SEMINAR

ADOLESCENT ISSUE &

H.E.A.D.D.S.
Cohort 9A Batch 3
 Presenters
1. Aly Ahmed Aly Moustafa Morsy SUKD1701194
2. Nur Baiti Binti Mad Nor SUKD1701024
3. Chia Jing Lyn SUKD1603269
4. Kubendran A/L T Athiberan SUKD1801062
5. Pijitra Kuboonya-arak SUKD1801299
6. Rishani A/P Jegathiswaran SUKD1701390
 Assessment of
Adolescent HEADSS
 Overview
● Leading causes of mortality & morbidity in adolescents in US are behaviorally
mediated.
● Motor vehicle injuries & other injuries account for more than 75% of all deaths.
● Unhealthy dietary behaviors and inadequate physical activity result in
adolescent obesity with associated health complications (e.g. diabetes,
hypertension)
● Important to inquire about risk-taking behaviors. Physical symptoms in
adolescents are often related to psychosocial problems.
Adolescent according to the age group :
● Early teens
○ 10-14
● Middle teens
○ 15-17
● Late teens
○ 18-21
 Interviewing Adolescents
Interview should take into account the developmental age of the adolescent
 Interviewing Adolescents
● Conversations about sports, friends, movies and activities outside school can be
useful for all ages and help develop a rapport.
● Confidentiality is a key element when interviewing an adolescent.
Guidelines for Confidentiality:
● Prepare the preadolescent and parent for confidentiality and being interviewed
alone.
● Discuss confidentiality at start of interview.
● Conversations with parents/guardians/adolescent are confidential ( with
exceptions such as abuse, suicide, homicide)
● Reaffirm confidentiality when alone with your adolescent patient.
● It is vital to engage the adolescent in an open discussion about risk-taking
behaviour, and this is more likely to happen when the adolescent is alone.
● Some issues cannot be kept confidential, such as suicidal intent, a positive human
immunodeficiency virus (HIV) test (a duty to warn third parties), and disclosure of
sexual or physical abuse.
● If there is an ambiguous situation, it is wise to obtain legal, ethical, or social worker
consultation.
Interview Adolescent Alone: Discussion of HEADDSS Topics
Interview Adolescent Alone: Discussion of HEADDSS Topics
Physical Development
Assessment
 Pre-adolescent/ School age
● Older school-age children who begin to participate in competitive sports should have
a comprehensive sports history and physical examination, including a careful
evaluation of the cardiovascular system.
● The American Academy of Pediatrics 4th edition sports preparticipation form is
excellent for documenting cardiovascular and other risks.
● The patient and parent should complete the history form and be interviewed to assess
cardiovascular risk.
● Any history of heart disease or a murmur must be referred for evaluation by a pediatric
cardiologist.
● A child with a history of dyspnea or chest pain on exertion, irregular heart rate (i.e.,
skipped beats, palpitations), or syncope should also be referred to a pediatric
cardiologist.
● A family history of a primary (immediate family) or secondary (immediate family’s
immediate family) atherosclerotic disease (myocardial infarction or cerebrovascular
disease) before 50 years of age or sudden unexplained death at any age requires
additional assessment.
● Children interested in contact sports should be assessed for special vulnerabilities.
 Adolescent
WHY ADOLESCENT HEALTH?

❏ Major physiological, psychological & behavioral changes take place

❏ Sexual maturity and onset of sexual activity
❏ Development of adult mental & adult identity
❏ Health responsible parenthood
❏ Great human resource for the society
❏ Growth spurt & physical activity
❏ Menstruation
❏ Pregnancy
 Adolescent
● Adolescents need annual comprehensive health assessments to
ensure progression through puberty without major problems.
● Sexual maturity is an important issue in adolescents.
● All adolescents should be assessed to monitor progression through
sexual maturity rating stages (also known as the tanner stages).
● Other issues in physical development include scoliosis, obesity, and
trauma.
● Most scoliosis is mild and requires only observation for progression.
● Obesity may first manifest during childhood and is an issue for many
adolescents.
 Adolescent Nutritional health problems
● Undernutrition, leads to impaired growth, anaemia,
● Iron deficiency anemia, Prevalence in adolescent girls range from 22-91%

● Reasons for IDA in adolescence are:

1. Increased requirement for growth
2. Menstrual loss
3. Dislike of iron rich food
4. Frequent dieting
● Obesity
1. Prevalence of obesity and overweight is 11.% & 14.2% respectively
2. The prevalence rates are higher in boys
● Eating disorders
1. Bulimia nervosa
2. Anorexia
 Reproductive problems
● Teenage pregnancy
● Abortion related problems
○ Unsafe abortions
○ Girls from problematic families are 11 times at a higher risk
● Irregular menstrual cycle
● Genitourinary tract infections and STDs
○ HIV/AIDS - young people between the ages of 10-20 years old
make 50% of the new HIV infections
○ Syphilis
○ Gonorrhoea
○ A report on world contraception day 2011 showed that 28% of
young people engaged in sexual activities & 32% of them did
not use any contraception
 Adolescent sexuality & Sex education
● Sexuality encompases a whole range of throughts feelings,
fantasies, emotions, desires, & language beside action, sexual
behaviour is only a part of it
● Sex education is important at all stages but it is more important that
it is imparted during childhood and adolescence
● Sex education on self awareness, personal relationships, human
sexual development, reproduction & sexual behaviour.
● It should help adolescents understand their sexuality, learn to
respect others feelings, & to make responsible decisions
Psychosocial
Assessment
 Bonding and Attachment in Infancy
● Attachment
Bonding and attachment inrelationships
describe the affective Infancybetween parents and
infants
○ Bonding occurs shortly after birth and reflects the feelings of the parents
toward the newborn (unidirectional)
○ Attachment involves reciprocal feelings between parent and infant and
develops gradually over the first year
● Infants who receive extra attention, such as parents responding immediately to any
crying or fussiness, show less crying and fussiness at the end of the first year.
● Stranger anxiety develops between 9 and 18 months of age, when infants normally
become insecure about separation from the primary caregiver. 17
 Developing Autonomy in Early Childhood
● Toddlers build on attachment and begin developing autonomy that
allows separation from parents
● In times of stress, toddlers often cling to their parents, but in their usual
activities they may be actively separated.
● Ages 2 to 3 years are a time of major accomplishments in fine motor
skills, social skills, cognitive skills, and language skills.
● Limit setting is essential to a balance of the child’s emerging independence.

18
 Early Childhood Education
● There is a growing body of evidence that notes that children who are in
high quality early learning environments are more prepared to succeed in
school.
● These children commit fewer crimes and are better prepared to enter the
workforce after school.
● Early Head Start (less than 3 years), Head Start (3 to 4 years), and
prekindergarten programs (4 to 5 years) all demonstrate better educational
attainment, although the earlier the start, the better the results.
19
 School Readiness
● Readiness for preschool depends on the development of autonomy and the ability
of the parent and the child to separate for hours at a time.
● Preschool experiences help children develop:
○ socialization skills
○ improve language
○ increase skill building in areas such as colors, numbers, and letters
○ increase problem solving (puzzles)
● Girls usually are ready earlier than boys
● If the child is in less than the average developmental range, he or she should not be
forced into early kindergarten 20
● Children tend to do better in kindergarten if their fifth birthday is at least 4 to 6
months before the beginning of school
● Holding a child back for reasons of developmental delay, in the false hope that
the child will catch up, can also lead to difficulties
○ The child should enroll on schedule, and educational planning should be
initiated to address any deficiencies.

21
 Evaluating School Readiness
PHYSICIAN OBSERVATIONS
● Ease of separation of the child from
the parent
● Speech development and
articulation
● Understanding of and ability to
follow complex directions
● Specific pre-academic skills
● Knowledge of colors
● Counts to 10
● Knows age, first and last names,
address, and phone number
● Ability to copy shapes
● Motor skills
● Stand on one foot, skip, and catch a
bounced ball
● Dresses and undresses without
assistance
PARENT OBSERVATIONS
● Does the child play well with other
children?
● Does the child separate well, such
as a child playing in the backyard
alone with occasional monitoring
by the parent?
● Does the child show interest in
books, letters, and numbers?
● Can the child sustain attention to
quiet activities?
● How frequent are toilet-training
accidents?
 Adolescent
● Adolescence is characterized by the developmental stages (early, middle, and late
adolescence) that all teens must negotiate to develop into healthy, functional adults.
● The age at which each issue manifests and the importance of these issues vary widely among
individuals, as do the rates of cognitive, psychosexual, psychosocial, and physical
development.

Early adolescence:

● attention is focused on the present and on the peer group

● Concerns are primarily related to the body’s physical changes and normality
● These young adolescents are difficult to interview because they often respond with short,
clipped conversation and may have little insight as they are just becoming accustomed to
abstract thinking

23
Middle adolescence:

● This stage can be a difficult time for adolescents and the adults who have contact with
them
● Cognitive processes are more sophisticated
● Through abstract thinking, middle adolescents can experiment with ideas, consider
things as they might be, develop insight, and reflect on their own feelings and the
feelings of others
● As they mature, these adolescents focus on issues of identity not limited solely
to the physical aspects of their body
● Many engage in high-risk behaviors, including unprotected sexual intercourse,
substance abuse, or dangerous driving
● The strivings of middle adolescents for independence, limit testing, and need for
autonomy often distress their families, teachers, or other authority figures
● These adolescents are at higher risk for morbidity and mortality from accidents,
homicide, or suicide 24
Late adolescence:

● Late adolescence is marked by formal operational thinking, including

thoughts about the future (e.g., educational, vocational, and sexual)
● Late adolescents are usually more committed to their sexual
partners than are middle adolescents.
● Unresolved separation anxiety from previous developmental stages may
emerge, at this time, as the young person begins to move physically away
from the family of origin to college or vocational school, a job, or military
service.
25
 Modifying
Psychosocial
Behaviours
 Modifying Psychosocial Behaviors
Child behavior is determined by heredity and by the environment. Many common
behavioral problems of children can be improved by the operant conditioning methods.
● The four major methods of operant conditioning are:
○ Positive reinforcement
■ increases the frequency of a behavior by following the behavior with a
favorable event. Positive reinforcement is more effective than punishment.
○ Negative reinforcement
■ Decreases the frequency of a behavior by removal, cessation, or avoidance
of an unpleasant event
○ Extinction
■ occurs when there is a decrease in the frequency of a previously
reinforced behavior because the reinforcement is withheld
○ Punishment
■ decreases the frequency of a behavior through unpleasant
consequences. Punishment is more effective when combined with
42
positive reinforcement.
Temperament
 Temperament
Significant individual differences exist within the normal development of temperament
(behavioral style)
Three common classes of temperamental characteristics are as follows:
● The easy child (about 40% of children)
○ is characterized by regularity of biologic functions, a positive approach to
new stimuli, high adaptability to change, mild or moderate intensity in
responses, and a positive mood
● The difficult child (about 10%)
○ is characterized by irregularity of biologic functions, negative withdrawal
from new stimuli, poor adaptability, intense responses, and a negative
mood
● The slow to warm up child (about 15%)
○ is characterized by a low activity level, withdrawal from new stimuli, slow
adaptability, mild intensity in responses, and a somewhat negative mood
29
● The individual temperament of a child has important implications for parenting
and for the advice a pediatrician may give in anticipatory guidance or
behavioral problem counseling.

Characteristics of Easy child Difficult child Slow to warm child

temperament

Regularity of Regular Irregular Irregular

biological function

Approach to new Positive approach Negative withdrawal Withdrawal

stimuli

Adaptability to High Poor Slow

change

Intensity in Mild-Moderate High Mild

response

Mood Positive Negative Somewhat negative 30

Evaluation of A Well Child
- Should comprise of a detailed assessment
of the child’s health and the caretaker’s
role in providing an environment for
ensuring optimal growth, development,
and health.
- There are a number of factors that need to
be explored as listed.
- Elements of each visit should include
evaluation and management of parental
concerns, any illness since the last visit,
growth and development, nutrition, and
anticipatory guidance.
- Physical examination also needs to be
carried out as well as screening tests and
immunization.
Screening tests recommended for children include:

- Newborn metabolic screening with hemoglobin electrophoresis

- Hearing and vision evaluation
- Anemia and lead screening
- Tuberculosis
- Screening for lipid disorders in those with family history of dyslipidemia.
- Screening for STDs should be performed in sexually active adolescents
Newborn Screening
- Metabolic screening
● Phenylketonuria, galactosemia, congenital hypothyroidism, maple sugar urine disease, organic
aciduria, cystic fibrosis, and immunoreactive trypsinogen.
- Hemoglobin Electrophoresis
● Important in children with hemoglobinopathies as they are at risk of infection and complications
from anemia. In the event of sickle cell disease patients, oral penicillin prophylaxis should be
given to prevent sepsis.
- Hearing Evaluation
● Hearing screening is performed before discharge from the newborn nursery. Performed by placing
headphones over the infant’s ears and electrodes on the head. Standard sounds are played and
transmission of impulse to the brain is documented. In the case of an abnormality, evoked
response testing is done via sound transmission
Hearing and Vision Screening for Older Children

- Infants and toddlers

● Performed by asking parents about responses to sound and speech and by examining speech and language
development closely.
● Vision is evaluated by assessing gross motor milestones and by physical examination of the eye.
● Auditory evoked responses can be done to screen for hearing.
● In older toddlers and older children who are unable to cooperate with audio testing with headphones,
behavioral audiology can be used.
● Sounds of a specific frequency or intensity are provided in a soundproof room.
● Vision is assessed by referral to pediatric ophthalmologist and by visual evoked responses.

