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Approach to the Unique Care of Adolescents

Approach to the Unique Care of Adolescents. Charles E. Irwin, Jr., M.D. Department of Pediatrics Division of Adolescent and Young Adult Medicine UCSF Benioff Children ’ s Hospital University of California, San Francisco July 2013.

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Approach to the Unique Care of Adolescents

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  1. Approach to the Unique Care of Adolescents • Charles E. Irwin, Jr., M.D. • Department of Pediatrics • Division of Adolescent and Young Adult Medicine • UCSF Benioff Children’s Hospital • University of California, San Francisco • July 2013

  2. I see no hope for the future of the world if they are dependent on the frivolous youth of today , for certainly all youth are reckless beyond words. When I was a boy we were taught to be respectful of elders but the present youth are exceedingly wise and impatient of restraint. Hesiod, 8th Century B.C.

  3. I would there were no age between ten and three-and-twenty, or that youth would sleep out the rest, for there is nothing in the between but getting wenches with child, wronging the ancientry, stealing, fighting... The Winter’s Tale, Shakespeare

  4. The grain of heedlessness… “The time from the 18th to the 24th year is best suited to military service. The body is then quite vigorous enough to endure hardships, and the soldier is as yet free and unfettered. The grain of heedlessness, a quality peculiar to the freshness of youth, is an excellent incentive to martial achievement” Baron Colmar von der Goltz The Nation in Arms 1883

  5. “Until recently, the pediatrician has been preoccupied with premature babies, transfusions, feeding problems, running ears… The internist has also been busy with the ills of adulthood and advancing age and has still to come to the period of adolescence. Yet this field is particularly important, marking as it does the transition from boy to man and from girl to woman.” - James Roswell Gallagher Gallagher, 1954.

  6. Granville Stanley Hall1844 - 1924 “Adolescence: its psychology and its relation to physiology, anthropology, sociology, sex, crime, religion and education” (1904)

  7. March 2007 April 2012

  8. Adolescent Health Substance use Accidents & injury Mental health & well being Sexual health Chronic illness Obesity & eating disorders Prevention - early intervention - clinical care

  9. Brain Development • Grey matter volume peaks in early adolescence • Selective pruning proceeds ‘from back to front’ • Greater efficiency of neurotransmission results from myelination • Neuromaturation underpins emotional regulation &control

  10. A Model of Development Late adolescence 20-24 yrs Early adolescence 10-14 yrs Mid adolescence 15-19 yrs Maturation of brain facilitates regulatory competence Period of heightened vulnerability to risk taking, problems in terms of affect & behaviour Puberty heightens emotional arousability, sensation-seeking, reward orientation Steinberg

  11. Biopsychosocial Development During Adolescence/ Emerging AdulthoodEarly Adolescence (Age 10 –14 Years)

  12. Biopsychosocial Development During Adolescence/ Emerging AdulthoodMiddle Adolescence (Age 14 – 18 years)

  13. Biopsychosocial Development During Adolescence/ Emerging AdulthoodLate Adolescence/Emerging Adulthood (Age 18 – 24 Years)

  14. Tips on Development • Early - be very specific; focus on youth’s concerns; be on alert for early developers; counsel parents • Middle – trusting friendly relationships are key; concrete still best; emphasize adult connections, health promotion & harm reduction; support/advise parents. • Late - abstract reasoning - understanding consequences of actions; include partners in office visits; transition planning

  15. The Clinical Visit

  16. Structure of Visit • Elicit Concerns of Adolescent/Family • Discuss How visit will go • Use Development to guide process • Time alone depending on cultural norms • Physical Exam guided by concerns • Feedback to Adolescent and Family at conclusion

  17. HEEADSSS ASSESSMENT for Psychosocial Concerns– Screening History

  18. HEEADSSS ASSESSMENT for Psychosocial Concerns– Screening History

  19. HEEADSSS ASSESSMENT for Psychosocial Concerns– Screening History

  20. HEEADSSS ASSESSMENT for Psychosocial Concerns– Screening History

  21. Recommendations for Adolescent Preventive Health Care X = To be performed; * = Risk assessment to be performed, with appropriate action to follow;  = Range during which a service may be provided with the symbol indicating the preferred age

  22. Recommendations for Adolescent Preventive Health Care X = To be performed; * = Risk assessment to be performed, with appropriate action to follow Adapted from Hagan JF, Shaw JS, Duncan PM. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, 3rd Ed. Elk Grove Village; IL: American Academy of Pediatrics, 2008.

  23. Recommendations for Adolescent Preventive Health Care X = To be performed; * = Risk assessment to be performed, with appropriate action to follow Adapted from Hagan JF, Shaw JS, Duncan PM. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, 3rd Ed. Elk Grove Village; IL: American Academy of Pediatrics, 2008.

  24. Recommendations for Adolescent Preventive Health Care X = To be performed; * = Risk assessment to be performed, with appropriate action to follow;  = Range during which a service may be provided with the symbol indicating the preferred age Adapted from Hagan JF, Shaw JS, Duncan PM. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, 3rd Ed. Elk Grove Village; IL: American Academy of Pediatrics, 2008.

