Adolescent health

1. Adolescent health PRESENTED BY-Dr. l.karthiyayini MODERATOR-DR. DAMBHARE

2. What is adolescence?

3. Adolescence • The World Health Organization defines adolescence in terms of age between 10 to 19 years. • Adolescence is a phase of life during which individuals reach sexual maturity • It is the period of transition from puberty to maturity Young people : Its defined as generally people aged 10–24 years. Its divided into three categories: • 10–14 years (early adolescence); • 15–19 years (late adolescence) • 20–24 years (young adulthood)

4. Adolescent population GLOBALLY- The 1.2 billion people aged 10 to 19 make up about 20% of the global population. SEAR- There are about 350 million adolescents comprising about 22% of the population in the countries of the South-East Asia Region (SEAR). INDIA-About 22% of India's population is in the adolescent age group of 10-19 years. It is estimated that there are almost 225 million adolescents in India. 12 % belong to the 10-14 years age group and nearly 10 %are in the 15-19 years age group. Females comprise almost 47 %and males 53 % of the total adolescent population. MAHARASHTRA-about 11 crores of adolescent population are there. WARDA- 1.25lakh population are adolescents.

5. Changes during adolescent period • Rapid physical growth and development. • Physical, social and psychological maturity • Sexual maturity and the onset of sexual activity • Experimentation • Development of adult mental processes and adult identity • Transition from total socio-economic dependence to relative independence. • Stage of life in which individuals establish their own identities and prepare to become adults.

6. Changes during adolescent period….contd. Pubertal changes begin at an average age of 10-11yrs in girls & 12-13yrs in boys. Sexual maturation should be used to assess the extent of biological growth & development & the individual nutritional needs of adolescence in chronological age. Sexual maturity rating (SMR), also know as tanner staging , is based upon a scale of secondary sexual characteristics that permits health professionals to gauge the degree of pubertal maturation that has occurred among adolescents, regardless of chronological age.

7. Tanner staging Boys: Genital Development • Stage 1: Preadolescent. Testes, scrotum and penis are about the same size and proportion as in early childhood. • Stage 2: Enlargement of scrotum and testes. Skin of scrotum reddens and changes in texture. Little or no enlargement of penis. • Stage 3: Enlargement of penis, at first mainly in length. Further growth of testes and scrotum. • Stage 4: Increased size of penis, with growth in breadth and development of glans. Testes and scrotum larger. Scrotal skin darkened. • Stage 5: Genitalia are adult in size and shape.

8. Tanner staging Girls: Breast Development • Stage 1: Preadolescent. Elevation of papilla only. • Stage 2: Breast bud stage. Elevation of breast and papilla as small mound. Enlargement of diameter of areola. • Stage 3: Further enlargement and elevation of the breast and areola, with no separation of their contours. • Stage 4: Projection of areola and papilla to form a secondary mound above the level of the breast. • Stage 5: Mature stage. Projection of papilla only, owing to recession of the areola to the general contour of the breast.

9. Tanner staging Both sexes: pubic hair • Stage 1: Preadolescent. Vellus over pubis is not developed further than that over abdominal wall (i.e., no pubic hair). • Stage 2: Sparse growth of long, slightly pigmented downy hair, straight or slightly curled, chiefly at base of penis and along labia. • Stage 3: Hair is considerably darker, coarser and more curled. It spreads sparsely over the junction of pubis. • Stage 4: Hair is adult in type, but area covered is still considerably smaller than in adult. No spread to medial surface of thighs. • Stage 5: Hair is adult in quantity and type, with distribution of horizontal (or classic “feminine” in females) pattern. Spread to medial surface of thighs but not up linea alba or elsewhere above base of inverse triangle (spread up linea alba occurs late and is rated Stage 6).

