Recent Advances in Pediatrics (Special Volume 17: Adolescence) Suraj Gupte
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Adolescence: Overview1

Suraj Gupte,
AK Sahni
 
INTRODUCTION
By definition, the term, adolescence, is applied to the lifespan, usually between 10 to 20 years, in which children undergo rapid changes in body size, physiology and psychological and social functioning.1,4 During this phase, all body dimensions, development and maturation are completed. This is the net result of hormones and social structures designed to foster the transition from childhood to adulthood. True to the literal meaning of the term (the Greek word, adolescere denotes “to grow and to mature”), the sentinel occurrence during the period of adolescence is “rapid growth”, not just physical and biologicals (sexual) but also emotional, cognitive, psychological, and social.
Adolescence begins with the onset of puberty, defined by the UNICEF as “the sequence of events by which the individual is transformed into a young adult by a series of biological changes.” It is during this period that secondary sex characteristics develop. These sex characteristics have been rated into five stages by Tanner. Globally a secular trend is being noticed towards earlier puberty. What indeed constitutes end of puberty remains controversial.
Arbitrarily, adolescence is divided into three phases: early, middle and late adolescence. Early adolescence refers to age 10 to 13 years, middle adolescence to 14 to 16 years and late adolescence to 17 to 20 years.
Until recently, the adolescent remained neglected by the medical profession as neither the physicians for adults nor the pediatricians looked after his problems. He, in actuality, appeared to be no one's responsibility, especially in India and other developing countries. Now, of course, thanks to the concerted efforts of the World Health Organization (WHO) and the UNICEF, a world wide campaign has begun to focus attention on adolescence. In India, for example, the Indian Academy of Pediatrics (IAP) took lead in focusing attention on adolescence by declaring the year 2000 as the IAP Year of the Adolescent and 2the August 1 (first day of the World Breastfeeding Week) every year as the Teenager Day. According to the IAP, health problems of children up to 18 years (inclusive) should be the responsibility of pediatricians.
 
ADOLESCENCE AGE: DIFFERENT DEFINITIONS13
  • In the United States of America (USA), adolescence includes individuals up to the age 21 years.
  • UNICEF is contented with “up to 18 years” as the upper age limit.
  • According to the WHO, adolescence is the period of life that extends from 10 years to 19 years.
  • The IAP defines adolescence as the period of life between 10 and 18 years (inclusive). All these definitions may well be all right for statistical convenience rather than for biological accuracy.
According to the WHO, term, youth, should be reserved for 15–24 year age group and the term, young people, for 10–24 years.
 
PUBERTY CHANGES
 
Girls
The common order of changes in girls is:
  • Accelerated gain in weight and height
  • Breast changes like pigmentation of areola and enlargement of breast tissue and nipple
  • Increase in pelvic girth
  • Appearance of pubic hair
  • Activity of axillary sweat glands
  • Appearance of axillary hair
  • Onset of menses (menarche). The first bleed occurs usually 2 years after the first manifestation of puberty
  • Abrupt slowing of gain in height.
 
Boys
The common order of changes in boys is:
  • Accelerated gain in weight and height
  • Enlargement of external genitalia
  • Appearance of pubic hair followed by hair in axilla, upper lip, groin, thigh, and between pubis and umbilicus. Facial hair appear about 2 years after the pubic hair
  • Changes in voice
  • Nocturnal discharge of seminal fluid
  • Abrupt slowing in gain in height.
    3
 
DEVELOPMENTAL CHARACTERISTICS
Table 1.1 summarizes the developmental characteristic of three phases of adolescence.
 
SEXUAL MATURITY RATING
Tanner's sexual maturity rating (SMR) is listed in Tables 1.2 and 1.3.
 
ADOLESCENT GROWTH SPURT
A remarkable feature of puberty is that as much as 50 percent of the adult weight and 25 percent of the adult height are attained during this period of life. No doubt, there is a wide variation in the age of onset as also the rate of puberty spurt. Major weight gain in boys is because of dominant muscular development. In girls, fat deposition in characteristic female distribution is responsible for it. Table 1.4 summarizes the three phases of growth spurt.
 
