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Specific Learning Objectives

 Who are adolescents?


 Health problems common in adolescence
and their management.
 Health programmes for adolescence
 Role of Family Physician in adolescent
health
Adolescence- WHO Definition
“A period of biologically accelerated physical and
sexual maturation, physiologically of major
growth in personality and development, and
socially of new status within and outside the
family.”
 Adolescence: 10 – 19 years
 Early Adolescence: 10 – 13 years
 Middle adolescence: 14 – 16 years
 Late adolescence: 17 – 19 years
 Youth: 15 – 24 years
 Young people: 10 - 24 years
ADOLESCENT IN INDIA
 India is home to 243 million adolescents –
children aged 10 to 19 years – the most
adolescents of any country.
 It accounts for about 21.3% of population of the
country.
 Girls currently married (age group 15-19yr) are
30%.
 Boys currently married (age group 15-19yr) are
4.6%.
 Birth by age 18 year- 21.7%
BURDEN OF HEALTH PROBLEM
 An estimated 1.3 million adolescents died in 2012,
mostly from preventable or treatable causes.
 Road traffic injuries were the leading cause of
death in 2012, with some 330 adolescents dying
every day.
 Other main causes of adolescent deaths include
HIV, suicide, lower respiratory infections and
interpersonal violence.
 Half of all mental health disorders in adulthood
appear to start by age 14, but most cases are
undetected and untreated.
ADOLESCENT NUTRITION
 Nearly half of adolescent girls aged 15–19
in India are underweight (unicef global
database 2011)
 There is increase in nutritional
requirement during this period of rapid
 Lack of sun exposure causes vitamin D
deficiency.
ADOLESCENT NUTRITION
 Insufficient dairy product intake in
underprivileged girls leads to poor intake of
protein and calcium
 Vitamin A deficiency is also an important issue
in economically deprived adolescents.
 Undernutrition delays
◦ the onset of puberty and sexual maturation,
◦ result in stunting,
◦ poor bone mass accrual and
◦ reduced work capacity.
ADOLESCENT NUTRITION
ADOLESCENT NUTRITION
 A large proportion of India’s adolescents are
anaemic
 Anaemia adversely affects these young
people’s
◦ growth,
◦ resistance to infections,
◦ cognitive development and work productivity.
 The national Ministry of Health and Family
Welfare (MHFW) launched a nationwide
Weekly Iron and Folic Acid Supplementation
(WIFS) programme in January 2013.
ADOLESCENT NUTRITION
The services delivered under scheme:-
1) weekly iron and folic acid supplementation;
2) bi-annual deworming; and
3) nutrition counselling about how to improve
diet and prevent anaemia.
 Kishori shakti yojna to improve nutritional
and health status of girls in age group of 11-
18 years.
 Improving nutritional status of adolescent
girls helps break the cycle of malnutrition
and low birth weight babies.
MENTAL HEALTH PROBLEMS
 Depression is the top cause of illness and
disability among adolescents and suicide is the
third cause of death.
 Other problems include:
◦ Adjustment disorder,
◦ anxiety disorder,
◦ delinquent behavior,
◦ poor body image, and
◦ low self-esteem.
 Completed suicides are higher in boys
 Attempted suicides are higher in girls
MENTAL HEALTH PROBLEMS-What can
be done?
 Building life skills in children and adolescents
and providing them with psychosocial
support in schools and other community
settings can help promote good mental
health.
 Programmes to help strengthen ties
between adolescents and their families are
also important.
 If problems arise, they should be detected