  25. 1Age if an adolescent/young adult comes under care for the first time at any point on the schedule, or if any items are not accomplished at the suggested age, the schedule should be brought up to date at the earliest possible time. 2At each visit, age-appropriate physical examination is essential. 3Schedules per the Committee on Infectious Diseases, published annually in the January issue of Pediatrics. Every visit should be an opportunity to update and complete an adolescents immunization. 4See AAP Pediatric Nutrition Handbook, 5th Edition (2003) for a discussion of universal and selective screening options. 5Tuberculosis testing per recommendations of the Committee on Infectious Diseases, Testing should be done on recognition of high-risk factors. 6“Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) Final Report” (2002) [URL:http://circ.ahajournals.org/cgi/content/full/106/25/3143] and “The Expert Committee Recommendations on the Assessment, Prevention, Treatment of Child and Adolescent Overweight and Obesity.” Supplement to Pediatrics. In press. 7All sexually active patients should be screen for sexually transmitted infections (STIs). 8All sexually active girls should have screening for cervical dysplasia as part of a pelvic examination beginning within 3 years on onset of sexual activity or age 21 (whichever comes first). 9Refer to the specific guidance by age as listed in Bright Futures Guidelines.

  26. Physical Examination • General Appearance • Vital Signs • Affect, Mood, Dress, Energy Level • BMI, VS, BP, Orthostatics if low BMI, Audiogram, Visual Acuity

  27. BMI • Assess height and weight EVERY visit • Calculate BMI • Look for trends • Consider the context of growth and development • Record on the appropriate Growth/BMI chart

  28. BMI Charts 2-17 year olds

  29. Physical Exam, cont. • Skin • Breasts • Lymph nodes • Chest/Cardiovascular • Rectal • GU • Acne, striae, cuts • Tanner stage, BSE • Palpate for size • Palpation/Auscultation • Symptomatic –GI/GU • Tanner/SMR Staging

  30. Physical Exam, cont. • Genitalia, Males • Genitalia, Females • Teach Testicular Self Exam: R/O • Pelvic if indicated

  31. PUBERTY

  32. Sequence of Pubertal Events Height Spurt FEMALES MALES Breast Development : Menarche : Female Pubic Hair : Male Public Hair : Testicular Volume : 2 3 4 5 2 3 4 5 2 3 4 5 >4 10 16 9 10 11 12 13 14 15 16

  33. Timing of Pubertal Onset--Females • Timing of onset is variable • Average age of onset of breast development is 8.9 years in African American girls and 9.9 years in white girls. Average age of onset of breast development for Mexican American girls appears to be in between. Herman-Giddens, 1997

  34. Sequence of Pubertal Events--Females Breast bud Pubic hair Peak height velocity Menarche

  35. Tanner Staging--Females • Breast staging • Pubic hair staging • Marshall WA, Tanner JM. Variations in the Pattern of Pubertal Changes in Girls. Arch Dis Child. 1969:44(235):291-303. • http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2020414/

  36. Timing of Pubertal Onset--Males • Timing of onset is variable • Average age of onset is 11.6 years (range: 9.5 to 14 years). • Onset appears to be earliest in African American males, latest in white males. Hispanic males are in between. Herman-Giddens, 2012.

  37. Sequence of Pubertal Events--Males 1. 2. 3. Testicular enlargement Sexual hair, phallic and scrotal changes Peak height velocity

  38. Tanner Staging (Sexual Maturity Ratings)--Males • Genital staging • Pubic hair staging • Marshall WA, Tanner JM. Variations in the Pattern of Pubertal Changes in Boys. Arch Dis Child. 1970:45(239):13-23. • http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2020414/

  39. Sequence of Pubertal Events Height Spurt FEMALES MALES Breast Development : Menarche : Female Pubic Hair : Male Public Hair : Testicular Volume : 2 3 4 5 2 3 4 5 2 3 4 5 >4 10 16 9 10 11 12 13 14 15 16

  40. Height Spurt • 25% of adult height is accounted for during pubertal growth • Growth spurt in females: • at average age of 11.5 • average Tanner stage of 2-3 • peak velocity of 8.3 cm/year • Growth spurt in males • at average age of 13.5 years • average Tanner stage of 4 • peak velocity of 9.5 cm/year

  41. Pubertal timing and behavior • Early pubertal timing • In females: associated with poor self esteem and negative body image. Associated with early onset of sexual activity and older partners. • In males: associated with early onset of sexual activity, but socially desirable. • Late maturity: • In males associated with poor self-esteem and negative body image • MEDIATORS? • Actual timing? • Perceived timing?

  42. Puberty – great opportunity for education • Growth Spurt –25% of adult height is accounted for during pubertal growth • Changes in Body Shape and Size • Voice Change • Acne • Body Odor • Menarche – Menses • Spermarche – Ejaculation • Vital Sign Changes • Bone MASS

  43. Questions Concerning Puberty by Early Adolescents

  44. Questions Concerning Puberty by Early Adolescents Ryan, Millstein, Irwin. J Adol Health (1996)

  45. C “Youth-friendly” care & services

  46. General Principles of Adolescent Health Care Delivery • Availability • Accessibility • Approachability • Acceptability • Appropriateness

  47. General Principles in Working with Teens • Rapport and respect are key • Review the parameters of your relationship, encounters, discussions up front AND on a regular basis • Use their developmental stage and interact with them accordingly • Seize every opportunity • Be up front & genuine: express your concerns

  48. General Principles of working with teens • Assess strengths & assets as well as risks & problems • Reinforce and bolster connections • Educate about mind-body connection • Engage and support family during adolescence • Be Authoritative

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