10. Pubertal disorders Short stature Delayed puberty Gynecomastia Pre pubertal hyperandrogenism hirsutism

11. Psychosocial changes

12. Adolescent body image • Body image is defined as “the way of perception of one’s body and its competences”. • Determinants of body image:  • General self-esteem- one’s overall perception of self- worth • Social self-esteem- one’s perception of interpersonal peer relationships • Parent-related self-esteem –one’s perception of her/his status at home, including how his/her parents view her/him. • Academic self-esteem- one’s perception of his/her ability to succeed academically • Physical self-esteem-one’s perception of physical ability & physical appearance

13. Clinical presentation of poor body image • Low weight for age, height & SMR stage • Anemia • Menstrual irregularities • Eating disorders • Excessive shyness • Sleep problems • Withdrawal & depression • postural problems.

14. Management and treatment of poor body image: The recognition of body image issues need high index of suspicion clearing their myths about normal changes in the body, about media projected image, and Counselling these adolescents and about various steps they might have adopted to correct their perceived poor body image may be sufficient treatment in majority of adolescents. Multimodal therapeutic approach include normalization of weight & eating behaviour , nursing & pedagogical measures , individual, group and family therapy, body therapy, art & music therapy .

15. Adolescent nutrition • Increased nutritional needs at this juncture relate to the fact that adolescents gain up to 50% of their adult weight, more than 20% of their adult height, and 50% of their adult skeletal mass during this period. • Caloric and protein requirements are maximal. Increased physical activity, combined with poor eating habits and other considerations, e.g. menstruation and pregnancy, contribute to accentuating the potential risk for adolescents of poor nutrition.  

16. Recommended dietary allowance

17. Eating behaviour of adolescents Missing one or more meals. Inappropriate choice of snack foods. Overriding fear of obesity among girls. No supervision of selection of meals eaten away from home. In some areas women eat after men have eaten & have access to lesser & inferior quality of food. Nutrition related issues: Anemia Obesity Malnutrition Anorexia Bulimia nervosa Binge eating disorder

18. Adolescent reproductive & sexual health(ARSH) Adolescentreproductive & sexual healthreferstothephysical, mental, and emotionalwellbeing of adolescents, and includesfreedomfrom: • unwantedpregnancy • unsafeabortion • sexuallytransmittedinfections (STIs), including HIV/AIDS • allforms of sexual violence and coerción.

19. Contd…. Age-specific fertility rate in the age group of 15-19years contributes to 19 % of the total fertility rate. Amongst currently married women, the unmet need of contraception is the highest in the age group of 15-19 years. Nearly 27 % of married female adolescents have reported unmet need for contraception . Most sexually active adolescents are in their late adolescence. Over 35 % of all reported HIV infections in India occur among young people in the age group of 15-24 years, indicating that young people are highly vulnerable. The majority of them are infected through unprotected sex.

20. Contd… • Factors influencing sexual health of adolescents: Protectivefactorswork in 3 ways, • Encourage & sustain positive behaviour. • Reduce therisk of negativehealthbehaviour & outcomes. • Diminishtheeffect of & supportrecoveryfromnegativehealthoutcomes. Risk factors Risk behaviours Negative outcomes Protective factors

21. Contd…. Protectivefactors are, • Caring and meaningfulrelationships. • Positive schoolenvironment. • Sructure and boundariesforbehaviour • Having spiritual beliefs • Encouragement of self-expression • Oppurtunitiesforparticipation & contribution. Consequences of inappropriate sexual behaviour leads to, • Adolescentpregnancy • Unsafeabortion • Sexuallytransmitteddiseases • Social & economicimpact.

22. Menstrual problems in adolescent girls • Premenstual syndrome- • Before the onset of the menstual cycle, females face many uncomfortable symptoms which last for a short period, stretching from few hours to few days called as premenstrual syndrome. • Dysmenorrhea- Dysmenorrhea is feeling intense menstrual pain and cramps.. • Amenorrhea - it is the condition in which the female skips her menses for more than three consecutive menstrual cycles. There are many causes of amenorrhea such as ovulation abnormality, eating disorders, birth defects, anatomical abnormalities, malnourishment, pregnancy, thyroid disorder, obesity and other medical conditions. • Dysfunctional uterine bleeding

