three larger types of violence accrdg to WHO. Interpersonal violence is subdivided into violence largely between family members or partners and includes child abuse. Community violence occurs between individuals who are unrelated. Collective violence incorporates violence by people who are members of an identified group against another group of individuals with social, political, or economic motivation. and the potential nature of violence involves physical, sexual, or psychologic force, or deprivation
Conduct disorder and oppositional defiant disorder are specific psychiatric diagnoses whose definitions are associated with violent behavior
Existing long-term follow-up studies involving infants of teen mothers suggest that many infants born to teen mothers have behavioral problems seen as early as the preschool period.
Adolescent acquaintance rape differs from adult acquaintance rape as weapons are less often used, and thus
are easily concealed (colorless, odorless, tasteless), have rapid onsets of action with resulting induction of anterograde amnesia, and have rapid eliminations due to a short half-life. Detection of these drugs requires a high index of suspicion and medical evaluation within 8–12 hr,
Adolescence - is a time of immense biologic, psychologic, and social change Puberty - the biologic process in which a child becomes an adult
Between 10 and 20 yr of age, young people undergo rapid changes in body structure and physiologic, psychologic, and social functioning
The resulting sequence of somatic and physiologic changes gives riseto the sexual maturity rating (SMR), or Tanner stages
In girls, the first visible sign of puberty and the hallmark of SMR2 is the appearance of breast buds, between 8 and 12 yr of age. Menses typically begins 2–2½ yr later, during SMR3–4 (median age, 12 yr; normal range, 9–16 yr), around the peak height velocity. Less obvious changes include enlargement of the ovaries, uterus, labia, and clitoris, and thickening of the endometrium and vaginal mucosa.
In boys, the first visible sign of puberty and the hallmark of SMR2 is testicular enlargement, beginning as early as 9½ yr. Penile growth during SMR3. Peak growth occurs when testis volumes reach approximately 9–10 cm3 during SMR4.
The health conditions having the greatest impact on the status of adolescent health: ◦ early unintended pregnancy ◦ sexually transmitted infections ◦ mental disorders ◦ Injuries ◦ substance use and abuse ◦ Automobile and motorcycle accidents-the leading causes of adolescent morbidity and mortality.
Legal Issues Minors are exempted from the requirement of parental consent for medical treatment under the following circumstances: ◦ 1. Emancipated minors children who live away from home, are no longer subject to parental control, are economically self- supporting, are married, or are members of the military.
◦ 2. Emergencies In a medical emergency, a minor may be treated without consent of parents if, in the physicians judgment, the delay resulting from attempts to contact parents would jeopardize the life or health of the minor◦ 3. Mature minor rule An emerging trend in the law is the recognition that many minors are sufficiently mature to understand the nature of their illness and the potential risks and benefits of proposed therapy and, therefore, should receive such treatment on their own consent.
The right of a minor to consent to treatment without parental knowledge is governed by state laws. Some states have age limitations, generally around age 12–15 yr. A chaperone should be present whenever an adolescent female patient is examined by a male physician. The necessity for chaperones in the situation of a female physician examining a male adolescent patient has not yet become an issue.
Violent behavior The World Health Organization (WHO) recognizes violence as a leading worldwide public health problem. WHO defines violence: ◦ “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.”
CLINICAL MANIFESTATIONS. The most common behavioral diagnoses associated with aggressive behavior in adolescents are: ◦ mental retardation ◦ learning disabilities ◦ moderately severe language disorders ◦ mental disorders such as attention-deficit/hyperactivity ◦ mood disturbance ◦ anxiety ◦ disruptive behavioral disorders
DIAGNOSIS The FISTS mnemonic providesguidance for structuring the assessment
TREATMENT Treatment plan should follow standards established by the American Academy of Pediatrics model protocol, which includes, but is not limited to ◦ the stabilization of the injury, ◦ evaluation and treatment of the injury ◦ evaluation of the assault circumstance ◦ psychologic evaluation of the functioning of the victim ◦ rehabilitation of the injury ◦ outpatient follow-up of the behavioral and physical sequelae
Substance Abuse is characterized by a maladaptive pattern of use indicated by continued use despite consequences or recurrent use where such use may be physically hazardous. Chemical dependence can be defined as a chronic and progressive disease process characterized by loss of control over use, compulsion, and the establishment of an altered state where one requires continued administration of a psychoactive substance in order to feel good or to avoid feeling bad
Substance Abuse Behaviors such as ◦ Rebelliousness ◦ poor school performance ◦ Delinquency ◦ criminal activity ◦ personality traits low self-esteem, anxiety, and lack of self-control frequently associated with or predate the onset of drug use
The Breast Breast development is one of the first obvious signs of puberty
FEMALE DISORDERSMASSES Cysts vary in size over the course of a menstrual cycle, so a patient should be re-examined 2 wk after the initial examination. Persistence of the mass or its enlargement over three menstrual cycles is an indication for surgical consultation. Multiple fibroadenomas ◦ occur in 10–20% of patients. Does not vary in size during the menstrual cycle. Cystosarcoma phylloides ◦ a rare variant of a fibroadenoma distinguished by having a more cellular stroma. It is typically larger than a fibroadenoma and rarely can be malignant
MASTALGIA. Physiologic swelling and tenderness occur on a cyclic basis, most commonly during the premenstrual phase, and are secondary to hormonal stimulation and resulting proliferative changes. Nodularity, poorly localized tenderness, and a soreness radiating to the axilla and arm are usual accompanying findings
NIPPLE DISCHARGE. usually due to local stimulation, use of medications including oral contraceptives, and pregnancy Benign conditions are associated with ◦ milky, sticky, thick discharge; Infection ◦ purulent discharge intraductal papilloma and cancer ◦ serous, serosanguineous, or bloody discharge.