ADOLESCENT PSYCHOLOGY
 
Self-esteem (Self Concept)
The adolescent's personal evaluation or view of “self” has a considerable fall out on his feelings and behavior. It is the result of an interaction between the adolescent's temperament and the environmental influences and considerably contributes to motivation and performance, peer relationship, failure or success and ability to bounce back from a failure. Any sort of a conflict in development of an adequate self-esteem may cause one or more psychological problems.
 
Formation of the Identity
Physical maturation, joining the peer group and heterosexual relationship are the hallmark of early adolescence. The middle and late adolescence is characterized by autonomy from parents, sex-role identity, morality and career choice. Failure to accomplish these tasks may cause psychological problems.
 
Relationship with Peers and Parents
A vital feature of middle adolescence is tendency to join a peer group and endeavor to win popularity among friends circle. At the same time, the adolescent moves away from parents, challenges their authority and, as a result, frequently gets into a conflict with them. In case parents are understanding and accomodating, the adolescent usually tides over this phase and adopts to the situation.
The conflicts and pressures may contribute to such problems as depression, suicide or suicidal attempt, school problems (school phobia, failures) and juvenile delinquency.4
Table 1.1   Developmental characteristics of three phases of adolescence
Characteristic
Early adolescence
Middle adolescence
Late adolescence
Age (years)
10 to 13
14 to 16
17 to 20
SMR
1 to 2
3 to 5
5
Somatic development
Secondary sex characters, onset of rapid growth, awkward
Height growth peaks, body shape and configuration change, acne appears, menarche, spermarche
Slower growth
Sexual development
Sexual interest much more than sexual activity
Sexual drive surges, experimentation, questions of sexual orientation
Consolidation of sexual identity
Cognitive and motor development
Concrete operations, conventional morality
Appearance of abstract thoughts, self-centered, questioning more
Idealism, absolutism
Self-concept
Preoccupation with changing body, self-conscious
Concern with attractiveness, increasing introspection
Relatively stable body image
Family
Struggles for greater independence
Struggles for acceptance of greater autonomy
Practical independence, family remains secure base
Peers
Same sex groups, conformity, cliques
Dating, peer group less important
Intimacy Possicommitment
Relationship to society
Middle-school adjustment
Gauging skills and opportunities
Career decisions (dropout college, work)
5
Table 1.2   Sex maturity rating (SMR) in girls
Stage
Breasts
Pubic hair
1.
Preadolescent
Preadolescent
2.
Breast and papillae elevated as small mounds, areolar diameter increased
Sparse, lightly pigmented, straight, medial border of labia
3.
Breast and areola enlarged, no contour separation
Darker, beginning to curl, increased amount
4.
Areola and papillae form secondary mound
Coarse, curly, abundant but amount less than in adults
5.
Mature nipple projects, areola part of general breast contour
Adult feminine triangle, spread to medial surface of thighs
Table 1.3   Sex maturity rating (SMR) in boys
Stage
Pubic hair
Penis
Testes
1.
None
Preadolescent
Preadolescent
2.
Scanty, long, slightly pigmented
Slight enlargement
Enlarged scrotum
3.
Darker, starts to curl, small amount
Longer
Larger
4.
Resembles adult type but less in amount, coarse
Larger, glans size further increases, in breadth, glans develops
Larger, scrotum dark
5.
Adult distribution spread to medial surface of thighs
Adult size
Adult size
6
Table 1.4   Three phases of puberty growth spurt
Phase 1
Moderate gain in height velocity in the prepubescent phase
Phase 2
Both height and weight show rapid gain in the pubescent phase
Phase 3
Growth velocity shows deceleration though weight gain continues in the postpubescent phase
 
Psychological Problems
Adolescent psychological problems may fall in one of the following three categories:
  • Emotional which include anxiety, hypersensitivity, impulsiveness, moodiness, immaturity, withdrawal, etc.
  • Multivational which include lack of ambition, low aspirational level, feelings of frustration, negative attitudes, lack of interests, etc.
  • Moral which include feelings of guilt, sense of being lost, confused ideas of right and wrong, delinquencies such as lying, stealing, unruly behavior, etc.
 
ADOLESCENT SEXUALITY5, 6
Though an adolescent is still a child, he is almost an adult as far as physiological and sexual maturation is concerned as a result of hormonal changes. No doubt, this sudden transformation together with exposure to influences of peers and print and electronic media leaves him utterly confused on his knowledge, attitudes and behavior concerning sex.
 
