Adolescent health problems

ADOLESCENT HEALTH PROBLEMS

DR NISHANT PRABHAKAR MD PEDIATRICS

ADOLESCENT IN INDIA India is home to 243 million adolescents –

children aged 10 to 19 years – the most adolescents of any country.

It accounts for about 21.3% of population of the country.

Girls currently married (age group 15-19yr) are 30%.

Boys currently married (age group 15-19yr) are 4.6%.

Birth by age 18 year- 21.7%UNICEF GLOBAL DATA 2011

BURDEN OF HEALTH PROBLEM

An estimated 1.3 million adolescents died in 2012, mostly from preventable or treatable causes.

Road traffic injuries were the leading cause of death in 2012, with some 330 adolescents dying every day.

Other main causes of adolescent deaths include HIV, suicide, lower respiratory infections and interpersonal violence.

Half of all mental health disorders in adulthood appear to start by age 14, but most cases are undetected and untreated.

UNICEF GLOBAL DATA 2011

Adolescence is a time of immense biologic, psychological, and social change. These rapid changes in hormonal milieu, changing ideas and concepts about the world, having to cope up with the expectations from the society and need to establish their own identity keep them in lots of pressure.

GHAI 8TH EDITION PG 63-69

VULNERABLE

ADOLESCENT NUTRITION Nearly half of adolescent girls aged 15–

19 in India are underweight, with a body mass index of less than 18.5.(unicef global database 2011)

There is increase in nutritional requirement during this period of rapid growth micronutrient being as important as energy and protein.

Lack of sun exposure with modest tradition of clothing coupled with dark skin pigment causes vitamin D deficiency.

Insufficient dairy product intake in underprivileged girls leads to poor intake of protein and calcium resulting low bone mineral density.

Vitamin A deficiency is also an important issue in economically deprived adolescents.

Undernutrition often delays the onset of puberty and sexual maturation, and result in stunting, poor bone mass accrual and reduced work capacity.


ADOLESCENT NUTRITION (Cont…)

Adolescent Nutrition: A Review of the Situation in Selected South-East Asian Countries (WHO)


Public Health Nutrition 2013; 16 (09): 1667-1676

A large proportion of India’s adolescents are anaemic: 56 per cent of girls and 30 per cent of boys.

Anaemia among adolescents adversely affects these young people’s growth, resistance to infections, cognitive development and work productivity.

The national Ministry of Health and Family Welfare (MHFW) launched a nationwide Weekly Iron and Folic Acid Supplementation (WIFS) programme in January 2013.


Public Health Nutrition 2013; 16 (09): 1667-1676

The services delivered under scheme:-1) weekly iron and folic acid supplementation;2) bi-annual deworming; and3) nutrition counselling about how to improve diet,

prevent anaemia and minimize the potential side-effects of IFA supplementation and deworming.

Kishori shakti yojna to improve nutritional and health status of girls in age group of 11-18 years.

Improving nutritional status of adolescent girls helps break the cycle of malnutrition and low birth weight babies.


EATING DISORDERS


ANOREXIA NERVOSA:- m/c among 15-19yr old. Charecterized by- Body weight <85% of expected weight for age and

height Intense fear of becoming fat even though

underweight. Disturbed body image and denial that current body

weight is low In postmenarcheal girls, amenorrhea.

Anorexia is commonly associated with depression, anxiety, suicidal ideation and/or OCD.

GHAI 8TH EDITION PG 57

Profound weight loss may result in hypothermia, hypotension, dependent edema, bradycardia, hypokalemic metabolic alkalosis.

Mortality is attributed to cachexia and suicide. MANAGEMENT-

Psychotherapy (individual + family therapy) to establish appropriate eating pattern and normal perception of hunger and satiety.

Nutritional rehabilitation (in severe cases NG/Parenteral nutrition)

Antidepressant and antipsychotic drugs as required.

EATING DISORDERS (Cont…)

GHAI 8TH EDITION PG 57

BULIMIA:- more common in girls between 10-19 yr of age. Charecterized by Recurrent episodes of binge eating Recurrent inappropriate compensatory behavior to

prevent weight gain, such as self induced vomitting, misuse of laxatives, diuretics enemas, fasting or excessive exercise

both at least twice a week for 3 months. Affected patients have comorbidities like

depression and psychosis. MANAGEMENT:- combination of psychotherapy and

antidepressants (such as fluoxetine)

EATING DISORDERS (Cont…)

MENTAL HEALTH PROBLEMS


Depression is the top cause of illness and disability among adolescents and suicide is the third cause of death.