INFECTION may be secondary to a human bite or the initial symptom of diabetes mellitus. Shaving or plucking of areolar hair, trauma from sexual play, and nipple Erythema and increased warmth of skin may be the first signs of infection. Appropriate antibiotic therapy (usually directed against Staphylococcus aureus), with culture if any discharge is present, is indicated; surgical drainage is rarely necessary.
Gynecomastia ◦ occurs in approximately one third of normal males during early to mid-puberty ◦ Nonpubertal gynecomastia with hypogonadism is associated with Klinefelter syndrome and places a patient at a higher risk of breast cancer ◦ Other conditions associated with nonpubertal gynecomastia are secondary to endocrine disorders, neoplasms, chronic disease, trauma, and medications as well as drugs of abuse
Menstrual ProblemsNORMAL MENSTRUATION An international study surveying age at menarche in 67 countries calculated a mean age of menarche at 13.53 years Menarche usually occurs about 2.3 yr after the initiation of puberty, with a range of 1–3 yr, and becomes regular after 2–2.5 yr.
The length of the menstrual cycle from the first day of menses of one cycle to the first day of the next cycle can range from 21 to 45 days(average is about 28 days) The average blood flow usually results in about 40 mL of blood loss, with a range of 25–70 mL. The later the age at which menarche occurs, the longer it is until the ovulatory cycles are established.
Amenorrhea(absence of menses) primary amenorrhea ◦ by age 14 yr she has not menstruated and has no secondary sex characteristics ◦ or at age 16 yr has not menstruated but has secondary sex characteristics. Clinical features such as ◦ clitoromegaly, hirsutism, or excessive acne are associated with adrenal or ovarian disease ◦ slender or obese body habitus or short stature also are characteristic of syndromes associated with amenorrhea.
secondary amenorrhea (pregnancy) ◦ A history of sexual intercourse, nausea, and breast tenderness and physical findings of increased pigmentation of nipples and linea alba, cyanosis and softening of the cervix, and an enlarged uterus form the classic picture.
Contraception Factors associated with early sexual activity in nations worldwide include ◦ lower expectations for education ◦ poor perception of life options ◦ low school grades ◦ involvement in other high-risk behaviors
For those who have never had intercourse, being against their religion and morals, avoiding pregnancy or a sexually transmitted infection (STI), and waiting for the right person were the most frequent reasons adolescents report for abstaining.
A higher likelihood of contraceptive use in women is associated with older age at sexual initiation, aspirations for higher academic achievement, acceptance of ones own sexuality, and a positive attitude toward contraception.
Adolescent Pregnancy traditional symptoms of pregnancy: ◦ morning sickness (vomiting, nausea that may also occur any time of the day) ◦ swollen tender breasts ◦ weight gain, and amenorrhea. ◦ Often the presentation is more vague. Headache, fatigue, abdominal pain, and scanty or irregular menses are common presenting symptoms.
On physical examination ◦ enlarged uterus, cervical cyanosis (Chadwick sign) ◦ soft uterus (Hegar sign) ◦ soft cervix (Goodell sign) are highly suggestive of an intrauterine pregnancy. A confirmatory pregnancy test is always recommended
CHARACTERISTICS OF TEENPARENTS. young women who become parents as teenagers tend to come from economically disadvantaged groups have poor school performance prior to becoming pregnant their families have low educational attainment frequently come from single-parent families where one or both parents became parents as teenagers
Teenaged men who become fathers ◦ poorer educational achievement than their age- matched peers. ◦ more likely than peers to have been involved with illegal activities and with the use of illegal substances. Adult men who father the children of teen mothers ◦ are poorer and educationally less advanced than their age-matched peers ◦ tend to be 2–3 yr older than the mother. Younger teen mothers are more likely to have a greater age difference between themselves and the father of their child, raising the issue of coercive sex or statutory rape
PSYCHOSOCIAL OUTCOMES/RISKS FOR MOTHER ANDCHILDEDUCATIONAL. Teenage mothers often quit school prior to becoming pregnant or defer completion of their education for some time after the birth of their child. Mothers who have given birth as teens generally remain 2 yr behind their age-matched peers in formal educational attainment Lack of education limits the income of these young families
SUBSTANCE USE. substance-abusing mothers appear to decrease their substance use while pregnant. However, use begins to increase again about 6 mo postpartum, complicating the parenting process and the mothers return to school.
