MANAGE ADOLESCENT HEALTH PROBLEMS

1. MANAGE ADOLESCENT HEALTH PROBLEMS Unit 4: Part 4 Module 1

2. REFERENCES C290 Nelson�s Essentials of Pediatrics C277 Toronto Notes C306 Hospital for Sick Kids Manual C18 Bates Class handout

3. OUTLINE Causes of Morbidity/Mortality Adolescent Screening History Nutrition Needs/Eating Disorders Acne** covered in dermatology Adolescent Mental Health Issues Anticipatory guidance Tanner Stages of Physical Development Legal Issues in Health care For Adolescents Adolescence is a unique developmental stage with many physical, emotional and social challenges to be faced as the adolescent moves from a life of dependency to independence This age group is one that attends for health care as most are relatively physical well , often only presenting for episodic illness care. Because of this fact, it is important clinicians seize every opportunity to screen for other health issues when adolescent patients do present. Another unfortunate characteristic of adolescence is a propensity for risk-taking behaviors, such as abuse of drugs and alcohol, which cause premature morbidity and death within this age group. Building a rapport and trusting relationship, is most important, confidentiality in regards to parents can also be an issue when trying to build trust Most adolescents respond positively when they perceive a genuine interest in them as persons not just their problems/ behaviourAdolescence is a unique developmental stage with many physical, emotional and social challenges to be faced as the adolescent moves from a life of dependency to independence This age group is one that attends for health care as most are relatively physical well , often only presenting for episodic illness care. Because of this fact, it is important clinicians seize every opportunity to screen for other health issues when adolescent patients do present. Another unfortunate characteristic of adolescence is a propensity for risk-taking behaviors, such as abuse of drugs and alcohol, which cause premature morbidity and death within this age group. Building a rapport and trusting relationship, is most important, confidentiality in regards to parents can also be an issue when trying to build trust Most adolescents respond positively when they perceive a genuine interest in them as persons not just their problems/ behaviour

4. LEADING CAUSES OF MORTALITY Accidents- MVA�s Suicide Malignant neoplasms Diseases of the heart Congenital anomlaies HIV Pulmonary disease - pneumonia, asthma

5. COMMON CHRONIC ILLNESSES IN ADOLESCENTS Asthma Cystic fibrosis Cerebral palsy Mental retardation Seizure disorder Auditory/visual defects Migraines Scoliosis

6. COMMON CHRONIC ILLNESSES IN ADOLESCENTS Traumatic paralysis Diabetes Obesity Eating disorders Dysmenorrhea Acne

7. CHARACTERISTICS OF DEVELOPMENTAL STAGES Early Adolescence - Preoccupation with body changes - High levels of physical activity and mood swings - Self consciousness and need for privacy Mid-Adolescence - Independence , sense of identity - Peer group dominates social life - Risk behaviors/experimentation more prevalent - Sexual matters are of most interest

8. CHARACTERISTICS OF DEVELOPMENTAL STAGES Late Adolescence - Adult appearance - More capable of orienting activities toward the future, of mutual caring and of internal control - Uncertainties about sexuality, future relationships and work possibilities