Adjustment disorder, anxiety disorder, delinquent behavior, poor body image, and low self-esteem are other psychological problems.

Completed suicides are higher in boys Attempted suicides are higher in girls Adolescents are at higher risk of committing

suicide because of their cognitive immaturity and increased impulsivity.


Building life skills in children and adolescents and providing them with psychosocial support in schools and other community settings can help promote good mental health.

Programmes to help strengthen ties between adolescents and their families are also important.

If problems arise, they should be detected and managed by competent and caring health workers.

MENTAL HEALTH PROBLEMS (Cont…)

EARLY PREGNANCY & CHILD BIRTH


Complications linked to pregnancy and childbirth are the second cause of death for 15-19-year-old girls globally.

Every year, some 3 million girls aged 15 to 19 undergo unsafe abortions.

Babies born to adolescent mothers face a substantially higher risk of dying than those born to women aged 20 to 24.

Unmarried adolescents are likely to resort to unsafe method of abortions, which increases the risk of complication like septicemia and also mortality.


Adolescent pregnancy are also at increased risk of pre-eclampsia, preterm labor, prolonged and obstructed labor, and postpartum hemorrhage. And such pregnancies are 2 to 4 times likely to die during childbirth as compared to adult pregnancies.

Many girls who become pregnant have to drop out of school.

Newborns born to adolescent mothers are also more likely to have low birth weight, with the risk of long-term effects.

EARLY PREGNANCY & CHILD BIRTH (Cont…)

UNICEF UPDATE SEPTEMBER 2012

WHO published guidelines in 2011 with the UN Population Fund (UNFPA) on preventing early pregnancies and reducing poor reproductive outcomes with 6 main objectives: reducing marriage before the age of 18; creating understanding and support to reduce pregnancy

before the age of 20; increasing the use of contraception by adolescents at risk

of unintended pregnancy; reducing coerced sex among adolescents; reducing unsafe abortion among adolescents; increasing use of skilled antenatal, childbirth and

postnatal care among adolescents.

EARLY PREGNANCY & CHILD BIRTH (Cont…)

GENDER DYSPHORIA

NELSON 20TH EDITION PG 931-936

According to DSM 5 criteria a marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 month duration as manifested by at least 2 of the following: Incongruence in experienced and assigned gender Strong desire to be rid of one’s secondary sex characteristics Strong desire of secondary sex characteristics of other gender Strong desire to be other gender Strong desire to be treated as other gender Strong conviction that one has feelings and reaction of the

other gender. The condition is a/w clinically significant distress or

impairment in social and occupational functioning

NELSON 20TH EDITION PG 931-936

To alleviate socially induced distress, interventions focus on stigma management and stigma reduction.

The main goal is not to change the child’s gender variant behavior but to assist families, school, and the wider community to create a supportive environment in which the child can thrive and safely explore his or her gender identity and expression.

Medical interventions are available as early as tanner stage 2. such treatment is guided by the standards of care set forth by the world professional association for transgender health (www.wpath.org).

GENDER DYSPHORIA (Cont…)

SLEEP DISTURBNCE


During the period of rapid growth, adolescents have increased sleep requirement.

But they are deprived of sleep due to increased academic activity, parents working in shift or watching TV late into the night.

Inadequate sleep may cause poor school performance , daytime drowsiness, aggressive behavior, conduct disorder, anxiety, restless leg syndrome and depression.

Sleep deprived teens may have periods of subconscious bouts of sleep during the daytime, making them prone to injuries and accidents.

SEXUALLY TRANSMITTED INFECTIONS


Early sexual activity is not uncommon in India. Various biological (immature and incompletely

estrogenised mucosa) and psychological factors (lack of preparedness, lack of familiarity with barrier contraceptives) make an adolescent susceptible to these infections.

Vaginal discharge is common in adolescent girls and may signify physiological leucorrhea of puberty or endogenous or sexually transmitted infections.

Pelvic inflammatory disease (PID) is a spectrum of inflammatory disorder of female genital tract. It can present with abdominal pain and vaginal discharge.