Sexual Concerns
The adolescent is often anxious about nocturnal discharge, penile size, shape and erection, growth of hair, menses, breasts, and appearance to influence the opposite sex. The usual barrier of communication with the parents enhances the adolescent's worry.
 
Self-Gratification
Most adolescents indulge in self-gratification (masturbation) to quench their sexual desire and obtain pleasure out of this practice. Yet, they are left with an intense feeling of “guilt” and run about foolishly to get treatment for this harmless practice from quacks and other unscrupulous elements.
 
Homosexuality
Sooner or later, the adolescent may develop a very intimate closeness with an individual of the same sex. As a rule this is a transitional phase in an adolescent's 7life and in due course dies down. However, in a small proportion of the adolescents, such an homosexual relationship may pass on into adult life on account of an enhanced “fixed identity”, leading to problems.
 
Promiscuous Sex
Aping the West is usual in the developing countries such as India. Understandably, therefore, the promiscuity in adolescents is on an increase. This is not restricted to peer groups. Quite a proportion of adolescents mate with prostitutes. A large majority of these sexually active but ignorant adolescents never use any contraceptive measure such as condoms, thereby exposing themselves to unsafe (unprotected) sex, resulting in sexually transmitted disease (STD), including HIV/AIDS and unwanted pregnancies, illegal abortions with complications, maternal deaths, abandoned babies and, no doubt, population explosion.
 
Sex Education in Schools
In order that adolescents do not grow up with beliefs and notions that are dangerous for the future sex life and protect themselves from sexual abuse and exploitation, it is being increasingly realized that sex education, in a well-conceptualized way, should be given in schools by the specially trained teachers. If need be, help from doctors, psychologists/psychiatrists and sexologists may also be sought for this purpose. We must empower children with knowledge and information so that they may fight the cancer of untruths with confidence. The argument by the cynics that burdening children's minds with what is essentially the task of the adults seems by and large unfounded.
 
ADOLESCENT NUTRITION710
On account of a rapid gain in height and weight, nutritional requirements, including calories, proteins and micronutrients such as iron, calcium, zinc, folic acid and iodine, are at peak during adolescence (Table 1.5). The adolescents who participate in athletics and sports are in need of a higher intake of proteins as well as calories. Similarly, nutritional requirements of a pregnant adolescent are relatively much higher (Table 1.6). Risk for undernutrition and micronutrient deficiency are, therefore, increased during this period. In adolescent girls in particular, importance of nutrition is remarkable since the growth and development of infants is dictated by their mother's past nutritional status.
The adolescent is particularly vulnerable to certain peculiar eating disorders on account of hormonal and psychological changes, say anorexia nervosa, bulimia, and obesity which are discussed later in this very chapter.8
Table 1.5   Nutritional requirements of Indian adolescents as per recommendations of the Indian Council of Medical Research (ICMR)
Age groups (years)
Weight (kg)
Calories* kcal
Protein* gram
Calcium mg
Phosphorous mg
Iron* mg
Zinc mg
Iodine μg
Folic acid μg
Vit. A μg RE
10–12
Boys
35.54
2194
51.9
600
600
34.2
15
150
100
600
Girls
37.91
1965
55
600
600
18.9
15
150
100
600
13–15
Boys
47.88
2447
67
600
600
41.4
15
150
100
600
Girls
46.66
2056
62.1
600
600
28
15
150
100
600
16–18
Boys
57.28
2642
75.1
500
500
49.5
15
150
100
600
Girls
49.92
2064
60.4
500
500
29.9
15
150
100
600
*Based on Indian diet of cereal and pulses
**Iron requirements are based on mixed cereal diet with dietary iron absorption of 3 percent in adolescent boys and 5 percent in adolescent girls.
9
Table 1.6   Recommended dietary allowances for pregnant adolescents
Food and Nutrition Board ICMR* USA
11–14 years
15–18 years
Energy (kcal/day)
extra 500
extra 400
+ 300
Protein (g)
1.7 g/kg
1.5 g/kg
+15 g/day
Vitamin A (μg RE)
800
800
Vitamin D (μg)
15
15
Vitamin C
(mg)
60
70
Thiamine (mg)
1.5
1.5
+0.2
Riboflavin (mg)
1.6
1.6
+0.2
Niacin (mg NE)
17
17
+2
Vit B6 (mg)
2.0
2.1
+0.5
Folate (μg)
370
400
+300
Vit B12 (μg)
2.2
2.2
Calcium (mg)
1600
1600
+600
Iron (mg)
30
30
+8
Zinc (mg)
15
15
Iodine (μg)
175
175
*Requirements in addition to those of age matched non-pregnant women.
In addition, fast food, junk food and snacking, which is fast becoming the order of the day, especially in urban adolescents but is imbalanced, may contribute to overweight and obesity plus nutritional deficiency states. The economically deprived children suffer from nutritional deprivation which they carry over to adolescence with physical and, at times, intellectual deficit limiting their productivity. The stunted and malnourished adolescent girls are particularly at a high-risk of producing LBW babies when they become mothers.
 