9. ADOLESCENT HISTORY - S- for sexuality issues - A- for affect (e.g., depression) and abuse (e.g., drugs) - F - for family (function and medical history) - E- for examination (sensitive and appropriate) - T - for timing of development (body image) - I - for immunizations - M- for minerals (nutritional issues) - E - for education and employment (school and work issues) - S- for safety (e.g., vehicle) An acute medical need is the most frequent reason for an adolescent to seek medical care. It is important to take this opportunity to discuss other topics important to adolescent health. The mnemonic SAFE TIMES is one way of remembering appropriate topics for discussion: HISTORY-TAKING Consider the following points when interviewing an adolescent: Ensure that the adolescent is the prime historian. It is preferable to interview the adolescent without his or her parents or caregiver, although it may be necessary to obtain collateral history from parents, caregivers, teachers and others. Assure the adolescent that all important problems will be kept strictly confidential (there are some obvious exceptions, including suicide intention and other high-risk, potentially destructive activity). Sensitively explore with the adolescent any problems with sexuality, drugs, alcohol, school and family. Try to elicit information about the activities in which the adolescent participates and what his or her peer group is doing. Peer group activities generally reflect the individual�s activities. If the adolescent is uncommunicative, a multiple-choice approach can be used (e.g., �How would you compare your school performance with that of others? Better, worse or the same?�). An acute medical need is the most frequent reason for an adolescent to seek medical care. It is important to take this opportunity to discuss other topics important to adolescent health. The mnemonic SAFE TIMES is one way of remembering appropriate topics for discussion: HISTORY-TAKING Consider the following points when interviewing an adolescent: Ensure that the adolescent is the prime historian. It is preferable to interview the adolescent without his or her parents or caregiver, although it may be necessary to obtain collateral history from parents, caregivers, teachers and others. Assure the adolescent that all important problems will be kept strictly confidential (there are some obvious exceptions, including suicide intention and other high-risk, potentially destructive activity). Sensitively explore with the adolescent any problems with sexuality, drugs, alcohol, school and family. Try to elicit information about the activities in which the adolescent participates and what his or her peer group is doing. Peer group activities generally reflect the individual�s activities. If the adolescent is uncommunicative, a multiple-choice approach can be used (e.g., �How would you compare your school performance with that of others? Better, worse or the same?�).

10. ADOLESCENT HISTORY H- home environment E - employment and education A - activities D- drugs S - sexuality/sexual activity S - suicide/depression S - safety

11. ADOLESCENT HISTORY Functional Inquiry Psychosocial Evaluation FUNCTIONAL INQUIRY A complete history of the health status of the adolescent should be undertaken whenever an opportunity to do so presents itself. A record of pubertal changes and, for young women, a complete menstrual history, are essential components of this history. PSYCHOSOCIAL EVALUATION Issues related to sexuality, drug or alcohol use, and family and school problems should be systematically reviewed. Questions about school attendance and performance and future plans for school and employment should be part of a complete evaluation. FUNCTIONAL INQUIRY A complete history of the health status of the adolescent should be undertaken whenever an opportunity to do so presents itself. A record of pubertal changes and, for young women, a complete menstrual history, are essential components of this history. PSYCHOSOCIAL EVALUATION Issues related to sexuality, drug or alcohol use, and family and school problems should be systematically reviewed. Questions about school attendance and performance and future plans for school and employment should be part of a complete evaluation.

12. COMPREHENSIVE PHYSICAL EXAMINATION Emphasis should be placed on common adolescent concerns Height, weight and blood pressure should be measured yearly in adolescents Sexual maturation (according to Tanner stages; should be noted

13. COMPREHENSIVE PHYSICAL EXAMINATION SKIN Obvious problems, particularly acne, should be noted and treated EYES/EARS Visual acuity should be screened, as myopia commonly develops during the adolescent growth spurt Hearing screening for at risk or symptomatic persons

14. COMPREHENSIVE PHYSICAL EXAMINATION NECK Thyroid MOUTH Dental decay and periodontal disease can be significant problems in adolescence BREASTS Development and symmetry of the breasts should be assessed, and girls should be taught how to perform breast self-examination

15. COMPREHENSIVE PHYSICAL EXAMINATION CARDIOVASCULAR SYSTEM Functional murmurs are common in adolescence, but look for other forms of cardiac pathology (e.g., mitral prolapse) MUSCULOSKELETAL SYSTEM Sports injuries, knee problems and other problems of the musculoskeletal system are common in adolescence Routine screening for scoliosis is controversial

16. COMPREHENSIVE PHYSICAL EXAMINATION GENITALIA Assess development of pubic hair-Tanner staging Boys should be examined with respect to normal growth and development of the external genitalia and taught TSE Girls who are sexually active should undergo a pelvic examination and Pap smear with appropriate STD screening at least once yearly General indications for pelvic examination would also include menstrual irregularities, severe dysmenorrhea, vaginal discharge, unexplained abdominal pain or dysuria. General indications for pelvic examination would also include menstrual irregularities, severe dysmenorrhea, vaginal discharge, unexplained abdominal pain or dysuria.

