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Table of Contents
CONTINUING EDUCATION SERIES NO: 41
Year : 2021  |  Volume : 22  |  Issue : 2  |  Page : 148-163

Adolescence: An overview of health problems


1 Assistant Professor, Department of Pediatric Nursing, College of Nursing, Christian Medical College, Vellore, Tamil Nadu, India
2 Professor & Head, Department of Pediatric Nursing, College of Nursing, Christian Medical College, Vellore, Tamil Nadu, India

Date of Submission19-Nov-2021
Date of Decision15-Dec-2021
Date of Acceptance21-Dec-2021
Date of Web Publication31-Jan-2022

Correspondence Address:
Ms. Esther Kanthi
Department of Paediatric Nursing, College of Nursing, Christian Medical College, Vellore - 632 002, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijcn.ijcn_110_21

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  Abstract 


Adolescents are individuals in the age group of 10–19 years. There are about 1.2 billion adolescents worldwide of which 356 million live in India. Adolescence is a period of transition from childhood to adulthood and involves development and growth in multiple organ systems. MRI studies have revealed that the prefrontal cortex that is responsible for reasoning, regions that process motivation and support higher levels of integration is still maturing during adolescence, and the regions that support emotional and social processing continue to develop even beyond 30 years of age. It is also a time when behaviours that affect present and future health begin. This article reviews the major adolescent physical health problems such as obesity, nutritional deficiencies, pubertal disorders, teen pregnancy, sexual abuse and road traffic accidents and highlights the nursing care of these health problems.

Keywords: Adolescent, nutritional deficiencies, obesity, puberty, sexual abuse and road traffic accidents, Tanner staging, teen pregnancy


How to cite this article:
Kanthi E, Johnson MA. Adolescence: An overview of health problems. Indian J Cont Nsg Edn 2021;22:148-63

How to cite this URL:
Kanthi E, Johnson MA. Adolescence: An overview of health problems. Indian J Cont Nsg Edn [serial online] 2021 [cited 2022 May 28];22:148-63. Available from: https://www.ijcne.org/text.asp?2021/22/2/148/336893




  Introduction Top


Adolescence is the transitioning period from childhood to adulthood wherein physical and psychological changes occur. Along with these, the expectations and perception of the society also change enormously towards the adolescent. Sexual maturation as a result of physical growth and development results in adolescents developing intimate relationships. Apart from physical and sexual maturation, thinking also matures from abstract to concrete along with self-awareness of societal expectations requiring emotional maturity.


  Adolescence Top


The World Health Organization (WHO) defines 'adolescents' as individuals in the 10–19 year age group and “youth” as the 15–24 year age group. These two overlapping age groups are combined in the group “young people,” covering the age range 10–24 years.[1]

WHO clearly states that adolescence is considered as a 'phase' and not as a fixed time period as each individual go through this phase at different age in years. This phase involves physical development from puberty to sexual and reproductive maturity; psychological development resulting in identity, and economic status of dependence to independence. The adolescents are a heterogeneous group as their needs differ based on their sex, developmental stage, circumstances and their environment.

According to the WHO, there are about 1.2 billion adolescents in the world comprising 1/6th of total world population, of which 85% are in developed countries.[2] The United Nations International Children's Emergency Fund (UNICEF) estimates that the largest adolescent and youth population of the world of about 253 million of 10–19 year olds and 356 million youths live in India.[3] The United Nations Population Fund predicted that this trend would continue at least till 2030.[4]


  Adolescent Growth and Development Top


Growth and development are predominant during the adolescence. There is development in size and strength of the body along with the ability to reproduce and to think abstractly. Social development involves shift of focus from family to peers and other adults. It is also a time wherein new knowledge, skills and attitudes are acquired. The time-bound definition of adolescence lasts a decade from 10 to 19 years of age. However, it is imperative to understand that the changes associated may not correspond exactly to the precise age. The onset and duration of these changes differ among individuals. Furthermore, the perception of each culture regarding this transition period varies based on their social, economic and cultural factors.[5]

Adolescence is divided into early, middle and late periods, which are the 10–15, 14–17 and 16–19 years of age groups, respectively. The classification is based on the changes in physical, social and psychological development resulting in transition from childhood to adulthood. This classification [Table 1] provides a framework but is not widely accepted.[1]
Table 1: Stages of adolescent development

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  Puberty Top


Puberty is the change a child's body undergoes as it develops into an adult's body. It is a time of rapid and complex changes of hormonal, physical and cognitive components. Puberty begins in girls with enlargement of the mammary glands and in boys with an increase of testicular volume. While every child will grow and develop at a different rate, the normal onset of puberty is between the ages of 8 and 13 for girls and between 9 and 14 years for boys.[6] Marshall and Tanner developed scales according to the development of external genitalia in males, breast changes in females and pubic hair growth in both, so as to make these complex changes trackable and documentable.[7] This scale is known as tanner staging or sexual maturity rating (SMR) which is described in [Figure 1] and [Table 2].[8],[9],[10]
Figure 1: Tanner staging for girls by Rosenfield RL, Cooke DW, Radovicks[9]

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Table 2: Sexual maturity rating (tanner staging) in adolescents by World Health Organization

