ADOLESCENT GROWTH AND DEVELOPMENT

Adolescence is a period of: (a) physical growth spurt, (b) sexual maturity (puberty), and (c) marked behavioral or psychological change. A general sequence of important physical and pubertal events during adolescence is illustrated in Fig.

Fig. 13.1: Chronology of pubertal changes.

I. Physical growth: Adolescent growth spurt begins with gradual increase in height velocity, followed by rapid weight gain in both sexes. Important characteristics of physical or somatic growth during adolescence are:

• Earliest physical change in adolescence is the linear (height) growth spurt, which begins, peaks and ends earlier in girls than in boys (Table 13.1), as testosterone is a weaker stimulant of growth hormone than estrogens. This spurt is asymmetrical in initial years of puberty, being more prominent in distal parts, e.g. limbs, giving a tall, thin and gawky appearance to adolescents.

• Peak height velocity (PHV) in girls is reached earlier than in boys during SMR stage III (discussed later) and precedes menarche by 1-1.5 years. In boys, PHV is reached later in SMR stage IV.

• Rapid weight gain begins later than the linear growth spurt. An adolescent gains 4-4.5 kg/year, compared to 2-3 kg/year in post-infancy childhood. The distribution of weight gain also differs in two sexes-predominant muscular growth in boys and predominantly fat deposition in girls. Consequently, the lean body mass, which is ~80% in prepubescent children, increases in boys to ~90% and decreases in girls to ~70%.

• Skeletal growth is more advanced in girls. In both sexes, bone age correlates better with sexual maturity than chronological age.

• Other important physical growth characteristics during adolescence are laryngeal enlargement with voice changes and elongation of optic globe with consequent myopia in some cases.

TABLE 13.1: Linear growth spurt in adolescence

PHV: Peak height velocity. All approximate values

II. Sexual maturity is the hallmark of adolescence, also referred as puberty, i.e. a series of biological changes that lead to development of reproductive capacity and involves development of primary (testicular and penile growth in boys and breast and uterine growth in girls) and secondary sexual characteristics (pubic and axillary hair, body odor, voice changes, etc.).

While age of the onset and completion of puberty has significant individual variations due to familial, genetic and environmental factors, the sequence of pubertal changes is fairly consistent, usually assessed by Tanner's sexual maturity rating (SMR) (Table 13.2). Important events in sexual maturity are as follows:

In girls, the first visible sign of puberty is Thelarche, i.e. appearance of breast buds at ~11 years (8-13 years), followed by adrenarche, i.e. appearance of fine, straight pubic hairs.

Average age of menarche in Indian affluent girls is ~12.5 years (10-16 years), i.e. after ~ 2-2.5 years of thelarche. PHV precedes menarche by 1-1.5 years, i.e. during SMR stage III.

Important genital changes in girls during puberty are: (a) enlargement of external/internal genitals, (b) start of ovulation after 1-1.5 years of menstruation, (c) vaginal mucosal changes, e.g.

In boys, first visible sign of puberty is the increase in testicular size at ~11.5 years (9-14 years), followed by adrenarche and penile enlargement. PHV in boys usually occur late in SMR stage IV.

Important genital changes in boys during puberty are: (a) increase in the testicular volume from ~4 ml in pre-pubertal age to ~20-25 ml by the completion of puberty, (b) effective sperm secretion (spermarche) at any time after ~12 years of age, and (c) penile enlargement beginning after ~1 year of starting the testicular growth and continuing till the end of puberty, though final size gain may vary individually.

III. Behavioral changes: Adolescence is a period of intense psychological and emotional turmoil, characterized by identity formation, including deve­lopment of sexual identity. Important behavioral changes during different phases of adolescence include:

• Early adolescence is characterized by the pre­occupation with body image and pubertal changes along with concrete thinking, i.e. literal perception of concepts and impulsivity with disregard to future implications. Sexual fantasies are common.

• Mid adolescence is characterised by peer-influence and family/social conflicts to develop self-identity. Risk­taking behavior is common including experiences, e.g. smoking, drinking and sexual actions, to display newly discovered autonomy. Abstract reasoning, to some extent, begins in this phase. This phase is also characterized by formation of sexual orientation and sexual identity.

• Late adolescence is a phase of stabilization with conflict resolutions with family/society, lessening of impulsivity and peer pressure, development of personal carrier goals and establishment of sexual identity.

Behavioral changes are most prominent during mid­adolescence and gradually culminate into development of stable body image, functional independence, consolidation of sexual identity and stable relationships.

13.2 COMMON HEALTH PROBLEMS IN ADOLESCENCE

Adolescence is not only a period of peak physical activity, hormonal changes and emotional stress, but also of heightened concern about body image. Consequently, many health problems present or noticed first time in this age group, apart from age-unrelated illnesses (Table 13.3).

*elevated breast/papilla.

A.

Delayed or precocious onset of pubertal changes is a common cause of medical consultations during adolescence. As most of these variations are familial, detailed parental history, specially regarding their pubertal events, is essential to differentiate normal variants from potentially disease states.

Precocious puberty (PP) is defined as:

• Appearance of secondary sexual characteristics before

8 years in girls and 9 years in boys; or

• Onset of menarche before 10 years, in girls.