17. COMPREHENSIVE PHYSICAL EXAMINATION RECTAL EXAMINATION At some point during the health maintenance program, a rectal examination should be performed on all adolescents, but this can be deferred to the late teens if necessary

18. LABORATORY INVESTIGATION CBC, Ferritin PRN( anemia not uncommon) Rubella immune status Hepatitis B, HIV screening PRN PAP annually - sexually active girls Cultures for STD�s PRN VDRL PRN

19. PUBERTY IN FEMALES Begins between the ages of 8 and 14 years and is usually complete within 3 years Menarche usually occurs 2.5 years after the onset of puberty; in North America, the mean age at menarche is 12.5 years At menarche the adolescent female has generally attained 95% of her adult height The female adolescent growth spurt usually occurs between Tanner stages II and I , during this period she will grow an average of 8 cm per year

20. PUBERTY IN MALES Begins 1.5-2 years later in the male than in the female, and it takes twice as long The male adolescent growth spurt occurs during Tanner stage V The average increase in height during this period is approximately 10 cm per year

22. NORMAL NUTRITIONAL NEEDS OF ADOLESCENTS Adolescent energy needs for boys are 2500 to 3000 calories per day Girls energy needs are about 2200 calories per day Protein- females 0.8g/kg./d males 1.0g/kg./d (30% of caloric intake) During adolescence there a high incidence of nutritional deficiencies and poor eating habits. This may lead to consequences in later years including osteoporosis, obesity, hyperlipedemia, sexual maturation delays, and final adult height. The development of eating disorders is very prominent during this period. Nutritional surveys have indicated that the highest prevalence of nutritional deficiencies occur during adolescence Adolescence is a time of major growth for young people and so it's also a time of amazing nutritional needs. Adolescents do 20% to 25% of their growth in 24 to 36 months on average. Girls usually start their growth spurt between 8 and 14 years of age and are usually finished growing within 3 years. On average, a girl will grow 2 to 8 inches and gain 15 to 55 pounds. Boys on average begin their growth spurt about 10 to 16 years of age. During this time they grow 4 to 12 inches and gain 15 to 65 pounds. For boys, this usually ceases at 18 to 20 years of age. Before adolescence, both girls and boys have an average of 15% body fat. During adolescence this increases to about 20% in girls and decreases to about 10% in boys.During adolescence there a high incidence of nutritional deficiencies and poor eating habits. This may lead to consequences in later years including osteoporosis, obesity, hyperlipedemia, sexual maturation delays, and final adult height. The development of eating disorders is very prominent during this period. Nutritional surveys have indicated that the highest prevalence of nutritional deficiencies occur during adolescence Adolescence is a time of major growth for young people and so it's also a time of amazing nutritional needs. Adolescents do 20% to 25% of their growth in 24 to 36 months on average. Girls usually start their growth spurt between 8 and 14 years of age and are usually finished growing within 3 years. On average, a girl will grow 2 to 8 inches and gain 15 to 55 pounds. Boys on average begin their growth spurt about 10 to 16 years of age. During this time they grow 4 to 12 inches and gain 15 to 65 pounds. For boys, this usually ceases at 18 to 20 years of age. Before adolescence, both girls and boys have an average of 15% body fat. During adolescence this increases to about 20% in girls and decreases to about 10% in boys.

