 18, need permission to discuss with parent • Personal responsibility for adult health

  20. Late Adolescent Visit: Anticipatory Guidance • Specific, adult-oriented issues • Teach lifelong health care strategies (diet, Pap screening, self-exam) • Consider transition to adult health care practitioner

  21. Soldiers are Adolescents • More than one half of all enlisted females in the US Armed Forces are younger than 25. • Nearly one half of all enlisted males in the US Armed Forces are younger than 25. • 60% Marines • 42% Army • 42% Navy • 35% Air Force • Population Bulletin 59(4) 2004

  22. O Adolescence, O Adolescence, I wince before thine incandescence, Thy constitution young and hearty Is too much for this aged party Ogden Nash

  23. Routine Physical Exam • You are seeing an 11 year old boy for his routine physical exam. What issues would be important to discuss during the anticipatory guidance portion of the visit? How do you discuss those topics? • 15 year old boy • 18 year old boy

  24. Pregnancy Test • A 14 year old 8th grader presents to the adolescent clinic with CC: “pregnancy test.” What is a developmentally appropriate way to discuss these issues? • A 20 year old College Junior presents to the health service with the same CC. Do you approach this patient differently?

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