and managed by competent and caring
health workers.
EARLY PREGNANCY &
CHILD BIRTH
 Complications linked to pregnancy and
childbirth are the second cause of death for
15-19-year-old girls globally.
 Every year, some 3 million girls aged 15 to
19 undergo unsafe abortions.
 Babies born to adolescent mothers face a
substantially higher risk of dying than those
born to women aged 20 to 24.
 Unmarried adolescents are likely to resort
to unsafe method of abortions, which
increases the risk of complication like
septicemia and also mortality.
EARLY PREGNANCY & CHILD BIRTH
 Adolescent pregnancy are also at increased risk
of
◦ pre-eclampsia,
◦ preterm labor,
◦ prolonged and obstructed labor, and
◦ postpartum hemorrhage.
 Many girls who become pregnant have to drop
out of school.
 Newborns born to adolescent mothers are also
more likely to have low birth weight, with the
risk of long-term effects.
EARLY PREGNANCY & CHILD BIRTH
 WHO published guidelines in 2011 with the UN
Population Fund (UNFPA) on preventing early pregnancies
and reducing poor reproductive outcomes with 6 main
objectives:
◦ reducing marriage before the age of 18;
◦ creating understanding and support to reduce pregnancy before
the age of 20;
◦ increasing the use of contraception by adolescents at risk of
unintended pregnancy;
◦ reducing coerced sex among adolescents;
◦ reducing unsafe abortion among adolescents;
◦ increasing use of skilled antenatal, childbirth and postnatal care
among adolescents.
SEXUALLY TRANSMITTED
INFECTIONS
 Early sexual activity is not uncommon in India.
 Adolescent are susceptible to these infections because
◦ biological (immature and incompletely estrogenised
mucosa) and
◦ psychological factors (lack of preparedness, lack of
familiarity with barrier contraceptives)
 Vaginal discharge is common in adolescent girls
 Pelvic inflammatory disease (PID) is a spectrum of
inflammatory disorder of female genital tract. It can
present with abdominal pain and vaginal discharge.
SEXUALLY TRANSMITTED INFECTIONS
 HIV-
◦ More than 2 million adolescents are living with
HIV
◦ Although HIV deaths decreased in last 8 years
but adolescents deaths are rising.
◦ Young people need to know how to protect
themselves and have the means to do so.
◦ This includes being able
 to obtain condoms to prevent sexual transmission of
the virus and
 clean needles and syringes for those who inject drugs.
 Better access to HIV testing and counselling.
OBESITY
 Among school children, 5% obesity and 17-19% overweight has been
reported.
 Prevalence of obesity and overweight is higher in boys than in girls.
 Causes:
 Change in sedentary life style,
 Increase consumption of calorie dense food and
 decrease outdoor activity contribute to these disorders.
 Obesity has strong association with
◦ asthma,
◦ sleep disorder,
◦ reflux disease,
◦ slipped femoral epiphysis,
◦ gallstones and fatty liver,
◦ metabolic derangements like type 2 diabetes, dyslipidemia,
hypertension and polycystic ovarian disease
SUBSTANCE ABUSE
 Most of the tobacco and alcohol use
starts during adolescence.
 Alcohol(21%),
 Tobacco(14%),
 cannabis(3%), and
 opium (0.4%) are the most prevalent
substance abuse in Indian adolescence.
VIOLENCE
 WHO defines violence as
“The intentional use of physical force or power,
threatened or actual, against oneself, another person,
or against a group or community that either results in
or has a high likelihood of resulting in injury, death,
psychologic harm, maldevelopment or deprivation”
 Physical and sexual violence are common in India.
 20-30% of young females suffering from domestic