23. NORMAL NUTRITIONAL NEEDS OF ADOLESCENTS Fats- 30% of daily calories Calcium-Daily requirement 1500 mg./day The need for vitamins and minerals are also very high during adolescence After menstruation begins, girls need more iron than boys to replace menstrual losses Protein- females 0.8g/kg./d males 1.0g/kg./d (30% of caloric intake) Many teens meet or exceed this level, including vegetarians. Fats- 30% of daily calories. Most adolescents get enough fats through fast foods and fried foods. Teenagers should be taught to read labels and learn about fat content of foods. Calcium- The majority of bone mass deposition occurs during adolescence. Daily requirement 1500 mg./day. Good sources include calcium enriched orange juice, green leafy vegetables, sardines, soymilk, and tofu. Antacid tablets contain 300 mg of calcium are good dietary supplements. Protein- females 0.8g/kg./d males 1.0g/kg./d (30% of caloric intake) Many teens meet or exceed this level, including vegetarians. Fats- 30% of daily calories. Most adolescents get enough fats through fast foods and fried foods. Teenagers should be taught to read labels and learn about fat content of foods. Calcium- The majority of bone mass deposition occurs during adolescence. Daily requirement 1500 mg./day. Good sources include calcium enriched orange juice, green leafy vegetables, sardines, soymilk, and tofu. Antacid tablets contain 300 mg of calcium are good dietary supplements.

24. NORMAL NUTRITIONAL NEEDS OF ADOLESCENTS Risks for Nutritional Deficiencies - Eating disorders - Chronic medical conditions - Use of alcohol or drugs - Strict Vegan diet - Low socio-economic status

25. NORMAL NUTRITIONAL NEEDS OF ADOLESCENTS Evaluation of adolescent nutrition should include: - Weighing and measuring and comparing to previous values. Make note of any weight loss, excessive gains in weight, or failure to grow - Amount of physical activity - Quality, quantity, and number of meals per day - Sexual maturation - Menstruation history in girls

26. ANOREXIA NERVOUSA An eating disorder characterized by severe weight loss to the point of significant physiologic consequences Commonly starting in adolescence Girls> boys Caucasians more prone Restricting type Bingeing/purging type Girls> boys 10:1 Anorexia nervosa is thought to result from psychological, biological, and societal stresses involving sexual development at puberty. Prepubescent patients who subsequently develop anorexia nervosa have a high incidence of premorbid anxiety disorder. The patient's altered body image results in a perception of fatness. Attempts to correct this flaw through food restriction or progressive purging lead to progressive starvation. Modern preoccupation with slenderness and beauty in the Western world may contribute to the mindset of slenderness as a valued quality in adolescents Associated physical characteristics include excessive physical activity, denial of hunger in the face of starvation, academic success, asexual behavior, and a history of extreme weight loss methods (eg, diuretics, laxatives, amphetamines, emetics). Psychiatric characteristics include excessive dependency needs, developmental immaturity, behavior favoring isolation, obsessive-compulsive behavior, and constriction of affect. Girls> boys 10:1 Anorexia nervosa is thought to result from psychological, biological, and societal stresses involving sexual development at puberty. Prepubescent patients who subsequently develop anorexia nervosa have a high incidence of premorbid anxiety disorder. The patient's altered body image results in a perception of fatness. Attempts to correct this flaw through food restriction or progressive purging lead to progressive starvation. Modern preoccupation with slenderness and beauty in the Western world may contribute to the mindset of slenderness as a valued quality in adolescents Associated physical characteristics include excessive physical activity, denial of hunger in the face of starvation, academic success, asexual behavior, and a history of extreme weight loss methods (eg, diuretics, laxatives, amphetamines, emetics). Psychiatric characteristics include excessive dependency needs, developmental immaturity, behavior favoring isolation, obsessive-compulsive behavior, and constriction of affect.

27. ANOREXIA NERVOUSA Diagnostic criteria include: - adapted DSMV-IV - an intense fear of obesity despite slenderness - an overwhelming body-image perception of being fat - refusal to maintain a weight at or above minimally normal for age and height e.g weight loss leading to a body weight less than 85% of expected

28. ANOREXIA NERVOUSA Diagnostic criteria include: - adapted DSMV-IV - failure to gain weight appropriately leading to a weight < 85% less than would be expected - absence of other physical illnesses to explain the weight loss or altered body-image perception - at least 3 months of secondary amenorrhea or primary amenorrhea in a prepubescent adolescent

29. ANOREXIA NERVOUSA Malnutrition from self-starvation causes: - protein deficiency - disruption of multiple organ systems - hypoglycemia - severe loss of fat stores - multiple vitamin deficiencies . .