Gonorrhea- vulvovaginitis, urethritis or proctitis- ceftriaxone 125mg iv or im single dose.

SEXUALLY TRANSMITTED INFECTIONS(Cont…)

GONOCOCCAL URETHRAL DISCHARGE

GONOCOCCAL CERVICITIS

SEXUALLY TRANSMITTED INFECTIONS(Cont.)


Chlamydia- urethritis, vaginal discharge- oral azithromycin 1g single dose, or doxycycline 100mg twice daily for 14 days.

Herpes – multiple painful vesicles and ulcers; tend to recur- oral acyclovir 400mg thrice daily for 7 days


Primary syphilis- painless genital ulcer- benzathine penicillin 2.4 MU IM (after test dose); oral doxycycline if allergic to penicillin.

Genital warts (papilloma virus)- tend to recur- Local application of podophylline weekly, cryotherapy or surgical removal; preventable with vaccination.



Chancroid- painful ulcer with lymphadenopathy- oral azithromycin single dose or ciprofloxacin 500mg twice daily for 3 days.

Trichomoniasis – malodorous yellow green discharge- oral metronidazole or tinidazole 2g single dose.



Candidiasis – itching, redness, white discharge- Clotrimazole cream or pessary for 7 days, metronidazole 400mg orally twice daily for 14 days and doxycycline 100mg twice daily for 14 days; abstinence; symptomatic treatment (any severe disease or mild to moderate not responding to above- i/v antibiotic)

Pediculosis pubis- pruritus- local application of 1% permethrine, wash after 10 min

Scabies- Pruritus and rash- local application of permethrin or oral ivermectin 2 doses 14 days apart



HIV- More than 2 million adolescents are living with HIV Although HIV deaths decreased in last 8 years but

adolescents deaths are rising. Young people need to know how to protect

themselves and have the means to do so. This includes being able to obtain condoms to prevent sexual transmission of the virus and clean needles and syringes for those who inject drugs. Better access to HIV testing and counselling is also needed.


OBESITY


Among delhi school children, 5% obesity and 17-19% overweight has been reported. Similar figures are available from other parts of the urban India as well.

Prevalence of obesity and overweight is higher in boys than in girls.

Obesity has strong association with asthma, sleep disorder, reflux disease, blount disease, slipped femoral epiphysis, gallstones, fatty liver, and numerous metabolic derangements like type 2 diabetes, dyslipidemia, hypertension and polycystic ovarian disease.


Change in sedentary life style, decrease consumption of calorie dense food and increase outdoor activity contribute to these disorders.

OBESITY (Cont…)

GYENECOLOGICAL PROBLEMS


It is common to have anovulatory and irregular menstrual cycles during first two years after menarche.

In polycystic ovarian syndrome, with a combination of menstrual irregularities and ovarian cyst with androgen excess like acne or hirsutism, occurs in around 9% of Indian adolescent girls. The condition has association with other metabolic derangements like obesity, insulin resistance and type 2 diabetes.

SUBSTANCE ABUSE


Most of the tobacco and alcohol use starts during adolescence.

Alcohol(21%), Tobacco(14%), cannabis(3%), and opium (0.4%) are the most prevalent substance abuse in Indian adolescence.

Addicts are more prone to accidents, injuries, violence, trading sex for drugs, HIV, hepatitis C, sexually transmitted disease and tuberculosis.

VIOLENCE


WHO defines violence as “The intentional use of physical force or power,

threatened or actual, against oneself, another person, or against a group or community that either results in or has a high likelihood of resulting in injury, death, psychologic harm, maldevelopment or deprivation”

Physical and sexual violence are common in India. 20-30% of young females suffering from domestic

violence and 5-9% young females reporting sexual violence (NFHS3).

Motor vehicle and industrial accidents are common in boys whereas burns are common in girls.

NELSON 20TH EDITION PG 946

The FISTS mnemonic provides guidance for structuring the assessment of violence-

VIOLENCE (Cont…)

NELSON 20TH EDITION PG 946

Multiple treatment modalities are used simultaneously in managing adolescents with persistent violent and aggressive behavior and range from cognitive-behavioral therapy involving the individual and family to specific family interventions (parent management training, multisystemic treatment) and pharmacotherapy.