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  Adolescent Brain Top


The ever-evolving scientific knowledge regarding the growth of human brain has identified that the adolescent brain is 'a work in progress'. The brain growth during adolescence gives second chance for those whose brain did not grow well during early childhood. One of the progressing noninvasive methods to study human brain is magnetic resonance imaging (MRI); wherein, structural MRI (sMRI) measures the brain structure involving grey and white matter functional MRI (fMRI) of brain measure the function. The recent advance in fMRI is resting-state fMRI which measures the networking of human brain at rest as reported by UNICEF.[11]

sMRI studies have identified that during adolescence, much of grey matter reach maturity, while regions that process complex information are progressing towards maturity. They include the prefrontal cortex that is responsible for reasoning, regions that process motivation and support higher levels of integration. These changes were evident in the thinning of the gray matter thought to reflect the known loss of neuronal connections or synaptic pruning. Most of the white matter connectivity develops in childhood. Yet, during adolescence, there is an adaptive process that aids in optimal survival according to the demands of the environment resulting in the development of reasoning to adult level. However, the regions that support emotional and social processing continue to develop even beyond 30 years of age.[12],[13],[14],[15],[16]

fMRIs help in understanding how the brain operates during reasoning and motivation. Though such development begins during childhood, they are strengthened and made reliable during adolescence. This development that supports the ability to generate behaviour in a voluntary manner for a planned goal is known as cognitive control/executive function. fMRIs reveal that cognitive control predominantly controlled by prefrontal cortex is varied according to age and task. Cognitive control includes the ability to stop an impulsive behaviour, guide behaviour by retaining and processing information, easily switch between cognitive processes according to demands of task changes, follow rules and execute optimal reasoning. Executive control by brain systems including engagement of prefrontal cortex is developed by adolescence. The network with other brain regions which is critical to control behaviour continues to be strengthened. There is also evidence of probable hypersensitivity in regions that support motivation with an opportunity to gain reward immediately during adolescence.[17],[18],[19],[20],[21],[22],[23],[24],[25]

The interesting fact of adolescent brain development is 'Driven dual systems' where a critical level of cognitive control is reached by adolescence. However, it is influenced by increased drive for rewards, that is, though adolescents are able to reason like adults, they do not apply the reasoning in all of their tasks. Their tasks are affected by their motivation through reward.[11]


  Physical Problems during Adolescence Top


Adolescence is relatively a healthy time of life. It is also a time when behaviours that affect present and future health begin. WHO reports that yearly, many adolescents are lost to unintentional injuries due to accidents, intentional injuries like suicide and violence, and teenage pregnancies.[26] In 2015, WHO reported that the mortality of adolescents worldwide was more than 1000/day amounting to 1.2 million/year which was largely preventable. Of which, >2/3rd occurred in Africa and South-East Asia. [Table 3] describes the age-specific global adolescent mortality rates.[27]
Table 3: Global adolescent mortality rates

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In view of the higher mortality rates but yet preventable deaths selected physical issues of adolescents that are included by WHO discussed in this article:[2]

  1. Obesity
  2. Nutritional deficiencies
  3. Pubertal disorders
  4. Teen pregnancy
  5. Sexual abuse and
  6. Road traffic accidents (RTAs).


Obesity

The prevalence of overweight and obese adolescents has been increasing worldwide along with metabolic syndrome in children and adolescents.[28]

Definition

The WHO has given the following classification using the Z-scores or percentiles to represent body mass index (BMI) in children that varies with the age and sex of the child.[29]

  • BMI Z-score >1.0 - At risk of overweight
  • BMI Z-score >2.0 - Overweight
  • BMI Z-score >3.0 - Obesity.


In 2001, the National Cholesterol Education Program of the United States of America recognised “Metabolic syndrome” as the presence of at least 3 risk factors involving central obesity, hyperglycaemia, hypertriglyceridemia, hyper high-density lipoprotein or hypertension.[30]
Figure 2: Tanner staging for boys by Rosen DS

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Epidemiology

It was estimated that 1/6th of 10–19 year old were overweight in 2016. The prevalence of overweight adolescents is 10% in South East Asia and 30% in America. The prevalence of metabolic syndrome and the rates of obesity in children and adolescents is on the increase worldwide.[27]

Aetiology

The major contributor for childhood and adolescence obesity is energy imbalance, where caloric intake is more than caloric expenditure. This is also affected by early childhood factors such as small for gestational age, formula feeding and early protein introduction in diet.[31],[32],[33]

The following factors are associated with overweight or obesity in adolescence:[34]

  • Poor eating habits – overeating and drinking of high-calorie sweetened beverages
  • Lack of exercise
  • Family history of obesity
  • Medical illnesses – endocrine and neurological problems
  • Medications – steroids and some antipsychotics
  • Stressful life events or changes-separations, divorce, moves, deaths, abuse
  • Family and peer problems
  • Low self-esteem
  • Depression or other emotional problems.