- Children 3 years of age and older

● Subjective evaluation is done by asking family and child about concerns of poor hearing and vision
● Re-examination must be one at a 6 month interval to ensure that their vision is normal. Snellen chart with
shapes are recommended.
● If the child can recognize letters, letter based chart should be used.
● Audiologic testing should commence after 4 years old. If any problem is suspected thorough examination
must be carried out and referred to the relevant specialist if necessary
Anemia and Lead Screening

- Screening is performed at ages where there is higher deficiency for iron

deficiency anemia. Infants are screened at birth and at 4 months if there’s a
documented risk (low birth weight, prematurity). Healthy infants screened at 12
months due to high incidence at this period.
- Lead intoxication can cause irreversible developmental and behavioral
abnormalities. Levels as low as 5-10 ug/dL can cause learning problems. Risk
factors include living in old homes with lead based paint, industrial exposure,
pottery with lead paint glaze.
- Standardized lead screening questions should be administered to those between
6 months and 6 years, and suspicious responses should be subject to assessment
of blood lead levels.
Tuberculosis Testing

- All children should be assessed for risk of tuberculosis at health maintenance visits,
especially after 1 year of age
- Standardized purified protein derivative intradermal test is used with evaluation by a health
care provider 48-72 hours after injection.
- Induration size denotes a positive test (normal< 5mm)
- A 10 mm induration is suggestive of TB while in HIV positive patients 5mm is considered
positive
Cholesterol

- Important in children and adolescents with family history of cardiovascular

disease or have at least one parent with high blood cholesterol level.
- Fasting lipid profile is used for screening for children between ages 2-18.
- Total cholesterol below 170 mg/dL is normal with 170-199 mg/dL being
borderline and >200 mg/dL being elevated
Sexually Transmitted Infections Testing

- Recommended annually for adolescents.

- Full adolescent psychosocial history must be obtained in a confidential manner.
- Any child or adolescent who has had any form of sexual intercourse should be
annually evaluated for STI by physical examination such as genital warts,
herpes, and pediculosis as well as laboratory testing for conditions such as
chlamydia, gonorrhoea, syphilis and HIV.
- Young women should be screened for HPV and precancerous lesions at 21 years
of age.
Immunization

- Should be checked at each office visit and appropriate vaccines should be

administered.
Dental Care and Nutritional Assessment

- Gross abnormalities such as large caries, gingival inflammation or significant malocclusion may be
seen.
- Recommended to undergo dental examination annually.
- Dental health care visits should include information on at home preventive care as well as prophylactic
methods to prevent caries such as use of concentrated fluoride topical treatment.
- With regard to nutritional assessment plotting child’s growth on standard charts are vital and a dietary
history must be obtained as it may hint at a possible nutritional deficiency.

Anticipatory Guidance
- Information conveyed to parents, verbally, written and or directing them to certain websites to help
them facilitate optimal growth and development of their children.
- Usually age specific guideline is used that corresponds to child's development and capabilities
- E.g - Safety (number one cause of death of ages 1 month to 1 year is motor vehicle crash)
a) Infants and toddlers- rear facing safety seat (until maximum height and weight reached)
b) Toddlers and preschoolers- forward facing safety seat (until maximum height and weight reached)
c) School age children- belt positioning booster seat
d) Older children- lap and shoulder seat belts
Well Adolescent
Care
 Approach to adolescent wellbeing
● Use a non-judgemental approach
● Encourage the adolescent to talk about themself
● Focus on positive actions that these adolescents are taking to ensure
their physical and mental well - being (protective factors)
● When discussing healthcare issues, make it clear that all information
is confidential
● The focus in adolescent care is on psychosocial issues, however a
general examination must also be performed
● Include paediatric issues such as immunization and health screening
Early adolescence (Ages 10 - 14 years)

● Major characteristics: rapid changes in physical appearance &

behaviour
● Leading to a great deal of self -consciousness & need for privacy
● History focuses on the early adolescents’ physical & psychosocial
health

Middle adolescence (Ages 15 - 17 years)

● Major characteristics: autonomy and a global sense of identity

● History focuses on their interactions with family, school, and peers
● High - risk behaviours as a result of experimentation are common
Late adolescence (Ages 18 - 21 years)

● Major characteristics: individuality & planning for the future

● Greater emphasis is placed on the late adolescents’
responsibility for his or her health
 Normal Variants of Puberty
1. Breast asymmetry and masses
● Reassure the patient that the
asymmetry will be less obvious
after full maturation
● Also mention that all women have
some degree of asymmetry
● Occasionally, young women
present with a breast mass which is
usually benign fibroadenoma or
cysts
 Normal Variants of Puberty
2. Physiological leukorrhea

● Peripubertal girls often complain of vaginal discharge

● If discharge is clear without symptoms such as pruritus or odor, it is
more likely physiological leukorrhea
● Occurs due to ovarian estrogen stimulation of the uterus and vagina
● Physical examination should reveal evidence of an estrogenized
vulva and hymen without any erythema or excoriation
● Physician should always be alert for signs of abuse
 Normal Variants of Puberty
3. Irregular menses

● Initial menses are anovulatory and tend to be irregular in duration

● Irregularity may persist for 2 - 5 years, reassurance may be required
● Anovulatory bleeding is usually painless
● As the hypothalamic - pituitary - gonadal axis matures, cycle
becomes ovulatory and menses are therefore secondary to
progesterone withdrawal
 Normal Variants of Puberty
4. Gynecomastia

