Adolescence

1
Adolescence

• Pediatrics Summer 2009
• Debbie King CFNP CPNP

2
Adolescence

• Is a period of rapid growth and development
• Physical
• Emotional
• Cognitive
• Social

3
Physical Growth

• Weight almost doubles
• Height increases by 15-20
• Organs double in size
• Lymphoid tissue decreases
• Muscle growth
• Little difference before puberty
• Boys attain greater strength and mass, and
  strength continues to increase into late puberty,
  with motor coordination lagging behind

4
Physical Growth

• Girls
• Pubertal growth spurt begins 2 years before boys
• Puberty begins around age 9
• Reach peak height velocity about 12 years
• Store more fat from age 6 which changes locations
  over time
• Following menarche there is very little growth
• Anovulatory cycles are common for two years, and
  even after five years 20 of cycles are
  anovulatory
• Review tanner staging

5
Physical Growth

• Boys
• First sign is scrotal and testicular growth about
  age 11
• Pubertal growth takes longer in boys lasting
  about 4 years
• Gynecomastia is common and resolves on its own
• Peak height velocity reached at age 13 ½ years
• Body hair increases at age 16

6
Emotional, Cognitive, and Social Growth

• Early adolescence 10-13 years
• Concerned about personal growth
• Peer relationship more important
• Still have vague and unrealistic goals
• Are very moody

7
Emotional, Cognitive, and Social Growth

• Middle adolescence 14-16 years
• Concerned about body image yet more comfortable
  with the changes
• Dating begins (and many times sex) Yet
  relationships are one sided
• Seeking Independence
• Will experience intense mood swings
• Become--All knowing
• Become---Invincible
• MORE--Self-centered

8
Emotional, Cognitive, and Social Growth

• Late Adolescence 17 and older
• Identity formation
• Face many choices
• Relationships are more intimate
• More realistic about goals and the future
• By 12th grade over 60 have had intercourse
• Are able to think more abstractly
• Are idealistic and have strong feelings about
  what is right and wrong

9
Web sites

• Mental health check ups
• Http//cme.medscape.com/viewarticle/702353?srccme
  mp
• CDC info on adolescents
• http//www.cdc.gov/nchs/data/infosheets/inforsheet
  _adoleshealth.pdf

10
Conversion Disorders in Adolescence

• Most common somatoform disorder in adolescence
• Seek attention for minor complaints
• Worry about physical development
• May have a hidden agenda for seeking care
• Many somatic symptoms
• Abdominal pain, fatigue, chest pain, ECT

11
Conversion Disorders in Adolescence

• More common during stressful times
• Physical Exam not consistent with symptoms
• Encourage patient to understand and that these
  symptoms are going to last, but must continue
  with normal life
• Encourage psychotherapy

12
Depression in Adolescence

• Signs and symptoms
• Lethargy, loss of interest, sleep problems, less
  energy, feeling worthless, difficulty
  concentrating
• Usually only result in minor impairment
• Severe symptoms need immediate attention and
  referral
• Often have vague physical complaints
• Treatment
• Discuss the situation
• Offer support and understanding
• REFER

13
Suicide

• Rates are too high, numbers vary, text says
• In 2000, almost 4,000 people 15- 24 years
• Males 5 times higher
• Unsuccessful attempts 3 times higher in females
• Suicide is the third leading cause of death for
  15 to 24 year olds, and the sixth leading cause
  of death for 5 to 14 year olds
• The adolescent suicide rate was 7.7 deaths per
  100,000 46 percent of the suicides were
  firearm-related and 40 percent of the suicides
  were by hanging- per the CDC

14
Suicide

• Signs and symptoms
• Type one involves normal mood swings
• Increased mood swings, unable work through grief,
  unable to get school work completed, no social
  activities, withdrawn, ECT.
• Type two involves angry adolescents
• Attempts to influence others, only mildly
  depressed, without a longstanding wish to die,
  uses a way to get back at someone, or to scare
  someone with an attempt
• Type three involves psychiatric problems
• Schizophrenia, or psychotic depressive disorder

15
Suicide Risk Assessment

• May not be brought up but observed by the
  provider!
• Start off with normal history questions, then
  follow with questions regarding suicide relating
  to
• Signs, recent events, long standing problems,
  substance abuse, delusions, rebellious behavior
• ASK have you thought about it? and do you have
  a plan and then act accordingly!