Diagnosis[34]

  • History of prenatal factors, family history of obesity, sleep duration and issues, exercise and screen time
  • Nutritional screening including basic dietary pattern, including frequency of meals and variety of foods consumed; beverage consumption, particularly sweetened or caffeinated beverages and alcohol
  • Detailed assessment of food portion sizes, weight control behaviours and/or binge eating, body image and influence of peers and media on diet, family meal routines, food preparation methods, grocery shopping routines and effects of culture and religion on nutrition
  • Measurement of height, weight and BMI. Physical examination for the presence of acanthosis nigricans, abdominal obesity, premature thelarche in females or gynecomastia in males, high blood pressure and increased body weight
  • Blood investigations – Insulin assay and lipid profile.[10]


Management

The treatment of obesity in adolescents requires a multidisciplinary approach which should comprise of a paediatric physician, nurse, dietician, physical instructor, behavioural therapist and a social worker along with a motivated team of parents, caretakers, teachers and policy makers.[35]

  • Dietary management: It aims at weight maintenance or weight loss without compromising appropriate calorie intake and normal nutrition. Standard protocol recommends a reduction of fat intake to 25%–35% of kcal, carbohydrate intake of 45%–65% of kcal and protein intake of 10%–30% kcal. Eating all food groups in appropriate proportions as mentioned in [Figure 3] is emphasised by U.S Department of Agriculture.[36]
  • Physical activity: Adolescents should engage in 60–120 min of moderate to vigorous physical activity per day. Moderate intensity exercises performed for longer periods like brisk walking burn more fat as calories and are excellent for reducing body fat.
  • Restriction of sedentary behaviour like watching TV, sitting in front of computers and video games to <1 h.
  • Pharmacotherapy


    • Sibutramine-serotonin non-adrenaline reuptake inhibitor enhances satiety and has been shown to be the most effective drug in treating adolescent obesity
    • Orlistat-pancreatic lipase inhibitor acts by increasing faecal fat loss
    • Metformin is valuable in the treatment of adolescents with severe insulin resistance, impaired glucose tolerance or polycystic ovarian syndrome.


  • Bariatric surgery: Roux-en-Y gastric bypass and adjustable gastric banding are surgical options for obesity and is advised with caution. Post-operative complications include small-bowel obstruction, incisional hernias and weight regain, as well as vitamin and micronutrient deficiencies.
Figure 3: Recommended Food Plate

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Adolescent candidates for bariatric surgery as recommended by CDC[37] should be:

  • Very severely obese-BMI of >40 kg/m2
  • Attained a majority of skeletal maturity->13 years old girls and >15 years old boys
  • Have co-morbidities related to obesity that might be remedied with durable weight loss.


Complications related to obesity include

  • Metabolic syndrome
  • Type 2 diabetes mellitus
  • Prediabetes
  • Cardiovascular disease
  • Hypertension
  • Nonalcoholic fatty liver disease
  • Obstructive sleep apnoea
  • Obesity hyperventilation syndrome
  • Dyslipidaemia
  • Polycystic ovary syndrome
  • Abnormal uterine bleeding
  • Breathing disorders
  • Chronic obstructive pulmonary disease
  • Depression
  • Gastroesophageal reflux disease
  • Stroke
  • Joint diseases such as osteoarthritis, pain in knees and lower back.[37],[38]


Adolescent can also develop eating disorders like

  • Bulimia nervosa – binge eating followed by purging.


  • Binge eating disorder – eating a lot of food in a short amount of time, even when not hungry
  • Night eating syndrome-overeating at night
  • Anorexia nervosa-fear of weight gain leading to faulty eating patterns, malnutrition and excessive weight loss.[28],[31],[33]


Prevention

Overweight and obesity can be prevented by reducing the foods high in saturated fats, trans-fatty acids, free sugars or salt and providing access to healthy foods.[27] A handout on healthy food choices can be provided to the adolescents to remind them about the best choices of food. Second, 60-120 min of moderate to vigorous-intensity physical activity which may include play, games, sports, cycling and walking should be introduced as a daily routine.

Nursing care

  • Identify adolescents who are obese or at risk for obesity and collect a detailed history
  • Assess the anthropometry, vital signs, dietary pattern, basic blood investigations, physical activity pattern and body image perception of the adolescent
  • Teach about the ideal weight
  • Educate adolescent and the parents about intake of a well-balanced diet
  • Coordinate the care with all the team members including paediatric physician, dietician, physical instructor, behavioural therapist and a social worker
  • Teach parents and the adolescent to foster healthy eating behaviours and lifestyle modification
  • Monitor the weight loss at regular intervals
  • Encourage and positively motivate the adolescent to reach the ideal body weight.


Nutritional deficiencies

Adolescence is a period of rapid physical growth when about 40% of their adult weight and 15% of height is attained. Poor dietary intake can result in delayed sexual development and slow linear growth. It is also a period of nutritional vulnerability where the nutrition and hormone levels determine pubertal development, associated linear growth and neurodevelopmental changes.[39]

Epidemiology

Many adolescents in developing countries are vulnerable to disease and premature death due to undernutrition. With regards to years lost to disability among adolescents, iron deficiency anaemia is among the top 5 causes and is prevalent nearly 1 in every 2 adolescents[27]and vitamin A deficiency-related disability-adjusted life years is higher in adolescent males from middle to lower socio-demographic index countries.[40]

Factors influencing nutrition intake

Peer influences, parental modelling, food availability, food preferences, food cost, convenience of food that is available, personal beliefs, cultural practices, advertisements and information from social and mass media, body image concerns and peer pressure are some factors that influence the dietary patterns and food choices in adolescents.[41]