SPECIAL HEALTH, MEDICAL AND PSYCHOSOCIAL CONCERNS
 
Anorexia Nervosa and Bulimia
In a pursuit for “slimness” and “weight loss”, many adolescents (by and large, girls), impose foolish dietetic restrictions on themselves (anorexia nervosa of “restrictor” type) or eat in binges and then get rid of the food intake by selfinducing vomiting or using cathartics (bulimia). As a result, they become grossly malnourished with disturbances related to almost all organ systems, i.e. electrolyte disturbances, postural hypotension, cardiac arrhythmias, CCF, hypothermia, amenorrhea, constipation, dry skin with lanugo hair, peripheral edema, rise in BUN, bone marrow hypoplasia, etc. Interestingly, the subjects are notably resistant to infection.
The exact etiology is unclear though it is generally believed to be a psychiatric eating disorder. The patients have such characteristics as developmental immaturity, isolation and excessive dependence. The family background is overprotective.10
Management revolves around psychotherapy (including pharmacotherapy with antidepressant agents), behavior modification and nutritional rehabilitation.
 
Malnutrition
No doubt, nutritional needs during adolescence are considerably enhanced as a result of hike in growth during these years. Unless and until they are provided extra calories, proteins, vitamins and minerals in diet to meet the increased demands for rapid gain in weight and height, they run the risk of developing nutritional deficiency states.
 
Iron Deficiency Anemia (IDA)
Adolescents are likely to develop iron-deficiency anemia because of increased demands. In girls, an important additional factor is excessive loss of blood in menses. It is, therefore, advisable to provide them supplements of medicinal iron/folate, preferably with vitamin C. A public health approach comprising once weekly distribution of iron/folate supplementation (preferably with vitamin C) through schools and welfare centers is a desirable strategy.
 
Obesity
An adolescent is particularly prone to develop obesity. A multiplicity of factors, including growth spurt, hormonal changes, erroneous eating habits (say excessive consumption of ice cream, candies, chocolates, sweets), excessive television viewing, lack of outdoor activity, etc. join hand to contribute to it. Obesity leads to psychological problems such as low self-esteem which further force them to turn to more food and isolation, causing further obesity.
The cornerstone of management is reduction in intake of calories and hike in physical activity. The pharmacotherapy aimed at suppressing appetite should be avoided.
 
Puberty Goiter
Puberty goiter is a common problem of the adolescents, especially the girls. Usually, it subsides in due course of time. But, at times, it may become much larger in size and multinodular. It should be treated with thyroid hormone.
 
Depression
Adolescence is a period of mood swings varying from depths of depression to heights of elation. This should be considered “normal”.
In addition, “acute depressive reactions” are a sort of healthy grief response following death or separation from a loved one. These resolve in due course of time, occasionally after weeks or months.11
“Neurotic depressive disorders” are unresolved grief reaction and are characterized by a feeling of guilt in relationship to the dead. A psychiatric treatment is in order.
“Masked depression” is characterized by denial and somatization of feelings of despair, hopelessness and helplessness by the adolescent. Manifestations include “acting-out” behavior in the form of substance abuse, school truancy, running away from home, multiple accidents, unexplained headache, abdominal pain, etc. A psychiatric treatment is mandatory.
“Psychotic depressive disorders” may have such additional manifestations as delusions of guilt, impaired reality testing and thought distortion. Psychiatric treatment is strongly indicated.
 