REPEAT PREGNANCY. ~ 30% of teen mothers become pregnant within 2 yr of their infants birth. Prenatal care is begun even later with a second pregnancy, and the second infant is at increased risk of prematurity, early death, and homicide.
Mothers at risk of repeat pregnancy ◦ include those who do not return to school within 6 mo of the index birth, ◦ those who are married or living with their infants father, or ◦ those who receive so much child care assistance from the adolescent mothers mother that the teen is left with too little involvement in the childs care.
BEHAVIORAL, EDUCATIONAL, AND SOCIALOUTCOMES OF INFANTS. many drop out of school early (33%) become adolescent parents (25%) if male, are incarcerated (16%)Explanations for these poor outcomes include ◦ poverty, maternal and paternal learning difficulties, negative parenting styles in teen parents, maternal depression, parental immaturity, and conflicts with grandparents, especially grandmothers.
Comprehensive programs focused on supporting adolescent mothers and infants utilizing life skills training, medical care, and psychosocial support demonstrate higher employment rates, higher income, and less welfare dependency in adolescents exposed to the programs.
Pregnancy prevention the identification of the sexually active adolescent through a confidential clinical interview is a first step in pregnancy prevention. the primary care physician should provide the teenager with factual information in a nonjudgmental manner and then guide him or her in the decision-making process of choosing a contraceptive to support the teenager who chooses to remain abstinent.
Adolescent Rape Rape ◦ is coercive sexual intercourse involving physical force or psychologic manipulation of a female or a male. ◦ defined as penetration of any genital, oral, or anal orifice by a part of the assailants body or any object. ◦ an act of violence, not an act of sex.
TYPES OF RAPE Acquaintance rape (by a person known to the victim) ◦ is the most common form of rape for victims between 16 and 24 yr of age. ◦ the acquaintance may be a neighbor, classmate, or friend of the family. ◦ victim-assailant relationship may cause conflicting loyalties in families, and the teens report may be received with disbelief and/or skepticism by her family.
◦ the victims are less likely to sustain physical injuries.◦ more likely to delay seeking medical care, may never report the crime (males greater than females), and are less likely to proceed with criminal prosecution even after reporting the incident(s).
Date rape (by a person dating the victim) ◦ is often drug facilitated . Gamma-hydroxybutyric acid (GHB), flunitrazepam (Rohypnol), and ketamine hydrochloride are the leading agents used ◦ are often new to a specific environment (college freshman, newcomer to a town) and lack strong social support. ◦ Victims may not be assertive in establishing boundaries or limits with their dates and may be intoxicated when the incident takes place. ◦ The date rape assailant may engage in more sexual activities than other men his age and often has a history of aggressive behavior toward women ◦ he may be intoxicated at the time of the assault.
A date rape victim often experiences long-term issues of trust, self-blame, and guilt. She may lose confidence in her judgment concerning men in the future. She is nearly always ashamed of the incident and is less likely to report the rape. She is reluctant to talk about the rape to family, friends, or a counselor and, hence, may never heal from the psychologic scars that ensue.
Male rape generally refers to same-sex rape of male teens by other males. ◦ is most prevalent within institutional settings ◦ victims often experience conflicted sexual identity whether or not they are homosexual. ◦ issues of loss of control and powerlessness are particularly bothersome for male rape victims, and it is not uncommon for these young men to have symptoms of anxiety, depression, sleep disturbance, and suicidal ideation. ◦ Males are less likely than females to report rape and less likely to seek professional help.
Gang rape usually occurs when a group of young men rape a solitary female victim. ◦ may be part of a ritual activity or rite of passage for some male group (gangs, college fraternity) or be displaced rage on the part of the assailants. ◦ Female victims of gang rape may find it difficult to return to the environment in which the rape occurred for fear of confrontation with the assailants (college setting or place of employment) and may insist on moving away from the locale entirely.
Statutory rape refers to sexual activity between an adult and an adolescent under the age of legal consent, as defined by individual state law. ◦ In some states in the United States, statutory rape laws apply to sexual contact or intercourse occurring between a minor and another individual with a specific age difference even when both are minors and both assert that the sexual act was voluntary (a 17 yr old male who has sexual intercourse with a 13 yr old female). ◦ Clinicians must be familiar with the laws of the nation and/or state/province.
Stranger rape ◦ occurs less frequently within the adolescent population and is most similar to adult rape. ◦ frequently occur with an abduction, use of weapons, and increased risk of physical injuries. ◦ more likely to be reported and prosecuted