Recommended daily allowance

Energy and nutrition requirements must match the needs of the adolescents as they typically engage in physical work or recreational exercise which benefits striated muscle mass enlargement. The following is the revised recommended dietary allowance for Indian adolescents given by the National Institute of Nutrition and The Indian Council of Medical Research in 2020.[42],[43]

  • Energy - 2220-3320kcal/day
  • Fat - 35-50 g/day
  • Proteins - 26.2-45.1 g/day
  • Carbohydrates - 100 g/day
  • Calcium - 650-850 mg/day
  • Magnesium - 214-338 mg/day
  • Iron - 12-18 mg/day
  • Zinc - 7-14.7 mg/day
  • Iodine - 100 mcg/day
  • Folate - 180-286 mcg/day
  • Vitamin B12-2 mcg/day
  • Vitamin D - 400 IU/day.


Diagnosis

  • Nutritional screening including basic dietary pattern, including frequency of meals and variety of foods consumed
  • Laboratory investigations to diagnose anaemia, micronutrient deficiency, decreased bone density, delayed bone age and serum levels of various minerals and vitamins
  • DEXA scan and X-ray to identify decreased bone density and delayed bone age
  • Investigations to rule out possible organic causes such as inflammatory conditions, malabsorption and malignancy.[44]


Prevention and management

The management involves dietary counselling about healthy eating, regardless of weight status. A detailed assessment for nutritional status and deficiencies is mandatory for any adolescent on the first visit to the clinic or in community.

In actual or potential risk for deficiencies are identified micronutrient supplementation of iron, folic acid, calcium, zinc, Vitamin A, Vitamin D and multivitamin need to be initiated.[35] Constant follow-up and assessment are essential for reassessment and further management. [Table 4] highlights the Common nutritional deficiencies, their clinical manifestations and deficiency diseases among adolescents.
Table 4: Common nutritional deficiencies, their clinical manifestations and deficiency diseases seen among adolescents

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Interventions such as periodic deworming, ensuring intake of iodized salt, exposure to sunlight and educating on well-balanced diet will help preventing nutritional deficiencies in this group.[27]

Nursing care

  • Assess the adolescent for signs of nutritional deficiency
  • Provide dietary counselling about intake of all types of foods
  • Administer and encourage regular intake of the supplements that are recommended.


Pubertal disorders

Definition

Pubertal disorders occur when the pubertal processes and changes do not occur as they normally should in a child.[45]

Epidemiology

Globally, the prevalence of precocious puberty is estimated at 1:5000–1:10,000. It is five to ten times more common in girls than in boys.[46] Gynecomastia of varying extent is seen in 50%–90% of boys. Delayed puberty is found in 5% of the population.[47]

Aetiology

  • Heredity
  • Hormonal disorders including polycystic ovary syndrome, growth hormone and thyroid hormone disorders
  • Genetic disorders
  • Disorders of the pituitary or thyroid glands
  • Chromosome disorders
  • Eating disorders
  • Excessive physical activity levels
  • Tumours
  • Infections
  • Chemotherapy
  • Other underlying medical conditions such as severe persistent asthma, sickle cell anaemia, cystic fibrosis, or ulcerative colitis.[46],[48]


Types of puberty disorders

[Table 2] explains about the pubertal disorders

  • Delayed puberty in girls is the absence of breast development by 13 years of age and in boys is the absence of testicular growth to at least 4 mL in volume or 2.5 cm in length by 14 years of age
  • Precocious puberty is the pubertal onset before age 8 in girls and before age 9 in boys
  • Contrasexual pubertal development is the development of male characteristics in females
  • Premature thelarche is isolated breast development without any other signs of puberty in girls
  • Premature menarche is when the periods start without any other signs of puberty
  • Premature adrenarche is the slow, progressive appearance of pubic and axillary hair, body odour, sweating and/or mild acne without any other signs of puberty such as change in linear growth velocity or enlargement of the testes, penis, breasts, ovaries, or clitoris
  • Gynecomastia or oestrogen-mediated glandular breast tissue is common in pubertal boys where there is the development of breast.


Red flags

  • Lack of breast development by age 13
  • Lack of pubic hair by age 14
  • More than 5 years between breast development and first period
  • The period has not started by age 16
  • Breast growth, period, pubic hair and other signs of puberty occur before age 7 or 8.


Diagnosis

  • Medical history including signs of puberty in the child and the mother's age at puberty
  • Physical examination, including use of tanner staging, pelvic and breast examinations when necessary
  • X-ray of the hand/wrist to determine bone age
  • Blood hormone levels of follicle-stimulating hormone, luteinising hormone, testosterone (boys) or estradiol (girls), thyroid function test including free T4 and thyroid-stimulating hormone and gonadotropin-releasing hormone (GnRH) stimulation test
  • Rule out chromosomal abnormalities such as Klinefelter syndrome, Ullrich-Turner syndrome
  • Brain MRI or computed tomography (CT) scan to rule out abnormalities in the brain or pituitary gland such as craniopharyngioma, germinoma, Langerhans cell histiocytosis, prolactinoma, adenoma, hypothalamic hamartoma
  • Abdominal-Pelvic Ultrasound to examine the health of the ovaries and adrenal glands
  • Ultrasound of the testicles to investigate cryptorchidism or a mass.[45],[46]


Management

The treatment will depend on the individual adolescent, the symptoms and the underlying cause of the puberty disorder. Some pubertal issues like late-onset may resolve on its own and for such issues observation and regular checkup is needed.[49] A GnRH may be administered for central precocious puberty.[50] Surgery may be an option to correct anatomical defects. Consistent support and counselling are needed and to be provided for adolescents and their families as emotional and social challenges are highly associated with puberty-related defects and issues.[48]

Late bloomers

Some adolescents start puberty later than most children their age but they catch up with the others. This delay is not caused due to any medical condition and they do not require any treatment.