Suicide
Suicide is one of the important causes of deaths among adolescents. Its causes include serious conflicts and pressures, successive failures in examination, marriage against will, chronic illnesses causing fear of fatality, impotence, diminished competence, poor self-image, vulnerability to loss of a loved one and easy and increased access to medication that could facilitate suicide.
Most successful suicides are known to have occurred in individuals who have threatened ending life or who have made earlier attempts or gestures. Secondly, threats of suicide must never be taken casually, especially if the person leaves a suicide note, a sign of seriousness and premeditation. A family history of suicide is significant.
Among the methods of suicide figure ingestion of medication such as phenobarbital or tricyclic antidepressants in very large amount, hanging, setting fire to one's personnel, drowning, shooting or slashing one's neck or wrist.
Any suicidal attempt is an indication for a psychiatric evaluation and management. A short-term hospitalization is of distinct value in providing a secure environment to the subject and helps the individual in the constructive resolution of his conflict.
 
Substance Abuse
The menace of substance abuse has not spared the adolescents in the developing countries too. Such is the magnitude of the problem that it has been suggested that each and every adolescent should be assessed for the drug abuse and its physical and functional adverse effects.
Among the drugs abused by adolescents figure CNS stimulants (dexedrine, methedrine), CNS depressants (opiates), hallucinogens (LSD, phenylcyclidine, mushrooms, datura), volatile substances (gasoline sniffing, airplane glue, nitrites), marijuana (hashish), cocaine, alcohol, smoking, anabolic steroids, etc.
Among the factors contributing to drug abuse figure burning the midnight oil at time of examination, sleeplessness, enhancing concentration, to get out of 12a difficult and tense situation, “just for hecks” enhancing competence in athletics, etc.
The most important preventive measure is channelization of the energy of the adolescents and creating awareness in them about the adverse effects of substance abuse. At times, services of an de-addiction center may be needed.
 
Juvenile Delinquency
A proportion of adolescents repeatedly indulge in antisocial behavior in the form of pre-mediated planned and purposeful unlawful activities. Such adolescents usually come from emotionally disturbed or broken families residing in overcrowded unhealthy environments with poor amenities. Often, a basically timid adolescent may act out to demonstrate his adventurous spirit in the eyes of his peers and indulge in a delinquent act (gang psychology).
Prevention lies in improving the enviromental and family settings. The pediatrician can play a pivotal role by interacting with parents, community leaders, social workers, school teachers and psychologist/psychiatrists and thereby provide a team approach to have the delinquent adolescents adjusted in the society.
 
Adolescent Violence
The adolescent is especially prone to be assaulted physically or sexually. He is also vulnerable to develop behavioral problems, resulting in rejection by the parents, peer groups and school teachers. Some of them may indulge in violent crimes, including murders.
 
Teenage Pregnancy
In India and most other developing countries, high incidence of teenage pregnancy is because of early marriage (on an average 16 years). Of course, with increasing permissiveness and, consequent upon that, higher incidence of premarital sexual encounters, increasing number of pregnancies in unwed adolescent girls are occurring. These pregnant adolescents are decidedly at increased risk for obstetric and perinatal complications such as toxemia, postpartum hemorrhage (PPH), postpartum infection, stillborn infants and low birthweight infants. Later, they have difficulty in proper care of the child and have a tendency to have multiple pregnancies and children. Those of the pregnant unwed girls who opt for abortion (usually at the hands of the unscrupulous quacks) too are at a special risk.
The pediatrician should put efforts for primary prevention of adolescent pregnancy. A sexually-active adolescent needs appropriate contraceptive advice. Introduction of sex education in schools may well help in safeguarding against early marriage, premarital sex and adolescent pregnancy.13
 
Sexually Transmitted Diseases (STD) and HIV/AIDS
Adolescents are on record as having an incredibly high incidence of STD (gonorrhea, syphilis, chlamydia, chancroid, herpes progenitalis, trichomonas) and HIV/AIDS because of sexual experimentation (usually unprotected/unsafe sex), biological characteristics of the vaginal epithelium, and intravenous drug abuse.
Manifestations may be in the form of pathological vaginal discharge (leukorrhea) because of development of vulvovaginitis or cervicitis. Such symptoms as lower abdominal pain, vaginal discharge, pyrexia and irregular vaginal bleed point to the so-called pelvic inflammatory disease (PID).
STD and allied infections are a potential risk to the sexual partner as well and may later be responsible for such serious sequelae as infertility and ectopic pregnancy.
The pediatricians must take the responsibility for creating awareness among adolescents about the transmission and prevention of these infections. They should also have the high-risk adolescents identified through screening to enable them to have timely treatment.
 