30. ANOREXIA NERVOUSA CVS abnormalities Renal GIT Bone marrow suppression Delayed puberty, amenorrhea, anovulation, low estrogen states Increased growth hormone Cardiovascular effects include: supraventricular and ventricular dysrhythmias, long QT syndrome, bradycardia, orthostatic hypotension, and shock due to congestive heart failure Renal disturbances include decreased glomerular filtration rate (GFR), elevated BUN, edema, acidosis with dehydration, hypokalemia, hypochloremic alkalosis with vomiting, and hyperaldosteronism Gastrointestinal findings include constipation, delayed gastric emptying, gastric dilation and rupture, dental enamel erosion, palatal trauma, enlarged parotids, esophagitis, Mallory Weiss lesions, diminished gag reflex, and elevated transaminases Bone marrow suppression may occur, leading to platelet, erythrocyte, and leukocyte abnormalities Cardiovascular effects include: supraventricular and ventricular dysrhythmias, long QT syndrome, bradycardia, orthostatic hypotension, and shock due to congestive heart failure Renal disturbances include decreased glomerular filtration rate (GFR), elevated BUN, edema, acidosis with dehydration, hypokalemia, hypochloremic alkalosis with vomiting, and hyperaldosteronism Gastrointestinal findings include constipation, delayed gastric emptying, gastric dilation and rupture, dental enamel erosion, palatal trauma, enlarged parotids, esophagitis, Mallory Weiss lesions, diminished gag reflex, and elevated transaminases Bone marrow suppression may occur, leading to platelet, erythrocyte, and leukocyte abnormalities

31. ANOREXIA NERVOUSA Euthyroid sick syndrome Decreased antidiuretic hormone, hypercarotenemia, Neuropathy, myopathy, encephalopathy, hypothermia Decreased gonadotropin levels and hypogonadism may occur among males

32. ANOREXIA NERVOUSA Patients may present to the ED with extreme weight loss, food refusal, dehydration, weakness, or shock Emotional affect may be flat or nearly catatonic Patients may be depressed and should be questioned to gauge risk of suicide Obtain a mental history because there is a strong association with depression and substance abuse Often, the family will bring in the patient because many patients may refuse to seek help or may have no insight into their problem Recurrent patients may recognize their problem and present spontaneously for therapyOften, the family will bring in the patient because many patients may refuse to seek help or may have no insight into their problem Recurrent patients may recognize their problem and present spontaneously for therapy

33. ANOREXIA NERVOUSA Physical examination may reveal: - hypothermia - peripheral edema - thinning hair - obvious emaciation Behaviorally: - often have a flat affect - display psychomotor retardation

34. BULIMIA NERVOUSA Criteria For Diagnosis - adapted DSMV-IV - recurrent episodes of binge eating characterized by eating abnormal amounts of food in a short period e.g. within 2 hours and feeling a lack of control over eating during the episode - recurrent compensatory behaviors to prevent weight gain e.g. self induced vomiting, abuse of laxatives, diuretics, fasting or excessive exercise

35. BULIMIA NERVOUSA Criteria ( cont�d) - binge eating and compensatory behaviors occur on average at least twice a week for 3 months - self image unduly influenced by body shape and weight - episodes are not occurring during episodes of anorexia nervousa

36. BULIMIA NERVOUSA Purging type - During episode regularly engaging in self induced vomiting, use of laxatives,enemas, diuretics Non-purging type - During episodes uses fasting or exercising but no purging behaviors as above

37. BULIMIA NERVOUSA Clinical features - psychological - Good peer relationships - High energy, talkative - Increased anxiety andafective disorders - Low self esteem

38. BULIMIA NERVOUSA Clinical feature - Behavioral - Self induced purging behaviors - Substance abuse - Secretive overeating - More likely sexually active - More likely to be distressed over symptoms