Complications

Precocious puberty– short height

  • Other psychological effects-depression, low self-esteem, poor school performance, reduced peer contact, aggression, emotional, social, or academic stress and general social immaturity.[48]


Nursing care

  • Collect detailed history
  • Perform physical examination including Tanner staging of the adolescent
  • Provide relevant pre- and post-operative nursing care for adolescents undergoing surgical correction
  • Administer the hormone supplements and teach parents about continuation as per physician's order
  • Assist in investigating the possible causes for pubertal disorder
  • Teach the adolescent and the family to watch for the red flags of pubertal disorders
  • Explain to the adolescent and parents the condition, treatment, prognosis and the need for follow-up in simple language and clarify their doubts.


Teen pregnancy

Definition

Teen or adolescent pregnancy is defined as a pregnancy in girls between 10 and 19 years of age.[51]

Epidemiology

An adolescent pregnancy is a global problem and is found in all countries. Globally, death due to complications during pregnancy and childbirth is the leading cause of death among 15–19-year-old girls, and in 2015, pregnancy-related deaths among 10–19 years old was 28,886, as reported by the WHO.[52] In developing countries, every year about 777,000 below 15 and 12 million 15–19-year-old girls give birth.[27]

Risk factors

Many social, personal, environmental and cultural risk factors can be attributed to teen pregnancy:[53],[54]

  • Poor literacy
  • Lack of knowledge about sex and contraception
  • Child labour
  • Drug and alcohol use
  • Peer pressure to have sex
  • Friends who are sexually active
  • Dating at an early age
  • Family history of teenage pregnancy
  • Poor parental supervision
  • Poor parent–child relationship and communication
  • Single-parent families
  • Societal pressure to marry and bear children at an early age
  • Marginalised communities
  • Poverty
  • Victim of child sexual abuse (CSA).


Diagnosis

Complete history collection including sexual activity, CSA and for those adolescents presenting with complaints of amenorrhea, irregular periods, nausea, vomiting, weight loss or gain or urinary problems;

  • Physical examination including abdominal palpation, breast and perineal examination
  • Presence of human chorionic gonadotropin in blood and urine
  • Blood investigations such as complete blood count and blood-borne viruses screening
  • Ultrasound to confirm the presence of yolk sac or the foetus.[51]


Prevention and management

Teen pregnancies can be avoided or prevented if a curriculum-based comprehensive education on cognitive, emotional, physical and social aspects of sexuality is provided and is accessible for all teens. Sexual abstinence is the best preventive method and teens should be encouraged to follow this behaviour. Information on contraception also should be available for teens. Awareness on the harsh realities of pregnancy, child-rearing during teenage on the mother and the baby needs to be created among adolescents. Abortion when pregnancy occurs is an option that is highly situational. Laws for minimum marriageable age must be enforced, in India, the minimum age for marriage is 21.[51]

Effective multidisciplinary approach involving clinical midwives specialised in teenage pregnancy along with obstetricians, general practitioners, public health nurses, lactation consultants, support groups for teenage parenting, breastfeeding teenagers, families and foster carers is needed to manage teen pregnancy.

The approach should ensure early identification of pregnancy and initiation of optimal antenatal care, care and support during pregnancy, continuous monitoring of health of teen antenatal and the baby, encouraging good nutrition with appropriate supplements of essential nutrients including folic acid, iron and calcium, discouraging and explaining the risks of smoking, alcohol and drug use during pregnancy, emphasising importance of screening for sexually transmitted infections and treating appropriately. Teen pregnancy counselling on continuation versus termination of pregnancy, parenthood, adoption and fostering must be clear, non-judgmental and inclusive[55],[56] Quality antenatal care must be accessible to pregnant teenagers along with the option for safe abortion if termination is permitted by law and is opted.[27]

Complications as reported by World Health Organization

For the mother:

  • Haemorrhage
  • Sepsis
  • Obstructed labour, and
  • Complications from unsafe abortions.[57]


For the baby:

  • Low birth weight
  • Preterm delivery and
  • Severe neonatal conditions.[52]


Nursing care:

  • Assess the wellbeing and nutritional status of the adolescent
  • Assess the adolescent, monitor the foetal growth and pattern of weight gain of the mother
  • Provide adequate emotional and psychological support to the adolescent and family
  • Teach the adolescent about antenatal nutrition, exercise, immunisation, supplements, regular antenatal checkup, labour and postpartum care
  • Conduct or assist in conduction of labour
  • Teach and demonstrate care of the newborn
  • Talk and council the adolescent in a non-judgmental manner
  • Use simple language while communicating and clarify doubts.