Menstrual Problems
Amenorrhea Absence of menstruation may be primary or secondary. In primary amenorrhea, menarche has never occurred. In secondary amenorrhea, there is cessation of menses for more than 3 months after establishment of a regular cycling. Table 1.7 lists the causes of amenorrhea in adolescent girls.
Determination of etiology of amenorrhea in the adolescent girl should permit initiation of appropriate treatment in a good proportion of the cases.
Menometrorrhagia Excessive menstrual bleeding may be the result of dysfunctional uterine bleeding, congenital coagulopathies (von Willebrand disease), aspirin ingestion, thrombocytopenia, exogenous hormones (oral contraceptives), thyroid disorders, diabetes mellitus, estrogen-secreting ovarian tumors, trauma, infection, pregnancy, or abortion.
Table 1.7   Important causes of amenorrhea in adolescent girls
Primary amenorrhea
Secondary amenorrhea
Chromosomal abnormalities
Chronic illnesses
   Gonodal dysgenesis
   Malnutrition
   Triple X syndrome
   Diabetes mellitus
   Isochromosomal abnormalities
   Inflammatory bowel disease
   Testicular feminization syndrome
   Anorexia nervosa
Structural abnormalities
   Cystic fibrosis
   Imperforate hymen
   Cyanotic congenital heart disease
   Hematocolpos
   Hematometrium
   Agenesis of cervix or uterus
14
A gynecological consultation is in order.
Dysmenorrhea Painful menstrual cramps are a leading cause of short-term school absenteeism in adolescent girls. The dominant type is primary. Secondary dysmenorrhea is the result of a structural abnormality of the uterus or cervix, a foreign body, endometritis or endometriosis. In primary dysmenorrhea, use of a prostaglandin-synthetase inhibitor is of value.
Premenstrual syndrome (PMS) It is characterized by such manifestations as breast engorgement and tenderness, fatigue, bloating, headache, increased appetite with craving for sweets and salty foodstuffs, weight gain, constipation, peripheral edema, irritability, mood swings, mental tension, and lack of concentration occurring 7 to 10 days before onset of periods and disappearing a day or two after the beginning of periods. The lifeline of management is reassurance.
 
Breast Disorders
Breast asymmetry True asymmetry usually follows surgery, injury or infection. Pseudoasymmetry is, as a rule, associated with deformity of spine (scoliosis) or thoracic cage.
Breast hypoplasia Its causes include quite frail but tall girls, hypothyroidism, ovarian dysfunction (Turner syndrome), adrenal hyperplasia, and androgen-producing tumors. A surgical correction (mammoplasty) is possible.
Congenital anomalies These include supernumerary nipples (polythelia), absence of nipples (athelia), absence of breast (amastia) and inverted nipples.
Breast mass A breast mass in an adolescent is usually a cyst, a fibroadenoma or an abscess. Whereas cystosarcoma (a low-grade malignancy) is infrequent, carcinoma of breast is extremely rare during adolescence. In case of a mass that shows persistence or increase in size, an aspiration or excision biopsy is indicated.
Gynecomastia Occurring in one-third of adolescent boys in early puberty, palpable development of breasts due to hormonal imbalance may be a matter of considerable concern. It is transient and resolves within 2 years. Rarely, it may be large and persistent, warranting plastic surgery.
Nipple discharge In addition to pregnancy, galactorrhea in adolescents may occur as a result of local stimulation, drugs (oral contraceptives, antihypertensives, tranquillizers, heroin, codeine, marijuana, amphetamines), pituitary or breast tumor or infection. Organic nipple discharge is termed amenorrhea-galactorrhea syndrome in which serum prolactin level is raised. Breast cancer is indeed rare in adolescence. Persistence of a mass or its enlargement is an indication for aspiration and/or excisional biopsy.15
 
Penile Problems
Congenital anomalies These include hypospadias, epispadias, abnormal curvature, hypoplasia and erectile or ejaculatory dysfunction. If not attended to, the adolescent may suffer psychologically.
Skin lesions These include venereal warts (condylomata acuminata) which may even involve the urethra causing bleeding during voiding, genital herpes simplex causing edematous wheal and severe pruritus, syphilitic chancre over glans and prepuce, and chancroid with ulcer edges that are not indurated.
Balanitis and balanoposthitis Sepsis of the glans (balanitis) or foreskin (balanoposthitis) is a common problem and is nearly always associated with phimosis. In addition to local and oral antibiotic therapy, it is often advisable to carry circumcision for the severe phimosis.
 