39. BULIMIA NERVOUSA Clinical feature - Physical - Dental decay, eroded enamel on posterior aspect of upper incisors - Parotid enlargement - Subconjunctival hemorrhages - Edema - Calluses on knuckles

40. BULIMIA NERVOUSA Clinical features - GI - Mallory- Weiss ears - Acute gastric dilatation - Esophagitis Clinical features - CVS - ECG shows prolonged QT - Cardiac toxicity ralted to ipecac use for purging -

41. BULIMIA NERVOUSA Clinical features - Metabolic - hypokalemia, hypochloremia, hyponotremia - increased amylase - metabolic akalosis Menstrual irregularities

42. EATING DISORDERS Lab Work CBC, diff RFT�s, electrolytes LFT�s, INR, TSH,T4 Total/fractionated serum proteins Calcium A complete blood count may reveal a normocytic normochromic anemia due to bone marrow suppression of starvation as well as a mild leukopenia. A chemistry panel may demonstrate a severe hypokalemia due to laxative abuse or due to alkalemia from vomiting. In addition, dehydration may result in significant electrolyte abnormalities including abnormal sodium and chloride levels. Hypocalcemia may result from a dietary deficiency or from associated protein deficiency. Ionized calcium is the best measure of calcium concentration in the body. A complete blood count may reveal a normocytic normochromic anemia due to bone marrow suppression of starvation as well as a mild leukopenia. A chemistry panel may demonstrate a severe hypokalemia due to laxative abuse or due to alkalemia from vomiting. In addition, dehydration may result in significant electrolyte abnormalities including abnormal sodium and chloride levels. Hypocalcemia may result from a dietary deficiency or from associated protein deficiency. Ionized calcium is the best measure of calcium concentration in the body.

43. EATING DISORDERS INR - clotting studies BhCG Urinalysis EKG Beta-human chorionic gonadotropin (HCG) assay assists in determining pregnancy as a cause of vomiting and electrolyte abnormalities. Possible ECG changes include nonspecific ST- and T-segment abnormalities, atrial tachycardia, idioventricular conduction delay, heart block, nodal rhythms, ventricular escape, premature ventricular contractions, and a prolonged QTC interval. The basis for these abnormalities is attributable to starvation, ipecac toxicity, and electrolyte and neuroendocrine abnormalities. Total and fractionated serum protein, liver function studies, and clotting studies may quantify the degree of starvation and protein malnutrition. Urinalysis may rule out urinary tract infections, dehydration, or renal acidosis abnormalities. Beta-human chorionic gonadotropin (HCG) assay assists in determining pregnancy as a cause of vomiting and electrolyte abnormalities. Possible ECG changes include nonspecific ST- and T-segment abnormalities, atrial tachycardia, idioventricular conduction delay, heart block, nodal rhythms, ventricular escape, premature ventricular contractions, and a prolonged QTC interval. The basis for these abnormalities is attributable to starvation, ipecac toxicity, and electrolyte and neuroendocrine abnormalities. Total and fractionated serum protein, liver function studies, and clotting studies may quantify the degree of starvation and protein malnutrition. Urinalysis may rule out urinary tract infections, dehydration, or renal acidosis abnormalities.

44. EATING DISORDERS Emergency Department Care includes: - Stabilization for any life-threatening conditions (eg, shock, cardiac arrhythmias) - Rehydration, correction of electrolyte abnormalities (eg, hypokalemia) - Protection if risk of suicide is present - Consults with psychiatry and adolescent medicine specialists in order to optimize inpatient care and facilitate outpatient follow-up care

45. EATING DISORDERS Criteria For Hospitalization hypothermia < 36 degrees C arrhythmia dehydration postural hypotension hart rate > 35 beats over baseline metabolic abnormality e.g hypokalemia absolute weight < 75% ideal body weight