Sexual abuse

CSA is sexually abusive acts towards children which include sexual assault, rape, incest and commercial sexual exploitation.[58] A nationwide survey conducted in 2007 revealed that 53.22% of the children responded by saying that they were subjected to 1 or more forms of sexual abuse, of those abused 57% were boys and adolescents were more affected.[59]

Definition

CDC defines CSA as 'any completed or attempted (non-completed) sexual act, sexual contact with, or exploitation (i.e., noncontact sexual interaction) of a child by a caregiver'.[60]

Sexual activity between a child and someone in relationship with child as a person having responsibility, trust or power over the child with an intention to gratify or satisfy the needs of that person is the evidence of CSA. This also can include coercing the child to take part in unlawful sexual activity or exploiting the child through prostitution, pornographic performances and or materials.[61] Protection of Children from Sexual Offences Act (POSCO) of 2012 makes any sexual activity with a child below 18 years a crime in India.[62]

Epidemiology

In the Global School-based Student Health Survey, 1 in 8 young people reported sexual abuse. However, even larger numbers are underreported. The survey also revealed that 42% of adolescent boys and 37% of adolescent girls were exposed to bullying.[27]

Risk factors

  • Poor family support
  • High poverty
  • Low parental education
  • Absent or single parent
  • Parental substance abuse
  • Domestic violence
  • Low caregiver warmth
  • Children who are impulsive, emotionally needy
  • Children with learning or physical disabilities
  • Children with mental health problems
  • Substance use
  • Out-of-home youth.[63],[64]


Very often, CSA is found with other abuse and neglects.

Diagnosis

Medical history

  • A meticulous history is important than physical findings
  • History of abuse, suspicious injuries, menstrual history and psychosocial background of the family.


Physical examination

  • In girls, general observation and inspection of the anogenital area including mons pubis, labia majora and minora, clitoris, urethral meatus, hymen, posterior fourchette, and fossa navicularis looking for bleeding, discharge, pain, signs of new or past injury, infection and noting the child's emotional status
  • In boys, examination of anal region for fissure, abrasion of penile shaft, tear of frenulum of glans penis, petechiae or marks due to biting or sucking
  • Visualisation of the more recessed genital structures, using handheld magnification or colposcopy as necessary
  • Doctors are legally bound to examine and provide treatment to survivors of sexual violence. Prompt reporting, documentation and forensic evidence collection are key in investigation of the crime.


Investigations

  • Gram stain of vaginal or anal discharge
  • Genital, anal and pharyngeal culture for Gonorrhoea
  • Genital and anal culture for Chlamydia.
  • Serology for syphilis
  • Wet preparation of vaginal discharge for Trichomonas vaginalis
  • Culture of lesions for herpes virus
  • Serology for HIV
  • Collection of forensic evidence employing the Rape Kit and Urine toxicology screen (if the abuse or assault was likely to be substance-facilitated) may be required.


Forensic examination

Forensic evidence of assault can include presence of blood, semen, sperm, hair or skin fragments or debris and can help to identify the location of the abuse.[65]

Management

Based on the type and extent of the injury, biopsychosocial approach is required for child and family that has undergone sexual abuse. A multidisciplinary team involving the evaluating physician, a paediatrician or forensic specialist along with child welfare committee, social worker, nursing staff, mental health professionals and the police is needed to resolve immediate effects of issue and for further treatment and management.

When a physician suspects physical abuse, law requires it to be reported to authorities. Medical management may need inpatient or outpatient care followed up with medical, social worker or child protection services to treat or prevent further harm. Inpatient care is provided for medical causes like severe burns or injuries much examination and when is needed. Furthermore, delay in out Patient services, safety concerns also warrant inpatient care.[66]

  • Treatment of STIs, emergency contraception in the likelihood of pregnancy, emotional support, detailed well documented medical records for legal proceedings, referral to mental health specialist, evaluation for posttraumatic stress are interventions that need to be initiated.[62] CSA, whether confirmed or strongly suspected, must be reported to the appropriate authorities
  • Trauma-focused cognitive-behavioural therapy which include psychoeducation, relaxation, affective modulation, cognitive processing, trauma narrative (gradual exposure) and cognitive restructuring of the trauma, in vivo desensitisation, Conjoint parent/child session and teaching safety skills need to planned and processed.[63]


Prevention

  • The parents should know the facts about CSA and take every care to watch over the child and never leave them unsupervised
  • The child aged between 3 and 5 years can be told what is “good” touch or “okay touch” and “bad touch,” and places over the body where nobody except the mother can touch or clean.
  • Older children should be informed about body parts, differences between boys and girls, and issues of privacy
  • School-based bullying should be addressed and prevented in all schools
  • Programmes that develop life and social skills, and community approaches to reduce access to alcohol and firearms should be implemented
  • Effective and empathetic care for adolescent survivors of violence, including ongoing support need to be established[65]
  • 1098 is an emergency telephonic helpline for CHILDLINE, which can link children in situations of abuse and neglect with socio-legal services. It is operational in more than 400 cities and districts across India and has proven to be of great help.[67]


Nursing care

  • Develop a trusting and a caring relationship with the adolescent
  • Assist the multidisciplinary team and the police in collecting the history of abuse
  • Accompany the child during the physical examination
  • Assist in collecting, safe storing and transport of various samples and evidences
  • Ensure safety of the adolescent
  • Provide emotional and psychological support to the adolescent
  • Advocate on the adolescent's behalf
  • Provide appropriate pre- and post-operative care if the adolescent is posted for surgery
  • Help the adolescent and the family in getting connected back to the community.