16
Obesity

• In 2003-2006, 17.6 percent of adolescents had
  high BMI-for-age.
• Almost 28 percent of non-Hispanic black teen
  girls aged 12-19 and almost 20 percent of Mexican
  American teen girls had high BMI-for-age compared
  with 14.5 percent of non-Hispanic white teen
  girls.
• Among boys aged 12-19, Mexican Americans were
  more likely to have high BMI-for-age than
  non-Hispanic whites

17
Teen pregnancy rates

• Following a 14 year downward trend in which teen
  births fell by 34 percent between 1991 and 2005,
  the teen birth rate in the U.S. rose in 2006.
• Between 2005 and 2006, the birth rate for teens
  aged 15-19 rose 3 percent, from 40.5 live births
  per 1,000 females to 41.9 births per 1,000 in
  2006.
• The largest increases were reported for
  non-Hispanic black teens, whose overall rate rose
  5 percent in 2006. The rate rose 2 percent for
  Hispanic teens, 3 percent for non-Hispanic white
  teens, and 4 percent for American Indian or
  Alaska Native teens.
• In 2006, pregnant females aged 12-19 made 4.3
  million ambulatory visits to either physician
  offices or hospital outpatient departments for
  either routine prenatal or unconfirmed pregnancy
  examinations.

18
Injury Mortality

• In 2005, injuries accounted for 75 percent of all
  deaths among adolescents aged 15-19. In the same
  year, there were 49.8 injury deaths per 100,000
  adolescents aged 15-19, down 2.9 percent from the
  rate in 2004. The leading causes of death among
  adolescents are unintentional injuries, homicides
  and suicides. The following reflect adolescent
  death rates due to injury in 2005.

19
Injury Mortality

• The adolescent unintentional injury death rate
  was 31.4 deaths per 100,000 73 percent of the
  unintentional injuries were motor-vehicle traffic
  related.
• The adolescent homicide rate was 9.9 deaths per
  100,000 84 percent of the homicides were
  firearm-related.
• The adolescent suicide rate was 7.7 deaths per
  100,000 46 percent of the suicides were
  firearm-related and 40 percent of the suicides
  were by hanging.

20
Substance Abuse in Adolescence

• A chronic, progressive disease
• Compromises physical, cognitive and psychosocial
  aspects of adolescent development
• Most first time users are between 12-14 years
• The data shows much up and down level of abuse
  over that last 30 years.

21
Abuse facts

• In calendar year 2000, an estimated 14.0 million
  Americans were currently illicit drug users,
  meaning they had used an illicit drug during the
  month prior to interview. This estimate
  represents 6.3 percent of the population 12 years
  old and older.

22
Abuse facts

• Among youth aged 12 to 17 in 2000, 9.7 percent
  had used an illicit drug within the 30 days prior
  to interview. This rate is almost identical to
  the rate for youth in 1999 (9.8 percent)

23
Abuse facts

• Approximately 2.1 million youths aged 12 to 17
  had used inhalants at some time in their lives as
  of 2000. This constituted 8.9 percent of youths.
  Of youth, 3.9 percent had used glue, shoe polish,
  or Toluene, and 3.3 percent had used gasoline or
  lighter fluid.

24
Abuse facts

• Among youths aged 12 to 17 in 2000, the rate of
  current illicit drug use was similar for boys
  (9.8 percent) and girls (9.5 percent). While boys
  aged 12 to 17 had a slightly higher rate of
  marijuana use than girls in the same age category
  (7.7 percent compared to 6.6 percent), girls were
  somewhat more likely to use psychotherapeutics
  non medically than boys (3.3 percent compared to
  2.7 percent). Between 1999 and 2000, there was no
  significant change in the rate of current illicit
  drug use for either males or females aged 12 to
  17.