Scrotal Problems
Undescended testes Cryptorchidism may be true or just a reflection of retractile testes, ectopic testes or absent testes. Delay in treating the condition may be complicated by testicular malignancy or infertility.
Hydrocele When present, it is invariably of communicating type with the hernial sac.
 
Urologic Problems
A majority of the urologic problems, including enuresis, in adolescents pertain to voiding dysfunction and are often psychosomatic in origin. Nevertheless, such organic conditions as urethral valves or strictures, spina bifida occulta, and infection should be considered in the differential diagnosis.
In case of urethritis (usually a manifestation of STD), leading symptom is dysuria with or without discharge that may be clear or purulent.
 
Dermatological Problems
Acne It is the most common manifestation of increased level of androgens by increased size and secretions of sebaceous follicles and apocrine glands during adolescence. Over 80 percent teenagers suffer from it. It may be mild that clears in due course to severe that causes disfigurement of the face. Since appearance is a matter of considerable concern to the adolescent, he needs to be offered proper guidance and, if the need be, treatment. He must wash face frequently, avoid cosmetics and squeezing the lesions. In case of girls, it must be ensured that pregnancy is not there before resorting to medication with tetracyclines and/or cisretinoic acid (Isotretinoin).
Hirsutism As a result of excess of androgens, an adolescent girl may develop an excessive male type growth of hair. Though the commonest type is idiopathic, 16gonadal, adrenal, exogenous (drugs like androgenic steroids, minoxidil, diphenylhydantoin, cyclosporin, anabolic steroids, penicillamine, oral contraceptives, acetazolamide, diazoxide, danazol) and congenital anomalies (trisomy 18, de Lange syndrome) must be considered in differential diagnosis. Cosmetic correction is advisable. Simultaneously, attention should be directed to counter excessive androgens.
An adolescent's skin is vulnerable to other adverse influences like STD, HIV/AIDS, neurosis/psychosis (trichotillomania), contact sports (herpes simplex) and substance abuse.
 
Sleep Disorders
Narcolepsy It manifests as shortened rapid eye movement during wakefulness (REM sleep) with excessive daytime sleepiness, hallucinations, sudden flaccidity or even paralysis of a muscle group during sleep (cataplexy), and enhanced daytime sleepiness after disturbed nightime sleep because of apneic spells from airway obstruction (apnea-hypersomnia syndrome).
Insomnia Adolescents are particularly prone to delayed bedtime (delayed sleep phase syndrome). This as also depression may contribute to insomnia in around 15 percent of the adolescents.
 
Orthopedic Problems
Such problems as slipped capital femoral epiphysis, idiopathic scoliosis, Osgood-Schlatter disease, costochondritis of the sternoclavicular joint (Tietze syndrome) on account of rapid growth of long bones, open epiphyses, increased traction at insertion of muscles and pulls and pressures of sports are common during adolescence. Further, incidence of arthralgia from rubella, infectious mononucleosis and other viral infections is relatively high in adolescents.
Though infections of bones and joints are relatively less frequent in adolescents, these may follow as a complication of sickle-cell anemia or disseminated gonococcemia.
About 10–14 percent adolescent girls and 5 percent boys manifest a slight curvature of the spine (scoliosis) during the peak of the height velocity curve. This requires no orthopedic attention unless the curve exceeds 10 degrees.
 
NEED FOR ENHANCED SPOTLIGHT ON ADOLESCENT CARE1012
Thanks to the efforts of several agencies, both at the international and national level, need for spotlight on adolescent care has been widely felt. There is now a consensus that adolescent care need not be restricted to health and medical care. On the contrary, endeavors must address to his all-round development. One of the strategy suggested is what has been termed “family life education” which draws its inspiration from the observation that when adolescents are 17assisted to develop responsible attitudes towards relationship in the family settings, their emotional, psychological, social and sexual needs get satisfied. The crux of FLE is “awareness through education” – yes, amongst the adolescents, health-providers, educationists and planners, policy-makers and implementers. Various components of FLE include adolescent nutrition, personality development, understanding human sexuality, and preparation for future parenthood.
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