Road traffic accidents

Definition

A RTA is any injury due to crashes originating from, terminating with or involving a vehicle partially or fully on a public road.[68]

Epidemiology

The WHO reported that the leading cause of death among 10–19 years old is road injuries. In 2019, 115,000 adolescent deaths were due to road injuries.[57] It is mostly reported among 15–19-year-old adolescent boys who are killed in road accidents as pedestrians, cyclists and motorcyclists.[69] India tops the global list of road fatalities with >1.5 lakh every year. Of the total RTA deaths in 2019, 6.6% were <18 years.[68]

Risk factors

According to the WHO, some of the risk factors for RTA include:[65]

  • Over speeding
  • Lack of helmet use
  • Lack of seat-belt and child restraint use
  • Drinking and driving
  • Lack of conspicuity
  • Rapid urbanisation and motorisation
  • Lack of appropriate road engineering
  • Poor awareness levels
  • Non-existent injury prevention programmes, and
  • Poor enforcement of traffic laws has exacerbated the situation.


Type of injury

The nature and severity of injuries that adolescents sustain in RTA are influenced by their age and on what type of road user they are. Head injury is the most common and adolescents also suffer from other injuries involving spinal cord, face, thorax, abdomen and pelvis and extremities as a result of RTA.[66] Increased mortality is associated with severe head injury and haemorrhagic shock.

Diagnosis

  • Detailed history collection of the nature of the accident
  • Complete head to foot physical examination including Glasgow Coma Scale
  • Blood investigations– Haemoglobin, total and differential neutrophil count, platelets count and arterial blood gas
  • X-ray– chest, pelvis, cervical spine and extremities involved
  • CT/MRI scan-brain, chest or other parts involved
  • Ultrasound– abdomen and pelvis.
  • Management
  • Triaging
  • Cardiopulmonary resuscitation
  • Airway and respiratory support– intubation, supplementary oxygen, inserting oropharyngeal airway
  • Cervical spine immobilisation
  • Fluid resuscitation– crystalloids, blood transfusion
  • Needle thoracostomy or intercostal drainage
  • § Injection Tetanus toxoid
  • Analgesics
  • Plaster cast or surgical intervention for fractured bone
  • Closed or open reduction of displaced bones
  • Suturing deep cuts injuries.


Rehabilitation care

Adolescents who sustain severe injuries develop disabilities requiring long-term rehabilitative care at the hospital and home. The care includes,

  • Nasogastric tube feeding
  • Care of tracheostomy
  • Intermittent catheterisation
  • Skin care
  • Physiotherapy
  • Occupational therapy
  • Speech therapy.


Complications

  • Many children and young people who have been involved in road traffic collisions are left with long-term injuries or disabilities. The extent of disability can range from minor or short-term incapacity which may affect day-to-day living or activities, to severe or permanent disabilities
  • Posttraumatic stress disorder is characterised by mood swings, sleeping pattern changes, eating habit changes, negative thinking, hopelessness, unable to concentrate, easily startled, severe anxiety, recklessness.


Prevention

Adolescents need to be taught road safety rules. Law enforcements related to driving should be consistent in the country especially related to license, helmet use, use of mobile devices while driving and drinking and driving. Role modelling of good driving behaviours by parents and other significant adults in the family is a vital factor in influencing good road behavior.[23],[67],[70]

Nursing care

  • Triage the injured adolescent
  • Perform or assist in cardiopulmonary resuscitation
  • Assist in intubation, airway and respiratory management
  • Monitor the vital signs, and respiratory status
  • Immobilise the cervical spine with cervical collar until cervical spine injury is cleared
  • Administer fluid resuscitation such as crystalloids and blood transfusion as per order
  • Assist in needle thoracostomy or intercostal drainage when tension pneumothorax is suspected
  • Assist in various investigations and procedures
  • Administer injection Tetanus toxoid as per physician's order
  • Administer analgesics and antibiotics as per physician's order
  • Assist in application of plaster cast for fractured bone
  • Provide appropriate pre- and post-operative care for adolescents undergoing surgery
  • Assist in suturing deep cuts injuries
  • Meet the nutritional, hygienic, elimination needs and ensure the skin integrity of the immobile adolescent
  • Maintain good pulmonary hygiene and perform early ambulation
  • Perform and teach active and passive exercises
  • Provide comfort and psychological support to the adolescent and the family
  • Explain the care and the treatment provided in simple terms to the adolescent and the family
  • Prepare the adolescent and the family for discharge and teach the appropriate home and rehabilitative care.


WHO has suggested that the adolescents need families which protect and nurture, Health Care systems which are responsive to adolescent needs, schools that promote healthy development. They need clean air, adequate water, sanitation and hygiene as well a transport system that is safe. They also need to have laws that protect their rights.