25
Abuse facts

• Among youths who were heavy drinkers in 2000,
  65.5 percent were also current illicit drug
  users. Among nondrinkers, only 4.2 percent were
  current illicit drug users. Similarly, among
  youths who smoked cigarettes, the rate of past
  month illicit drug use was 42.7 percent, compared
  with 4.6 percent for nonsmokers

26
Abuse facts

• Almost half of Americans aged 12 and older
  reported being current drinkers of alcohol in the
  2000 survey (46.6 percent). This translates to an
  estimated 104 million people. Both the rate of
  alcohol use and number of drinkers were nearly
  the same in 2000 as in 1999 (46.4 percent and 103
  million).
• Heavy drinking was reported by 5.6 percent of the
  population aged 12 and older, or 12.6 million
  people. These 2000 estimates were nearly
  identical to the 1999 estimates

27
Abuse facts

• Males aged 12 to 20 were more likely than their
  female peers to report binge drinking in 2000
  (21.3 percent compared to 15.9 percent)
• One in ten Americans aged 12 and older in 2000
  (22.3 million persons) had driven under the
  influence of alcohol at least once in the 12
  months prior to interview. Between 1999 and 2000,
  the rate of driving under the influence of
  alcohol declined from 10.9 percent to 10.0
  percent, which is a statistically significant
  difference. Among young adults aged 18 to 25,
  19.9 percent had driven under the influence of
  alcohol in 2000.

28
Project not my kid, home drug testing by CASA
August 2008

• Key findings from this years CASA study include
  
• Kids are abusing drugs about two years before
  parents aware
• Almost half (46 percent) of teens say they leave
  their house to hang out with friends on school
  nights, but only 14 percent of parents say their
  teens do so.
• For the 13th year, drugs are the top concern
  among teens with 28 percent reporting that is the
  biggest problem they face. Only 17 percent of
  parents think drugs are the top teen concern.
• The number of teens who say prescription drugs
  are easiest to buy rose a whopping 46 percent
  since 2007, and for the first time teens said
  prescription drugs are easier to buy than beer.

29
Study University of Michigan released Dec. 2007
of students in 8th, 10th and 12th
gradescomparing 10 years ago and 1 year ago

• Reports a modest decline in the following drugs (
  no significant declines since 2006)
• Amphetamines
• Methamphetamine
• Crystal meth lowest ever since 1992 with a peak
  in 2002
• Marijuana
• From 11.7 to 10.3 2006-2007
• Anabolic steroid- lowest use reported since 1999
• OTC medications
• Alcohol
• Cigarettes
• No decline in the following
• Cocaine
• Crack cocaine
• LSD
• Heroin
• Prescription drugs such as psychoactive,
  narcotics,

30
Pharmacy Times Nov. 2007

• Reports OTC drug use up
• The Partnership for a Drug-Free America recently
  reported that an increasing number of teenagers
  are abusing a variety of prescription and OTC
  medications.1 Although drug-abuse rates overall
  have been decreasing for teens, the rate of
  prescription and OTC drug abuse has increased.1
  Currently, 1 in 11 teens has abused an OTC
  medication, such as cough medicine containing
  dextromethorphan (DXM), and 1 in 5 has abused a
  prescription painkiller.1 In light of such
  statistics, it is important to have knowledge of
  how to deal effectively with the issue of teen
  drug abuse.