● Breast enlargement in boys is usually a benign, self - limited

condition
● Noted in 50 - 60% of boys during early adolescence
● Often idiopathic but may be noted in various conditions
● Typical findings: appearance of a 1 - 3 cm round, freely mobile, often
tender and firm mass beneath the areola
● If enlargement is large, hard, or fixed with nipple discharge, further
investigations would be required
Adolescent
Gynecology
 Normal Menstrual Cycle
● Average adult menstrual cycle is 28 or 31 days and lasts 4-6 days
● Blood loss during menstrual period = 30-50ml
● Upper limit of normal = 80ml
 Irregular Menses
● Irregular menses is the most common concern of early adolescent girls.
● As regular, ovulatory cycles become established, pain with menstruation
(dysmenorrhea) becomes a frequent complaint.
● Menstrual disorders commonly experienced by adolescent girls include:
○ Abnormal uterine bleeding
○ Dysmenorrhoea
○ Amenorrhoea
 Abnormal Uterine Bleeding (AUB)
- Normal ovulatory menses occur between 21 and 45 days apart, measuring
from the first day of menstruation to the first day of the next menstruation.
- The average duration of flow is 3-7 days
- More than 7 days is considered prolonged.
- More than 8 well-soaked pads or 12 tampons per day may be considered
excessive, although classically blood loss is difficult to estimate.
 Abnormal Uterine Bleeding (AUB)
- Treatment is indicated for AUB that affects the quality of life.
- Chronic and acute bleeding can be managed with CHC (COCP).
- If the etiology of bleeding is related to an immature HPO axis, use of CHCs to regulate
menstruation and allow the HPO axis to mature is appropriate.
- Tranexamic acid, is an additional therapeutic option for decreasing flow in heavy
menstrual bleeding.
- For young women with a contraindication to estrogen, progestin-only methods can also be
prescribed.
- The levonorgestrel-releasing intrauterine system, a long-acting contraceptive, can provide
over 70% reduction in blood loss in AUB as well as effective contraception for sexually
active adolescents.
 Amenorrhea
Primary amenorrhea:
The complete absence of menstruation by 16 years of age in the presence of secondary
sexual characteristics or by 14 years of age in the absence of growth or breast
development.
- May be a result of functional or anatomical abnormalities of the hypothalamus,
pituitary gland, ovaries, uterus, or vagina.
- The most common etiologies are premature ovarian insufficiency and müllerian
agenesis.
Secondary amenorrhea:
Refers to the cessation of menses for more than 3 consecutive months any time after
menarche.
- The most common causes of secondary amenorrhea are pregnancy, anorexia/stress
(low LH, FSH, and estradiol), and polycystic ovary syndrome (PCOS)
 Amenorrhea
Therapy for the amenorrhea should be directed at the cause.
- Anovulation: Either cyclic progesterone withdrawal or combined hormonal
contraceptives (CHCs).
- Irreversible hypothalamic amenorrhea ovarian failure: Therapy is directed at
replacing estrogen and progesterone, either with a combined hormone replacement
regimen or a CHC.
- Reversible etiologies of hypothalamic amenorrhea: Therapy is directed at changing
the underlying state: reducing stress, reducing excess exercise, or changing disordered
eating to allow reversal of the amenorrheic state.
- PCOS: Treated effectively with weight loss, exercise, progesterone withdrawal, or CHC.
If there is evidence of androgen excess, CHCs reduce androgen production from the
ovaries and increase sex hormone–binding globulin to reduce the amount of available
androgen. Spironolactone helps treat hirsutism, and when there is evidence of insulin
insensitivity, metformin can restore ovulatory cycles.
- Contraception should be prescribed if applicable.
 Dysmenorrhea
● Painful menstruation
● Experienced by 45-90% of young women, one of the most common
gynecologic complaints
● Primary (spasmodic) - painful periods since menarche (1st occurrence of
menstruation), unlikely to be associated to pathology
● Secondary (congestive) - painful periods that develop over time, usually have
a secondary cause
- The treatment should be considered in patients with significant distress caused by the symptoms.
 Adolescent Pregnancy
● Adolescent age of coital initiation is similar among different socioeconomic groups

● However, adolescent pregnancy and childbearing is highly prevalent in lower socioeconomic strata

● Risk factors:-

○ Lower socioeconomic status

○ Lower or lack of education

○ Lack of access to contraception

○ Alcohol and drug use

○ Adverse early life experiences in the

adolescent home

○ Low self esteem

 Adolescent Pregnancy
● Adolescents who continue their pregnancy have ↑ incidence of:

○ Preterm & very preterm births

○ Low birth weight infants

○ Infant neonatal admission

○ Postneonatal mortality

○ Child abuse

○ Subsequent maternal unemployment

○ Poor maternal educational achievement

 Adolescent Pregnancy
● Pregnancy should be considered and ruled out in any adolescent presenting with secondary
amenorrhoea

● Early adolescents often present with symptoms, including:

○ Vomiting

○ Vague pains

○ Deteriorating behavior

○ May report normal periods even with symptoms

● Urine pregnancy tests: sensitive approximately 7 to 10 days after conception

● Rape & incest should be ruled out in all cases of adolescent pregnancy
 Management of adolescent pregnancy
● When pregnancy is confirmed, immediate gestational dating is important to assist in planning

● Pregnancy adolescents should be encouraged to involve their families to assist with decision making Options

(a) Continue with the pregnancy

(b) Terminate the pregnancy

- Adolescent may choose to parent the child or have the child adopted

- Need early, consistent and comprehensive prenatal care by a team of health providers

- Socioeconomic situation should be evaluated in an effort to optimize the infant’s health and development

- Special attention should be given to keep the adolescent in school during/after pregnancy

(pregnancy is the most common cause for girls to drop out of school)

- Good prenatal care, nutrition and social support can improve pregnancy outcomes
 Contraception
● Teenagers have a relatively high
failure rate in the use of condoms and
oral contraceptive pill

● Adolescents should be counselled and

educated properly about all methods

● Implementation of ‘Double Dutch’

method of contraception (combination
of condom and oral contraception) to
protect against both STIs and pregnancy
 Rape and Sexual Assult
● Rape - Legal term for non-consensual intercourse

● Almost half of rape victims are adolescents (happens both in male & female)

● Physician’s role = gather historical and physical evidences for criminal investigations in a
supportive and non-judgemental manner

○ History

○ Details of sexual assault

○ Time from the assault until presentation

○ Whether the victim cleaned herself

○ Date of last menstrual period

○ Previous sexual activity, if any

 Rape and Sexual Assult
● Physical examination

- presence of bruises, abrasions, bitemarks, scratches, oral/genital/anal trauma

○ Photographs to be taken for investigation

● Investigations

○ Vaginal swab for microscopy and culture (presence of sperm and STIs)

○ HIV, VDRL, HBV, HCV screening

 What to do?
● Emergency contraception (2% failure rate within 72 hours)

○ 0.75 mg of levonorgestrel x2, 12 hours apart OR 1.5mg single dose OR

○ Combined oral contraceptive (equivalent of 50 mg of ethinyl estradiol and 250 μg of

norgestrel, each repeated in 12 hours)

● Prophylaxis for STIs - Cefixime 400 mg single dose oral + azithromycin 1g single dose
oral + metronidazole 2g single dose oral

● May need hepatitis immune globulin and hepatitis vaccine

● Refer for immediate and ongoing psychological support

● Repeat cultures, wet mounts, and a pregnancy test at 3 weeks after the assault

● VDRL, hepatitis and HIV test at 12 weeks

 EATING
DISORDER
 Anorexia nervosa
● The prevalence of anorexia nervosa is

1.5% in teenage girls.

● The female-to-male ratio is approximately 20:1,

and the condition shows a familial pattern.

● Peak age of onset- 14 years.

● The cause of anorexia nervosa is unknown,

but it involves a complex interaction between social, environmental,

psychological, and biologic events.

Characterized by three essential criteria:

1. The first is a self-induced starvation to a significant degree a

behavior.
2. The second is a relentless drive for thinness or a morbid fear of
fatness.
3. The third criterion is the presence of medical signs and symptoms
resulting from starvation.

Overall, anorexia nervosa is associated with :

● Depression in 65 percent of cases

● Social phobia in 35 percent of cases
● Obsessive-compulsive disorder in 25 % of cases.
 RISK FACTOR
● More prevalent in females than in males
● Higher concordance rates in monozygotic twins than in dizygotic
twins. Sisters of patients with anorexia nervosa are likely to be
afflicted
● Participation in strict ballet schools increases the probability of
developing anorexia nervosa at least sevenfold.
● In high school boys, wrestling is associated with a prevalence of full
or partial eating disorder syndromes during wrestling season of
approximately 17 percent, with a minority developing an eating
disorder and not improving spontaneously at the end of training.
 Psychological and psychodynamic factors
Reaction to the demand that adolescents behave more independently and
increase their social and sexual functioning.

Lack a sense of autonomy and selfhood. Many experience their bodies as

somehow under the control of their parents, so that self-starvation may be an
effort to gain validation as a unique and special person.

The body may be perceived as though it were inhabited by the introject of an

intrusive and unempathic mother. Starvation may unconsciously mean arresting
the growth of this intrusive internal object and thereby destroying it.
● Restricting type: During the last 3 months, the individual has not
engaged in recurrent episodes of binge eating or purging behavior
(i.e., self-induced vomiting or the misuse of laxatives, diuretics, or
enemas). This subtype describes presentations in which weight loss
is accomplished primarily through dieting, fasting, and/or excessive
exercise.