46. OBESITY Review In E.O. Endocrine /metabolic Obesity is reaching endemic proportions in NA children

47. ACNE Review in E.O. 021 - Dermatology

48. SUBSTANCE USE Experimental use - common to all youth - Infrequent , episodic use of various substances during contact with peers that does not interfere with activities at home, school or at work Substance abuse - habitual/ compulsive use - Use involves most if not all areas of life, psychologically socially, physiologically addicted :life revolves around obtaining and use of substance. Use becomes it�s own reward . Interferes with normal life activities

49. SUBSTANCE ABUSE Risk For Substance And Alcohol Abuse - Family history of alcohol or substance abuse on either side of the family - Use of alcohol, marijuana or cocaine in early adolescence - Use of cross-dependent drugs, such as marijuana, sedatives, tranquilizers - Drug use within peer group Drug abuse is widespread in North American society. The use of so-called gateway drugs, such as alcohol, tobacco and marijuana, usually begins in adolescence, and today's adolescents experiment at earlier ages than adolescents of previous generations. Nicotine is the most commonly abused drug, followed by alcohol, marijuana and then stimulants such as amphetamines and cocaine. In Aboriginal communities, gas and solvent sniffing also constitute a significant hazard. Ecstasy (a drug used at raves) is a new drug of abuse. Generally, adolescent boys abuse all forms of drugs and alcohol to a greater extent than do adolescent girls. Drug abuse is widespread in North American society. The use of so-called gateway drugs, such as alcohol, tobacco and marijuana, usually begins in adolescence, and today's adolescents experiment at earlier ages than adolescents of previous generations. Nicotine is the most commonly abused drug, followed by alcohol, marijuana and then stimulants such as amphetamines and cocaine. In Aboriginal communities, gas and solvent sniffing also constitute a significant hazard. Ecstasy (a drug used at raves) is a new drug of abuse. Generally, adolescent boys abuse all forms of drugs and alcohol to a greater extent than do adolescent girls.

50. SUBSTANCE ABUSE Risk For Substance And Alcohol Abuse - Adolescents with attention deficit hyperactivity disorder, learning disability or depression - Adolescents who are suicidal - Family dysfunction: divorce, alcohol or drug abuse, child abuse, inconsistent or impulsive stealing - Adolescents with school problems (e.g., absenteeism) or problems with the law

51. INTERVENTIONS IN SUBSTANCE ABUSE Prevention Treatment Healthcare professionals need to promote awareness about the health hazards of substance abuse to children, adolescents, parents and caregivers, teachers, vendors of volatile substances and community leaders Education is considered the most effective prevention strategy, particularly if it is initiated before the usual age of experimentation. Adolescents with significant alcohol, solvent or other drug problems should be referred to the most appropriate social services Provincial alcoholism foundations also sponsor treatment programs specifically aimed at teenagers Healthcare professionals need to promote awareness about the health hazards of substance abuse to children, adolescents, parents and caregivers, teachers, vendors of volatile substances and community leaders Education is considered the most effective prevention strategy, particularly if it is initiated before the usual age of experimentation. Adolescents with significant alcohol, solvent or other drug problems should be referred to the most appropriate social services Provincial alcoholism foundations also sponsor treatment programs specifically aimed at teenagers

52. DEPRESSION Mild depression occurs in up to 10% of high school students, moderate depression in 5 to 6%, and major depression in 1 to 2% More than half of adolescent suicidal behaviors stem from depression The range of symptoms is very similar to that in adults, but signs of depression are modified by circumstances in the adolescent's life DEPRESSION IN ADOLESCENTS Diagnostic frequency rises when a standard depression inventory is used, and adolescents rarely object to such questionnaires. There is a significant genetic contribution to adolescent depression, and the younger a parent's depression began, the earlier it is likely to do so in the adolescent. For example, substance abuse is often self-medication for depression. Younger adolescents may be less able to explain inner feelings or moods for developmental reasons, whereas mid- and older adolescents may believe that to do so is weak. Depression in adolescence is overlooked at least as often as in other age groups. DEPRESSION IN ADOLESCENTS Diagnostic frequency rises when a standard depression inventory is used, and adolescents rarely object to such questionnaires. There is a significant genetic contribution to adolescent depression, and the younger a parent's depression began, the earlier it is likely to do so in the adolescent. For example, substance abuse is often self-medication for depression. Younger adolescents may be less able to explain inner feelings or moods for developmental reasons, whereas mid- and older adolescents may believe that to do so is weak. Depression in adolescence is overlooked at least as often as in other age groups.