  Conclusion Top


Adolescence is a second window of opportunity to influence the development of the child's brain and a healthy lifestyle. The Lancet Commission in 2016 concluded that investing in adolescents will yield a triple benefit-today, into adulthood, and the next generation of children. Therefore, the promotion and maintenance of good adolescent health are vital. However, adolescents now are facing several health issues that put them at risk for developing various health problems. Some of these health problems include obesity, nutritional deficiencies, pubertal disorders, teen pregnancy, sexually transmitted infections, sexual abuse and RTAs. These are mostly prevented when appropriate and a healthy lifestyle is followed. Regular monitoring can help in early detection and treatment. It is imperative that Nurses play preventive, promotive, educative and rehabilitative role in adolescent wellbeing and thereby reduce the effects of poor adolescent health, mortality and morbidity.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.


  CE Test No. 41- Questions Top



  Adolescence: An Overview of Physical Health and other Health Problems Top


1. World Health Organization defines adolescents as individuals in the age group of__________

  1. 10-19 years
  2. 11-18 years
  3. 11-20 years
  4. 10-20 years


2. Brain growth influencing problem solving skills occurs during__________

  1. Early adolescence
  2. Middle adolescence
  3. Late adolescence
  4. Entire adolescence


3. In Tanner staging for girls, long downy pubic hair near the labia and breast budding is seen during__________

  1. Stage I
  2. Stage II
  3. Stage III
  4. Stage IV


4. Cognitive control includes the following EXCEPT__________

  1. Inability to stop an impulsive behavior
  2. Guide behavior by retaining information
  3. Follow rules
  4. Execute optimal reasoning


5. The body mass index of an adolescent you assess is more than 2.0 in reference to z score. According to WHO the adolescent's weight is classified as__________

  1. Normal bodyweight
  2. At risk of overweight
  3. Overweight
  4. Obesity


6. Metabolic syndrome is defined the as presence of at least 3 risk factors namely__________

  1. Central obesity
  2. Hyperglycemia
  3. Hypertriglyceridemia
  4. Hypertension


  1. 1, 2, 3 b. 2, 3, 4 c. 1, 3, 4 d. 1, 2, 4


7. The treatment of obesity in adolescents include__________

  1. Dietary management, 60-120minutes of physical activity and 1 hour of screen time
  2. No dietary restriction, 60-120minutes of physical activity and 1 hour of screen time
  3. Dietary management, up to 60minutes of physical activity and 1 hour of screen time
  4. No dietary restriction, up to 60minutes of physical activity and 1/2 hour of screen time


8. A mother brings her 11 year old daughter to the OPD with complaints of fear of weight gain, malnutrition, and excessive weight loss. This condition is termed as __________

  1. Bulimia Nervosa
  2. Binge eating disorder
  3. Night eating syndrome
  4. Anorexia Nervosa


9. The ICMR recommended dietary allowance of Iron for an Indian adolescent is __________

  1. 10-16mg/day
  2. 12-18mg/day
  3. 14-20mg/day
  4. 16-22mg/day


10. Osteopenia is caused due to the deficiency of________

  1. Zinc
  2. Folate
  3. Calcium
  4. Iodine


11. Isolated breast development without any other signs of puberty in girls is termed as __________

  1. Premature menarche
  2. Premature adrenarche
  3. Gynecomastia
  4. Premature thelarche


12. Which of the following is a red flag for pubertal disorders__________

  1. Lack of breast development by age 10
  2. Lack of pubic hair by age 16
  3. More than 5 years between breast development and first period
  4. Period has not started by age 14


13. A major complication of a baby born to a teenage mother is__________

  1. Low birth weight
  2. Sepsis
  3. Hemorrhage
  4. Post term delivery


14. The act that makes any sexual activity with a child below 18 years a crime in India is__________

  1. CLPR Act
  2. Child abuse
  3. POSCO Act
  4. POCSO Act


15. According to a national survey conducted in 2007, most of the sexually abused children were__________

  1. Girls
  2. Boys
  3. Boys and girls were equally abused


16. The emergency telephonic helpline number for CHILDLINE is__________

  1. 1098
  2. 1980
  3. 8901
  4. 1089


17. The leading cause of death among adolescents is__________

  1. Sexually transmitted diseases
  2. Teen pregnancy
  3. Road traffic accidents
  4. Nutritional disorders


18. Needle thoracostomy is an emergency procedure performed for__________

  1. Hemothorax
  2. Cardiac tamponade
  3. Tension pneumothorax
  4. Pulmonary edema


19. The rehabilitative care of an adolescent who sustained a lower spinal cord injury in a road traffic accident include the following EXCEPT__________

  1. Clean intermittent catheterization
  2. Skin care
  3. Physiotherapy
  4. Gastrostomy feeding


20. According to the Lancet commission in 2016, investing in adolescents will yield__________

  1. Double benefit
  2. Triple benefit
  3. Quadruple benefit
  4. Quintuple benefit



  ANSWERS FOR CE TEST NO. 40: Nursing Management of Patients with Psychiatric Emergencies Top


1. b

2. c

3. c

4. b

5. c

6. d

7. a

8. a

9. d

10. a

11. c

12. b

13. b

14. a

15. c

16. c

17. c

18. a

19. d

20. d



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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Abstract
Introduction
Adolescence
Adolescent Growt...
Puberty
Adolescent Brain
Physical Problem...
Conclusion
CE Test No. 41- ...
Adolescence: An ...
ANSWERS FOR CE T...
References
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