23. Adolescent pregnancy

24. Adolescent pregnancy About 16 million women 15–19 years old give birth each year, about 11% of all births worldwide. In low- and middle-income countries, almost 10% of girls become mothers by age 16 years, with the highest rates in sub-Saharan Africa and south-central and south-eastern Asia. Births to unmarried adolescent mothers are far more likely to be unintended and are more likely to end in induced abortion. Coerced sex, reported by 10% of girls who first had sex before age 15 years, contributes to unwanted adolescent pregnancies

25. Contd… Although adolescents aged 10-19 years account for 11% of all births worldwide, they account for 23% of the overall burden of disease (disability- adjusted life years) due to pregnancy and childbirth. Many health problems are particularly associated with negative outcomes of pregnancy during adolescence. These include anaemia, malaria, HIV and other sexually transmitted infections, postpartum haemorrhage and mental disorders, such as depression. Educational levels for girls have risen in most countries, and job opportunities have expanded. Low education levels are closely associated with early childbearing.

26. Sexually transmitted diseases Adolescents are at risk of acquiring STD. Many adolescents particularly runaway, the homeless & gay males are exposed to HIV infection by risky sexual behaviors & drug abuse. Although most teenagers are likely to know that the disease is transmitted by sexual intercourse & reused needles, they are continuing misconceptions and ignorance. The prevalence of unprotected sex or unsafe sex is high & knowledge about safer sex practices is to be limited. Extensive health education & preventive programs are required to reduce STDs, using mass media, school & communication based strategies with sensitive consideration of developmental needs of different age groups.

27. Mental health among adolescents • World-wide up to 20% of children and adolescents suffer from a disabling mental illness • World-wide suicide is the 3rd leading cause of death

28. MENTAL DISORDERS • Conduct and behavioural disorders • Learning disorders • Anxiety disorders • Teen depression • Juvenile delinquency • Adjustment problems

29. Contd.. Depression and associated suicide. The combination of depression with substance abuse puts children and adolescents at greater risk for suicide. Psychosis. Psychoses can result in a host of maladaptive behaviors. The early treatment of psychotic disorders such as schizophrenia not only brings relief to patients, families and society, but improves the prognosis. Anxiety disorders. A heterogeneous category of disorders with variable diagnosis in even the most sophisticated settings. At the extreme phobias and panic disorder can lead to significant social isolation and lack of occupational attainment.

30. Contd… Conduct disorder/anti-social personality-. It should not be made prematurely because once made it is often seen as having such a negative prognosis that it may establish a self-fulfilling prophecy. Substance abuse. While it is often impossible to diagnose children as meeting the criteria for substance dependence, whether it be alcohol or other drugs, the serious manifestations of the abuse of substances is evident. Eating disorders. These disorders are now seen in developing as well as developed countries and may even manifest themselves in the face of apparent starvation.

31. Prevention of mental illness • Enhancing social skills, problem-solving skills and self confidence can help prevent mental health problems such as conduct disorders, anxiety, depression and eating disorders as well as other risk behaviours including those that relate to sexual behaviour, substance abuse, and violent behaviour. • Also there should be competencies to relate to young people, to detect mental health problems early, and to provide treatments which include counselling, cognitive-behavioural therapy and, where appropriate, psychotropic medication.

32. Other special issues • Substance abuse • Violence and gender bias • Road safety

33. Substance abuse Substance abuse refers to the harmful or hazardous use of psychoactive substances, including alcohol and illicit drugs.

34. Drug abuse • Psychoactive substance use can lead to dependence syndrome - a cluster of behavioural, cognitive, and physiological phenomena that develop after repeated substance use and that typically include a strong desire to take the drug, difficulties in controlling its use, persisting in its use despite harmful consequences, a higher priority given to drug use than to other activities and obligations, increased tolerance, and sometimes a physical withdrawal state. • The projected number of drug abusers in India is about 3 million and most drug abusers are in the age group of 16-35 years

35. Alcohol Alcohol is a medication that blocks painful or intolerable reality. Alcohol abuse occurs when there are ongoing negative consequences from drinking. Alcohol dependence, or alcoholism, is more severe and occurs when people have problems stopping drinking. About 20% of men and 8% of women are alcohol dependent.40 percent of people who begin to drink before age 15 will become alcohol dependent at some point in their lives. They are four times more likely to become alcohol dependent than those who delay drinking until age 21.

