Adolescent medicine Dénes Molnár Dept. Pediatr. Univ. Pécs

Mortality – Accidents – Homicide~ 75% of mortality – Suicide Sexually transmitted infections (including AIDS) Substance use/abuse Life-long health habits – Food – Smoking – Exercise Adolescent Health Problems

u Eating disorders (anorexia, bulimia, obesity) u Depression, psychiatric disorders u Hypertension u Menstrual disorders (PCOD) u Chronic fatigue sy

Growth Spurt (Peak Height Velocity) composition Δ (Girls ↑ fat; Boys ↑ lean) Organ Δ (↓ lymhpoid; ↑ brain organization) Hormone changes Sex organ changes (reproductive capacity) Secondary sex characteristics (appearance) Major Events of Puberty

Changes of Puberty  Sequencing (predictable)  Onset (variable)  Tempo or Velocity (variable)  Physical ≈ hormonal  Permanent  Completed?

Normal stages & tasks of adolescence PubertyAutonomyIdentityThinking 8-14 yOnset and tempo variable AmbivalenceAm I normal?Concrete operational yFemales > males Limit testing, experimental behavior Who I am?Transitional 17 y +Adult appearance AmbivalenceWho I am in relation to others Formal operational (75%) Concrete: Here and now (5 senses), Formal: Abstraction (algebra, metaphors, symbols, etc); Hypothesizing and considering thefuture

Adolescent Thinking  Egocentrism  Normal narcissism, self-centeredness, selfishness”  Personal fable – Invulnerability, invincibility – “Nothing bad can happen to ME…”  Imaginary audience – “Everybody is looking at ME and thinking about ME…”

“The children now love luxury; they have bad manners, contempt for authority; they allow disrespect for elders and love chatter in place of exercise. Children now are tyrants, not the servants of their households. They no longer rise when elders enter the room. They contradict their parents, chatter before company, gobble up dainties at the table, cross their legs, and tyrannize their teachers.” Socrates

Leading causes of death US population, years, 1999 Rank Cause # deaths % of total unintentional injury 1st unintentional injury 6, homicide 2nd homicide 2, suicide 3rd suicide 1, th malignancy th heart disease Ref: CDC - NCHS

Motor vehicle crash fatalities 5586 teenagers u 42,000 Americans killed in MVCs in 1999, including 5586 teenagers and 2055 children u driver inexperience u speeding 14.1% u non-use of safety belts % rarely or never wear seat belts [YRBS 2001] u driving older vehicles u alcohol use

Alcohol and Adolescent Mortality 45% - 50% “Postmortem studies show that 45% - 50% of adolescent victims of violent death had been drinking alcohol before their death.” u motor vehicle crashes: driver, passenger, pedestrian, motorcycle u unintentional injury: drowning, fire, falls u homicide u suicide Ref: J Stud Alcohol 1985;46:

Scope of the Problem u Prevalence of alcohol use: “Had 5 or more drinks in a row in the last 2 weeks.” 8th grade:13% 10th grade:25% 12th grade:30% Source: Monitoring the Future Study: 2001 data

Alcohol: Binge Drinking

Scope of the Problem u Drinking and driving: RodeDrove 9th grade: 30% 7% 10th grade: 31% 10% 11th grade: 29% 17% 12th grade: 33% 22% Source: CDC 2001 Youth Risk Behavior Survey

Scope of the Problem u Sexual risk behavior: “Alcohol or drug use at last sexual intercourse, among students currently sexually active.” malefemale 9th grade:25%24% 10th grade:21%36% 11th grade:18%31% 12th grade:20%32% Source: CDC 2001 Youth Risk Behavior Survey

Adolescent homicide deaths u homicide is the second leading cause of death among year-olds - first leading cause among African Americans age years u 2903 homicides15-19 year 82%firearms u 2903 homicides in the year high school age group in % were killed with firearms u two thirds of high school students report physical fighting in the past year - 4% sustained serious injury u one fifth of high school students report carrying a weapon in the previous 30 days

Behaviors associated with violence male female u carried a weapon - past 30 days29% 6% u physical fight - past 12 months43%24% u injured in fight - past 12 months 5% 3% u forced to have sexual intercourse 5%10% u threatened with weapon at school12% 7% u felt too unsafe to attend school 6% 7% Source: CDC 2001 Youth Risk Behavior Survey

Adolescent suicides tripled u youth suicide rates have tripled since the 1950s u suicide is the third leading cause of death for year-olds u 1615 suicides15-19 year u 1615 suicides in the year high school age group in 1999 u more youth suicides annually than cancer, heart disease, AIDS, birth defects, stroke, pneumonia, influenza, and chronic lung disease combined

Behaviors associated with suicide male female u felt sad or hopeless22%35% u seriously considered suicide14%24% u made a suicide plan12%18% u attempted suicide 6%11% u attempt required medical care 2% 3% Source: CDC 2001 Youth Risk Behavior Survey

Cigarettes

Smokeless Tobacco

Obesity Trends* Among U.S. Adults BRFSS, 1991, 1995 and 2000 (*BMI  30, or ~ 30 lbs overweight for 5’4” woman) Source: Mokdad A H, et al. J Am Med Assoc 1999;282:16, 2001;286:10. No Data <10% 10%-14% 15-19%  20%

Behaviors associated with weight control male female 68% u exercised to lose weight51%68% 59% u ate less food to lose weight28%59% 19% u fasting > 24 hr to lose weight 8%19% 13% u took diet pills, powders, liquids 6%13% 8% u vomited or took laxatives 3% 8% Source: CDC 2001 Youth Risk Behavior Survey

Sexual risk behavior u ever had sexual intercoursemalefemale grade 9 41%29% grade 1042%39% grade 1154%50% grade 1261%60% u >4 lifetime sexual partnersmalefemale grade 914% 6% grade 1224%20% Source: CDC 2001 Youth Risk Behavior Survey

Sexual risk behavior u initiation of sexual intercourse before age 13 male students 9% female students 4% white students 5% black students 16% Hispanic students 8% all students 7% Source: CDC 2001 Youth Risk Behavior Survey

Sexual risk behavior u condom use during last sexual intercourse white students 57% 67% black students 67% Hispanic students54% u alcohol or drug use at last sexual intercourse male students 31% female students21% white students 28% 18% black students 18% Hispanic students24% Source: CDC 2001 Youth Risk Behavior Survey

Adolescent Pregnancy “Have been pregnant or gotten someone pregnant.” male 4% female 5% white 3% 11% black11% Hispanic 6% Source: CDC 2001 Youth Risk Behavior Survey

New cases of STD by age

STD Overview u 3 million US adolescents acquire STDs each year u 1 in 4 sexually active adolescents STD u 1 in 4 sexually active adolescents will acquire an STD before high school graduation u 1 in 5 Americans with AIDS were infected during adolescence u $10,000,000,000 total costs for STDs in US in 1994, excluding HIV infection

Infection rate per 100,000 sexually active women Ref: CDC Division of STD Prevention, 1995

Adolescent development and STD risk u psychosexual maturation u cognitive development u biologic development u knowledge u attitudes u behavior u sociocultural context

Pelvic inflammatory disease sequelae u tubal infertility one episode 8% - 11% two episodes20% - 30% three episodes40% - 55% u ectopic pregnancy increased risk times u tubo-ovarian abscess u chronic PID/adhesions Ref: Lawson MA, Blythe MJ. Pediatr Clin North Am 1999; 46:767

Functional domains in adolescence u individual u family/home u peer group u school u employment u sociocultural