31
Substance abuse stages

• Stage one
• From nonuser to user
• Limited to experimentation with tobacco or
  alcohol (so called gateway drugs)
• Second stage
• Involves psychoactive substance
• Non normative risk behavior
• Potential to compromise adolescent development

32
Substance abuse stages

• Third stage
• Progression within a class of substances, ex beer
  to liquor
• Forth stage
• Progression across classes of substance, ex
  alcohol to marijuana
• Refer to table 4-2 in your text for physiologic
  effects

33
Morbidity of substance abuse

• Is the leading cause of adolescent and young
  adult death and injury
• Associated with accidents
• Motor vehicle crashes, unintentional injuries
• Associated with violent behaviors
• Physical and sexual abuse, homicide, suicide
• Associated with high risk behaviors
• Increased sexual activity leading to babies,
  STDs, ECT

34
Morbidity of substance abuse

• Physical side effects of just two of the
  substances
• Marijuana
• With light use can see--Tachycardia, HTN,
  bronchodilation, lung changes as in tobacco use
• With heavy use can seedecreased fertility,
  immunosuppression, disruption of learning,
  coordination, memory,
• Ecstasy
• Can cause permanent brain damage
• Chronic use destroys serotonin system
• Schizophrenia
• Irreversible cardiomyopathy, noncardiogenic
  pulmonary edema ECT

35
Abuse of enhancement supplements

• Dates back to use by the warriors
• Used to improve performance
• Common supplements
• Creatine and protein powders

36
Creatine and the prohormones

• Creatine
• Produced naturally in the body
• increases free energy for muscle contraction
• Maximizes power during short-duration
• Improves baseline strength in adults
• DOES NOT improve performance in longer duration,
  aerobic exercise
• Has not been tested in children which includes
  adolescents

37
Creatine and the prohormones

• While not tested in children, is used extensively
  in athletes in 6th 12th grade!
• Side effects
• Weight gain, headache, abdominal pain, diarrhea,
  increased muscle strain, questionable renal
  damage
• Prohormones-
• Includes DHEA, Androstenedione which are sold
  without regulation and research

38
Protein powders and shakes

• Used to enhance muscle repair and mass
• Typical amount consumed exceeds recommended
  allowance
• Excess of protein provides no added strength or
  muscle mass
• Can provoke renal failure in teens with
  underlying renal dysfunction

39
What do we do??

• Recognize the warning signs
• Identify potential abuser early
• Intervene in an effective and timely manner
• Review high risk characteristics in table 4-5
• Realize substance abuse is a symptom of personal
  and social maladjustment
• Most theories emphasize social influences as most
  reliable predictors

40
AAP recommends

• Become knowledgeable about the extent and nature
  of drugs
• Provide anticipatory guidance to parents starting
  with the first prenatal visit
• Be aware of community referral and treatment
  resources for adolescents
• Advise parents of the increased risk of abuse
  with the availably of the internet

41
Diagnosis

• Positive findings on your initial physical and
  history
• May lead to diagnosis
• May need to implement a tool such as CAGE or the
  Perceived Benefits of Drinking Scale.
• These tools may by helpful to stimulate
  discussion
• See text for other tools

42
Diagnosis

• Pharmacologic Screening
• Urine and blood tests
• AAP recommends
• Screening in certain circumstance such as
  obtunded patients
• AAP does not recommend routine screenings
  because
• Voluntary screening is rarely that
• Infrequent users are missed
• Confronting users rarely makes a difference
• Our role is to counsel and treat, not police
• False positives, and false negatives

43
Treatment

• Per the AMA and the AAP
• All adolescents should receive counseling about
  the dangers
• Offer confidential health care services and
  routinely counsel about risks, ECT
• More intervention is required when the behavior
  is regarded as acceptable recreation in their
  situation
• Assess patients readiness to change then select a
  program

44
Treatment

• Smoking cessation
• Table 4-12
• Referral
• Table 4-13

45
Prevention of substance abuse

• Start young with your patients with education!
• Primary level
• Prevention
• Secondary
• Target population at increased risk
• Tertiary
• Target young people who are abusers

46
FACTS

• Most adolescents who abuse do so for the high
• These behaviors are often purposeful,
  developmentally appropriate coping strategies
• Will not abandoned behaviors unless an equally
  good alternative is available
• Example of failure. When encouraging a teen not
  to smoke because of stress but no other stress
  coping strategy is introduced