53. DEPRESSION Depression should be considered when a previously well-performing youth does poorly in school, withdraws from society, or commits delinquent acts Diagnostic categories and treatment of adolescent depression are similar to those of adult depression

54. SUICIDE Suicide has increased among children, at least among boys, and particularly among adolescents 2nd only to accidents as the leading cause of death In the 15- to 24-yr age group, male suicide has increased 50% since 1970; female suicide, only slightly The suicide rate for children between ages 5 and 14 continues to be much lower but represents minimum incidence figures because official designation of a death as suicide generally requires proof of intent. Thus, many deaths attributed to accidents (eg, motor vehicle and firearms) may be suicides. The suicide rate for children between ages 5 and 14 continues to be much lower but represents minimum incidence figures because official designation of a death as suicide generally requires proof of intent. Thus, many deaths attributed to accidents (eg, motor vehicle and firearms) may be suicides.

55. SUICIDE For people 15 to 24 yr , the 1990s suicide rate has averaged about 12/100,000 Male:female ratio of 4:1 The suicide rate for children between ages 5 and 14 continues to be much lower

56. SUICIDE Predisposing factors include: - A history of suicide in family members or close friends, - A recent death in the family, - Substance abuse, and conduct disorders Precipitating factors often involve: - Loss of self-esteem (eg, resulting from family arguments, a humiliating disciplinary episode, pregnancy, or school failure); - Loss of a boyfriend or girlfriend; - Loss of familiar surroundings (school, neighborhood, friends) due to a geographic move

57. SUICIDE Other factors may be: - A lack of structure and boundaries, leading to an overwhelming feeling of lack of direction - Intense parental pressure to succeed accompanied by the feeling of falling short of expectations - A frequent motive for a suicide attempt is the effort to manipulate or punish others with the fantasy "You'll be sorry after I'm dead." A rise in suicides is seen after a well-publicized suicide (eg, of a rock star) and among self-identified populations (eg, a high school, a college dormitory), indicating the importance of suggestion. Early community intervention to support youths in such circumstances can be helpful. A rise in suicides is seen after a well-publicized suicide (eg, of a rock star) and among self-identified populations (eg, a high school, a college dormitory), indicating the importance of suggestion. Early community intervention to support youths in such circumstances can be helpful.

58. VIOLENCE Increasing in prevalence in adolescents A major heath risk Unintentional accidents are leading cause of death followed by suicide and homicide Prevention of violence and destructive adolescent behavior is an important health and social goal Identifying personal and social antecedents to violent behavior is an important step in prevention

59. VIOLENCE High risk adolescents - history of being abused - depression - attention deficit /hyperactivity disorder - substance abuse - hx. of impulse control problems - hx. Of risk taking behaviors - dysfunctional family- hx. family violence - living in dysfunctional community community

60. VIOLENCE Prevention must take on a personal and community and societal approach Positive youth development - When a community encourages young people: to have a sense of personal meaning , to value others, to have a perception of being connected to and being an important member of a community, the adolescents from that community seem to be more resistant to numerous problem behaviors including violence

61. ANTCIPATORY GUIDANCE Counseling and Health promotion topics - Dietary-Canada�s food guide, low fat, high fiber - Physical activity - Healthy weights - Contraception - Healthy sexuality/safe sex - Healthy relationships - Substance use/abuse - tobacco/illicit drugs - Safety- no drink/drive,no drink/dive, helmet/seat belts use

62. LEGAL ISSUES Age of consent Confidentiality Chaperones

63. RESOURCES FOR MENTALHEALTH ISSUES Discussion on available resources