violence and 5-9% young females reporting sexual
violence (NFHS3).
 Motor vehicle and industrial accidents are common in
boys whereas burns are common in girls.
VIOLENCE
 The FISTS mnemonic provides guidance
for structuring the assessment of
violence-
VIOLENCE
Treatment-
 cognitive-behavioral therapy involving the
individual and family
 specific family interventions (parent
management training, multisystemic treatment)
 pharmacotherapy.
 Treatment of existing comorbid conditions,
such as attention-deficit/hyperactivity disorder,
depression, and substance abuse, appears to
reduce aggressive behavior.
EATING DISORDERS
 ANOREXIA NERVOSA:-
◦ Most Common among 15-19yr old.
◦ Charecterized by-
 Body weight <85% of expected weight for age and
height
 Intense fear of becoming fat even though underweight.
 Disturbed body image and denial that current body
weight is low
 In postmenarcheal girls, amenorrhea.
◦ Anorexia is commonly associated with
depression, anxiety, suicidal ideation and/or
Obsessive Compulsive Disorder.
EATING DISORDERS
◦ Profound weight loss may result in
 hypothermia,
 hypotension,
 dependent edema, b
 radycardia,
 hypokalemic metabolic alkalosis.
◦ Mortality is attributed to cachexia and suicide.
 MANAGEMENT-
◦ Psychotherapy (individual + family therapy) to
establish appropriate eating pattern and normal
perception of hunger and satiety.
◦ Nutritional rehabilitation (in severe cases
NG/Parenteral nutrition)
◦ Antidepressant and antipsychotic drugs as required.
EATING DISORDERS
 BULIMIA:
◦ More common in girls between 10-19 yr of age.
Charecterized by
 Recurrent episodes of binge eating
 Recurrent inappropriate compensatory behavior to prevent
weight gain, such as self induced vomitting, misuse of laxatives,
diuretics enemas, fasting or excessive exercise
 both at least twice a week for 3 months.
 Affected patients have comorbidities like
depression and psychosis.
 MANAGEMENT:- combination of psychotherapy
and antidepressants (such as fluoxetine)
ADOLESCENT HEALTH
PROGRAMMES
Kishori Shakti Yojana
• Key component of ICDS scheme which
aims at empowerment of adolescent
girls.
Scheme-II (Balika Mandal)
Scheme- I (Girl to Girl
Approach) • Age group 11-18 years
irrespective of income levels
•Age group of 11-15 years of the family
•Belonging to families whose •Younger girls 11-15 years
income level is below Rs. and belonging to poor
6400/- per annum families
Kishori Shakti Yojana- Objectives
• To improve nutritional and health status of girls in age group
of 11-18 years
• To provide required literacy and numeracy skills through the
non-formal stream of education
• To stimulate a desire for more social exposure and knowledge
and to help them improve their decision making capabilities
• To train and equip the adolescent girls to improve/ upgrade
home-based and vocational skills
• To promote awareness of health, hygiene, nutrition and family
welfare, home management and child care
• Measures to facilitate their marriage only after attaining the age
of 18 years and if possible, even later
• To gain a better understanding of their environment related
social issues and the impact on their lives
RMNCH+A
Coverage targets for key RMNCH+A
interventions for 2017 in Adolescents:
 Reduce anaemia in adolescent girls and
boys (15–19 years) at annual rate of 6%
from the baseline of 56% and 30%,
respectively(NFHS 3)
 Decrease the proportion of total fertility
contributed by adolescents (15–19 years)
at annual rate of 3.8% per year from the
baseline of 16% (NFHS 3)
RMNCH+A: Priority interventions