Treatment of existing comorbid conditions, such as attention-deficit/hyperactivity disorder, depression, and substance abuse, appears to reduce aggressive behavior.

VIOLENCE (Cont…)

LACK OF SEX EDUCATION


The majority of Indian adolescent do not get formal sex education in an effective way.

Peers, books, internet and magazines are their main source of information about sex.

Parents and teachers often fail to discuss issues like safe sex, dating, abortion, HIV, and sexually transmitted diseases.

SOCIAL CHALLENGES


MEDIA With the availability of electronic media,

adolescents are exposed to information from all across the world.

This exposure is unsupervised because of working parents and increasing use of electronic gadgets.

Due to inability to separate fact from fantasy, adolescents succumb to the glamorous portrayal of tobacco or alcohol consumption, unrealistic expectations, physical aggression, destructive behavior and unprotected sex.


PEER PRESSURE Peer formation is a part of adolescent social

development. Pressure for conforming to norms drive many of

their actions and decisions, including risk taking behavior and initiation of substance abuse.

POVERTY Children belonging to poorer families are likely to

have inadequate diets, have higher chances of having depression, antisocial behavior and engaging in drugs or sexual activity at earlier ages.

SOCIAL CHALLENGES

SOCIAL CHALLANGES


ILLITERACY Though situation is improving over the

years, still 33% of Indian youth are not able to complete their primary education.

Female gender belonging to rural and poor background are risk factor for illiteracy.

EARLY MARRIAGE Though the legal age for marriage is 18 yr

for girls, many states still have the practice of childhood and early marriage.

SOCIAL CHALLANGES


ACADEMIC AND EMOTIONAL STRESS Examinations cause significant

physiological and psychological stress. Apart from rapid changes in their body

structures, various other factors like peer acceptance, discrimination, academic burden, parental expectations, changing social environments cause stress among adolescents.

Some adolescents may face adjustment problems resulting in various psychological and somatic effects.

SOCIAL CHALLANGES


DISCRIMINATION Adolescent girls are often asked to limit

their outdoor or extracurricular activities and are not involved in any decision making. They are expected to do household work.

Gender based discrimination is seen in education and even food distribution

ROLE OF HEALTH CARE PROVIDER


Identifying risk Establishing rapport Confidentiality Consent(<12, 12-18, >18) Nutritional intervention Providing health information Contraception



Referral to social services, psychological evaluation and support National Commission for Protection of Child

Rights Act 2005 consider a person below 18 yr as a child.

It is mandatory for a health care provider to report all cases of child abuse (even suspected) to the chairperson of the commission (online/writing).

Doctors are protected in case of erroneous reporting but punishable if they fail to report.


Adolescent immunisation



Adolescent friendly health services Management of sexual violence

Forensic examination and collection of blood or body fluid samples by trained staff

Care of injuries Prophylaxis against pregnancy Prophylaxis against sexually transmitted diseases Prophylaxis against HIV HBV vaccination if not immunised Psychological support


CHECKLIST FOR ADOLESCENT HEALTH VISIT


History from parents and adolescents History of presenting problem Parental concern on growth and

development Academic success; school absenteeism Diet intake including calcium, protein and

iron intake; junk food Menstrual history; sleep problems


History on questioning of adolescents Emotional problems; relationship with

family and peers Outlook toward physical and sexual

changes Involvement in relationship or sexual

activity Awareness about safe sex and

contraception Specific problems related to sex organs Tobacco or other substance use Counsel and clear doubts on sensitive

topics

CHECKLIST FOR ADOLESCENT HEALTH VISIT (Cont…)


History on separate questioning of parents Relationship with family Level of communication on sensitive

matters Physical examination

Anthropometry Blood pressure, obesity, acanthosis Sexual maturity rating Signs of malnutrition, anemia and vitamin

deficiency Signs of skin and genital infection



Level of general hygiene Signs of trauma; abuse Signs of drug abuse and tobacco abuse

Counseling Nutritional intervention Hygiene practices Building rapport between parents and

adolescents Providing information and sources on sex

education



Investigations Hemoglobin level Blood sugar, lipid profile Genital swab Ultrasound of ovaries



Referral Counselor Dietitian Psychiatrist Gynecologist Voluntary and confidential HIV testing Social services, child protection agencies,

support groups.


THANK YOU

Healthcare

Adolescent health problems