36. Tobacco Forty lakh tobacco related deaths occur annually all over the world of which India accounts for 20%. One person dies in every seven second due to Tobacco related diseases. Tobacco & pan chewing is definitely linked to oral cancer. The incidence is highest in India. Smoking is linked to 80 – 90% cases of lung cancer. Within seconds after tobacco smoke is inhaled some 4000 toxic byproducts are absorbed into blood stream and transported to every cell.Forms of tobacco use, 1 Smoking 2 Chewing along with other substances 3 Snuffing 4 Application in the mouth as powder or paste

37. Violence by & against adolescents • The World Health Organization 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, psychological harm, maldevelopment or deprivation. • Homicide and non-fatal assaults involving young people contribute greatly to the global burden of premature death, injury and disability forms of violence in society. Participating in physical fights, bullying and carrying of weapons are important risk behaviours for youth violence.

38. Contd… Worldwide some 250 000 homicides occur among youth 10-29 years of age each year – 41% of the annual total number of homicides globally. For each young person killed, 20-40 more sustain injuries requiring hospital treatment. Youth violence has a serious, often lifelong, impact on a person's psychological and social functioning.

39. Gender biased violence Gender-based violence is another area of concern, especially for female adolescents. As per NFHS 3, nearly one out of every three (31%) ever-married female adolescents, in 15–19 age group, reported having experienced physical, sexual or emotional violence perpetrated by their spouse.

40. Risk factors of violence Individual factors Family influences Relationship factor Peer influences Community factors Demographic & social changes Income inequality Political structures Cultural influences

41. Road safety among adolescents

42. Contd.. Each year, almost 400,000 young people under 25 years old are killed in a road traffic crash - about 1049 youngsters every day. Most of these tragic deaths occur in low- and middle-income countries, particularly among pedestrians, cyclists, motorcyclists and those using public transport

43. Contd.. Young road users are at risk for road traffic injuries for a number of reasons: • insufficient consideration of their specific needs when roads are being planned; • physical and developmental characteristics that increase their risk, for example, the small stature of young children; • risk taking behavior and peer pressure particularly among adolescents; and • other risk factors such as speeding, drink-driving, not using helmets or not wearing seat-belts.

44. Adolescent Health Programs:PROGRAMS 1. Reproductive and Child Health Programme Adolescent Friendly Health Services: 2. National AIDS Control Programme 3. Millineum developmental goals. 4. ICDS

45. Reproductive and Child Health-II a)REPRODUCTIVE & CHILD HEALTH PHASE II In the National Rural Health Mission (NRHM), a national strategy for Adolescent Reproductive and Sexual Health (ARSH) has been approved as a part of the Reproductive and Child Health Phase II . Adolescent Reproductive and Sexual Health(ARSH): Services provided to all adolescent married and unmarried girls and boys

46. ARSH Package of services • Promotive services: • Focused care during antenatal period • Counselling & provision of emergency contraceptives • Counselling & provision of reversible contraceptives • Information/advice on SRH services • Preventive services: • Services for TT and prophylaxsis against nutritional anemia • Nutritional counselling • Services for early and safe termination of pregnancy and management of post abortion complications

47. 3.Curative services: • Treatment for common RTI/STIs • Treatment & counselling of menstrual disorders sexual concerns of males and female adolescents 4. Referral services: • Integrated Counselling and Testing Centre • Prevention of Parent to Child Transmission 5. Outreach services: • Periodic health checkups and community camps • Periodic health education activities • Co-curricular activities

50. Adolescent Friendly Health Services: • AFHS provides a broad range of preventive, promotive & curative services • AFHS in India is first taken by Safdarjang Hospital in New Delhi • Package of health services at AFHS: • Monitoring of growth & development&behaviour problems • Offer information & counselling on developmental changes, personal care & ways of seeking help • Reproductive health including contraceptives, STI treatment, pregnancy care & post abortion management • Integrated counselling & testing for HIV • Management of sexual violence • Mental health services including management of substance abuse