1. Adolescent nutrition; iron and folic acid


supplementation
2. Facility-based adolescent reproductive and
sexual health services (Adolescent health
clinics)
3. Information and counseling on adolescent
sexual reproductive health and other health
issues
4. Menstrual hygiene
5. Preventive health checkups
New Initiative: National Iron Plus
Initiative
• 6-60 months: IFA
administered •NEW
COMPONENT
biweekly, on fixed
days , under direct •Weekly IFA
supplementation (WIFS)
supervision of for both adolescents
ASHAs ; boys & girls in
5-10 years: at AWC Government/Governme
& through schools nt aided/municipal
schools

Children Adolescent

Pregnant &
lactating Reproductive • NEW COMPONENT
• As part of the women Age group • IFA to be distributed by
antenatal care ASHA during doorstep
package, at all delivery of contraceptives;
levels of health IFA tablets to be given for
52 weeks each year
facilities , sub
centre and
outreach
RMNCH+A: AFHS
◦ Adolescent Friendly Health Services include
 Reproductive health services
 Sexual & reproductive health education
 Contraception
 Pregnancy testing andoptions
 MTP
 STD/HIV Screening, counselling, treatment
 Prenatal and Post natal care
 Well baby care
 Nutritional Services
 Growth and Development monitoring
 Anticipatory guidance regarding substance abuse
 Counseling on life skill development
 Screening for various disorders
RMNCH+A: AFHS
 Services at sub centre: ANM
 Adolescent Information and Counseling
Centre will be made functional by MO and
ANM at PHC on weekly basis.
 At CHC, DH/SDH/ and Medical College:
Adolescent Health Clinics(daily basis)
 Special focus will be given to establishing
linkages with Integrated Counseling and
Testing Centres (ICTCs) and making
appropriate referrals for HIV testing and
RTI/STI management
RMNCH+A: Scheme for
promotion of menstrual hygiene
among adolescent girls in rural
India
 This scheme promotes better health and
hygiene among adolescent girls
 Sanitary napkins are provided under
NRHM’s brand ‘Free days’.
 These napkins are being sold to
adolescent girls by ASHAs
RMNCH+A: Preventive health
checkups and screening for diseases,
deficiency and disability
 Components of School Health Programme
include screening, basic health services and
referral
 Bi-annual health screening is undertaken for
students (6–18 years age group)
 Implementation of School Health Programme
 Team consist of:
- 2 Medical Officers
(MBBS / Dental / AYUSH qualified)
- 2 paramedics
(one ANM and any one of the following
Pharmacist/ Ophthalmic Assistant/Dental assistant)
SOCIAL CHALLENGES
 MEDIA
 PEER PPRESSURE
 POVERTY
 ILLITERACY
 EARLY MARRIAGE
 ACADEMIC AND EMOTIONAL STRESS
 DISCRIMINATION
 LACK OF SEX EDUCATION
ROLE OF HEALTH CARE
PROVIDER
 Identifying risk
 Establishing rapport
 Confidentiality
 Consent(<12, 12-18, >18)
 Nutritional intervention
 Providing health information
 Contraception
ROLE OF HEALTH CARE
PROVIDER
 Referral to social services, psychological
evaluation and support
◦ National Commission for Protection of Child
Rights Act 2005 consider a person below 18
yr as a child.
◦ It is mandatory for a health care provider to
report all cases of child abuse (even
suspected) to the chairperson of the
commission (online/writing).
◦ Doctors are protected in case of erroneous
reporting but punishable if they fail to report.
ROLE OF HEALTH CARE PROVIDER
 Adolescent immunisation
CHECKLIST FOR ADOLESCENT
HEALTH VISIT
 History from parents and adolescents
◦ History of presenting problem
◦ Parental concern on growth and development
◦ Academic success; school absenteeism
◦ Diet intake including calcium, protein and iron
intake; junk food
◦ Menstrual history; sleep problems
CHECKLIST FOR ADOLESCENT
HEALTH VISIT
 History on questioning of adolescents
◦ Emotional problems; relationship with family
and peers
◦ Outlook toward physical and sexual changes
◦ Involvement in relationship or sexual activity
◦ Awareness about safe sex and contraception
◦ Specific problems related to sex organs
◦ Tobacco or other substance use
◦ Counsel and clear doubts on sensitive topics
CHECKLIST FOR ADOLESCENT
HEALTH VISIT
 History on separate questioning of parents
◦ Relationship with family
◦ Level of communication on sensitive matters
 Physical examination
◦ Anthropometry
◦ Blood pressure, obesity, acanthosis
◦ Sexual maturity rating
◦ Signs of malnutrition, anemia and vitamin
deficiency
◦ Signs of skin and genital infection
CHECKLIST FOR ADOLESCENT
HEALTH VISIT
◦ Level of general hygiene
◦ Signs of trauma; abuse
◦ Signs of drug abuse and tobacco abuse
 Counseling
◦ Nutritional intervention
◦ Hygiene practices
◦ Building rapport between parents and
adolescents
◦ Providing information and sources on sex
education
CHECKLIST FOR ADOLESCENT
HEALTH VISIT
 Investigations
◦ Hemoglobin level
◦ Blood sugar, lipid profile
◦ Genital swab
◦ Ultrasound of ovaries

 Referral
◦ Counselor
◦ Dietitian
◦ Psychiatrist
◦ Gynecologist
◦ Voluntary and confidential HIV testing
◦ Social services, child protection agencies, support groups.
References
 OP Ghai- Essential Pediatrics
 Nelsons Textbook of Pediatrics
 UNICEF Global Data – 2013
 Integrated Child Development Services
Scheme. Kishori Sakati Yojana. Available from:
http://wcd.nic.in/KSY/ksyguidelines.htm.
 A Strategic Approach to Reproductive, Maternal,
Newborn, Child and Adolescent
Health(RMNCH+A) in India. Ministry of
Health & Family Welfare Government of
India February 2013
Thank You.