● Binge-eating/purging type: During the last 3 months, the individual

has engaged in recurrent episodes of binge eating or purging
behavior (i.e., self-induced vomiting or the misuse of laxatives,
diuretics, or enemas).
Term anorexia is a misnomer, because loss of appetite is usually rare until late
in the disorder. Evidence that patients are constantly thinking about food is their
passion for collecting recipes and for preparing elaborate meals for others.

Some patients cannot continuously control their voluntary restriction of food

intake and so have eating binges. These binges usually occur secretly and often at
night and are frequently followed by self-induced vomiting. Patients abuse
laxatives and even diuretics to lose weight, and ritualistic exercising, extensive
cycling, walking, jogging, and running are common activities.
 INVESTIGATION
● Complete blood count often reveals leukopenia with a relative
lymphocytosis in emaciated patients with anorexia nervosa.
● If binge eating and purging are present, serum electrolyte
determination reveals hypokalemic alkalosis.
● Fasting serum glucose concentrations are often low during the
emaciated phase, and serum salivary amylase concentrations are
often elevated if the patient is vomiting.
● The ECG may show ST segment and T-wave changes, which are
usually secondary to electrolyte disturbances, emaciated patients
have hypotension and bradycardia.
● Young girls may have a high serum cholesterol level. All these
values revert to normal with nutritional rehabilitation and cessation
of purging behaviors.
 TREATMENT
● Comprehensive treatment plan, including hospitalization when
necessary and both individual and family therapy, is recommended.
Behavioral, interpersonal, and cognitive approaches are used
and, in many cases, medication may be indicated.
● Restore patients' nutritional state, dehydration, starvation, and
electrolyte imbalances
● Anorexia nervosa who are 20 percent below the expected weight for
their height are recommended for inpatient programs, and patients
who are 30 percent below their expected weight require psychiatric
hospitalization for 2 to 6 months.
● Inpatient psychiatric programs for patients with anorexia nervosa
generally use a combination of a behavioral management approach,
individual psychotherapy, family education and therapy, and, in
some cases, psychotropic medications.

● Cyproheptadine (Periactin), a drug with antihistaminic and

antiserotonergic properties, for patients with the restricting type of
anorexia nervosa. Amitriptyline (Elavil) has also been reported to
have some benefit.
 PROGNOSIS
● The prognosis for children and adolescents is variable, with as many as
50% failing to make a full recovery.

● Factors predicting a poorer outcome include a low BMI and physical

complications prior to treatment, bulimic symptoms, especially
self-induced vomiting, as well as family disturbance and interpersonal
difficulties.

● The prognosis includes a 3% to 5% mortality (suicide, malnutrition)

rate, the development of bulimic symptoms (30% of individuals), and
persistent anorexia nervosa syndrome (20% of individuals).
 BULIMIA NERVOSA
● Bulimia nervosa is more prevalent than anorexia nervosa
● 1 to 4 percent of young women.
● Onset is often later in adolescence than that of anorexia nervosa.
The onset may also occur in early adulthood.
● patients with bulimia nervosa are more outgoing, angry, and
impulsive than those with anorexia nervosa. Alcohol dependence,
shoplifting, and emotional liability (including suicide attempts)
are associated with bulimia nervosa.
 PROGNOSIS
● higher rates of partial and full recovery compared with anorexia
nervosa.
● 30 percent continued to engage in recurrent binge-eating or
purging behaviors on 10 year follow up
● 40 percent of women fully recover at follow-up on 10 years
● The mortality rate for bulimia nervosa has been estimated at 2
percent per decade
Substance
Abuse
 Introduction
● Substance abuse refers to excessive use of a drug/substance in a
way that is harmful to self, society, or both. This definition
includes both physical dependence and psychological
dependence.
● Physical dependence caused by prolonged use of a drug refers
to an altered physiological state in which withdrawal symptoms
develop when the drug is discontinued.
● Psychological dependence refers to a state of intense need to
continue taking a drug in the absence of physical dependence.
● Drug and substance use is a worldwide problem as it also lead
to greater susceptibility to HIV/AIDS, Hepatitis B or C, and
tuberculosis infections.
 In Adolescents
● Adolescents are the group most prone to addiction. Due
to they have;
○ strong inclination toward experimentation,
○ curiosity,
○ susceptibility to peer pressure, and poor self-worth,
● This makes them vulnerable to drug abuse. The initiation
of drug use generally begins during adolescence, and
the maximum usage of drugs occurs among youth aged
18–25 years.
● Most studies have shown that a person who takes a drug
at a young age has a high risk of becoming addicted and
an increased risk of substance abuse problems in the
future.
 Commonly Abused Substances
● Alcohol
● Marijuana
● Tobacco
● Prescription drugs
● Hallucinogens
● Cocaine
● Amphetamines
● Opiates
● Anabolic steroids(among
adolescent boys seeking
enhanced athletic performance)
● Inhalants
● Methamphetamine
 Causes
● Cultural and societal norms influence acceptable standards
of substance use
○ Children of alcoholic parents are at higher risk for
developing alcoholism and drug dependence than are
children of nonalcoholic parents.
● Public laws determine the legality of the use of substances,
cost and availability
● Substance-related disorders in adolescence are caused by
multiple factors including
○ Genetic vulnerability
○ Environmental stressors
○ Social pressures
○ Individual personality characteristic
○ Psychiatric problems
 Presentation of Drug Abuse
Mood: Behavioral: Psychological:

● Behavioral changes Cravings for the drug of abuse

● Irritability ●
● Stealing or borrowing money Increasing problems with
● Depression ●
● Not caring about others memory
● Aggression
● Declining performance at work Poor concentration
● Violent mood ●
or decline in scholastic Increased confusion
swings ●
performance ● Forgetfulness
● Changes in mood
● Lying especially regarding the ● Aggression
● Personality amount of drugs being abused ● Violent behaviors
changes ● Abusing drugs while driving or ● Hallucinations
● Feeling hopeless engaging in other dangerous ● Paranoia
● Feeling depressed drug abuse ● Delusions
● Suicidal feelings ● Frequent problems with the law ● Thoughts of harming self or
● Avoiding friends, family and others
previously-enjoyed activities in
order to get high
Screening Tool
Common Substance Abuse
 Complications
● Heavy alcohol use can cause acute gastritis and acute
pancreatitis.
● Intravenous drug use can result in hepatitis B, bacterial
endocarditis, osteomyelitis, septic pulmonary embolism,
infection, and acquired immunodeficiency syndrome (AIDS).
● Chronic marijuana or tobacco use is associated with
bronchoconstriction and bronchitis.
● Compulsive drug or alcohol use results in an adolescent
being unable to navigate out of the psychosocial sequelae
that attend such habituation (e.g., stealing, prostitution, drug
dealing, unemployment, school failure, social isolation).
 Management
● Specific treatment for substance abuse will be determined based on:
○ Adolescent's age, overall health, and medical history
○ Extent of the adolescent's symptoms
○ Extent of the adolescent's dependence
○ The substance abused
○ Adolescent's tolerance for specific medications or therapies
● Medical detoxification and long-term follow-up management are important features of
successful treatment.
● Long-term, follow-up management usually includes formalized group meetings and
age-appropriate
● psychosocial support systems, as well as continued medical supervision.
● Individual and family psychotherapy are often recommended to address the
developmental, psychosocial, and family issues that may have contributed to and
resulted from the development of a substance abuse disorder.
 Management
Pharmacologic treatment in substance abuse has two main purposes: to permit safe
withdrawal from alcohol, sedative-hypnotics, and benzodiazepines and to prevent relapse.

● Benzodiazepines. Alcohol withdrawal is usually managed with a

benzodiazepine-anxiolytic agent, which is used to suppress the symptoms of abstinence.
● Disulfiram may be prescribed to help deter from drinking.
● Acamprosate. may be prescribed for recovering from alcohol abuse or dependence to
help reduce cravings for alcohol and decrease the physical and emotional discomfort
that occurs especially in the first few months of recovery.
● Methadone is used as a substitute for heroin in some maintenance programs.
● Levomethadyl is the treatment of opiate dependence.
● Naltrexone is an opioid antagonist often used to treat an overdose. It can also be used
to treat alcohol abuse.
 Prevention
There are three major approaches used to prevent adolescent substance use and abuse,
including the following:

● School-based prevention programs. School-based prevention programs usually

provide drug and alcohol education and interpersonal and behavior skills training.

● Community-based prevention programs. Community-based prevention programs

usually involve the media and are aimed for parents and community groups.

● Family-focused prevention programs. Family-focused prevention programs involve

parent training, family skills training, adolescent social skills training, and family
self-help groups. Research literature available suggests that components of
family-focused prevention programs have decreased the use of alcohol and drugs in
adolescents and improved effectiveness of parenting skills.
 References
1. Ismail R, Abdul Manaf MR, Hassan MR, Mohammed Nawi A, Ibrahim N, Lyndon N, Amit N,
Zakaria E, Abd Razak MA, Zaiedy Nor NI, Shukor MS, Kamarubahrin AF. Prevalence of Drug
and Substance Use among Malaysian Youth: A Nationwide Survey. Int J Environ Res Public
Health. 2022 Apr 13;19(8):4684. doi: 10.3390/ijerph19084684. PMID: 35457562; PMCID:
PMC9027138
2. Nelson Textbook of Paediatrics, 20th edition, Kliegman, Stanton, et al.
3. Substance Abuse/Chemical Dependence in Adolescents. Stanford Medicine Children's Health -
Lucile Packard Children's Hospital Stanford. (n.d.). Retrieved February 14, 2023, from
https://www.stanfordchildrens.org/en/topic/default?id=substance-abusechemical-dependence-in-
adolescents-90-P01643
4. Kaplan& Sadock’s Synopsis of Psychiatry 11th edition
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YOU