Precocious puberty may be central in origin-due to premature activation of hypothalamic-pituitary-gonadal (HPG) axis or due to peripheral causes, e.g. exogenous administration/endogenous overproduction of gonadal steroids. Peripheral puberty is usually limited to premature development of one or more secondary sexual characteristics, e.g. thelarche or adrenarche, without actual reproductive maturation (Ch 22.6.2).

Delayed puberty denotes maturational lag in HPG axis, as indicated by:

• Absence of first pubertal indicator by 13 years in girls (primary breast mound) and 14 years in boys (testicular enlargement),

• A Gap of gt; 5 years between first sign of puberty and completion of genital growth/ menarche, or

• Absence of menarche by 15 years in females.

Delayed puberty is usually constitutional, with similar family history and simultaneous delay in height and bone age. Pathological delay may be due to central gonadotropin deficiency or peripheral non­responsiveness to these hormones (Ch 22.6.2).

B. Physical problems: Adolescents are susceptible to broad range of physical problems due to growth spurt, increased physical activity, hormonal changes and environmental influences.

Nutritional problems: Common nutritional problems in adolescents include: (a) iron deficiency anemia, more likely in girls due to menstrual losses, (b) calcium deficiency, due to rapid skeletal growth with less sun exposure, (c) iodine deficiency due to increased requirement, i.e. pubertal goiter, (d) undernutrition or obesity due to faulty food habits and changing life style. Adolescents are also prone to psychogenic eating disorders, e.g. anorexia nervosa, discussed later.

Obesity is emerging as a major cause of concern in Indian adolescents due to inappropriate dietary habits and sedentary life style, with immediate risk of developing of low self-esteem due to poor body image and later risk of serious diseases, e.g. diabetes, hypertension, coronary heart disease, strokes and malignancies.

Skin problems, specific during adolescence, usually relate to hormonal changes and imbalance, e.g. acne and hirsutism. Hirsutism, i.e. androgenic male hair pattern in females, is frequently familial or iatrogenic in origin (steroids, minoxidil, dilantin) and should be distinguished from pathological virilization, which is associated with early appearance of secondary sexual characteristics as well.

Orthopedic problems in adolescents originate due to rapid growth of long bones, consequent hypertraction over muscle/tendon insertions and increased sports activity. Important orthopedic problems, specially pertaining to adolescents include—idiopathic adolescent scoliosis, slipped capital femoral epiphysis, rheumatoid disorders and sports injuries, etc.

Systemic illnesses: Many physical illnesses, e.g. hyper­tension, diabetes and rheumatic disorders precipitate or exacerbate during adolescence, due to increased metabolic demands and activity.

TABLE 13.4: Causes of gynecomastia

TABLE 13.6: Causes of nipple discharge

• Benign gynecomastia in adolescents

• Drugs: NSAIDs, digoxin, INH, hormones

• Chronic liver or renal disease

• Tumors: Adrenal, gonadal, etc.

• Endocrinal: Hypogonadism, hyperthyroidism

At the same time, many childhood illnesses tend to improve, disappear or enter into long remissions at puberty, e.g. asthma, nephrotic syndrome, rheumatic fever, sino-pulmonary infections, etc., due to hormonal changes or reduced risk of environmental exposure.

C. Breast problems: Physiological variations, e.g. asymmetric breast size, marginally delayed thelarche or transient nipple discharge in girls and transient gynecomastia in boys are common causes of concern during adolescence, though most of these are normal variations and do not require any intervention except reassurance.

Gynecomastia, i.e. breast enlargement in boys is common (~50-60%) during mid-adolescence, which may be unilateral or bilateral and tender or non-tender. Usually, it is a benign process due to hormonal changes that regresses spontaneously within few months and no treatment is required except reassurance. Pharmacotherapy with bromocriptine is indicated only in severe cases with significant physical or psychological discomfort. However, persistent or progressive gyneco­mastia in adolescents may be pathological (Table 13.4) and needs evaluation.

Congenital anomalies, e.g. amastia (absent breast), athelia (absent nipple), polymastia and polythelia (supernumerary breasts or nipples), are usually unilateral and frequently missed till adolescence.

Amastia may be associated with Poland syndrome (aplasia of pectoralis muscle, rib abnormalities, webbed fingers and radial aplasia). Supernumerary breasts/ nipples commonly present along the milk-lines-drawn from shoulder-tip to xiphisternum. Surgical intervention is rarely needed in these cases, except for cosmetic purpose.

Breast hypertrophy or masses may be physiological or pathological (Table 13.5).

Virginal hypertrophy, i.e. massive bilateral breast enlargement in females probably indicates end-organ

TABLE 13.5: Causes of breast masses

• Virginal hypertrophy

• Mastodynia

• Fibroadenoma (commonest mass in adolescence)

• Fibrocystic breast disease

• Mastitis or breast abscess

• Malignancy: Rhabdomyosarcoma, lymphoma

• Gynecomastia in boys due to any cause (Table 13.4)

• Benign: Local stimulation

• Pregnancy

• Drugs: Contraceptives, methyldopa

• #8593; prolactin: Pituitary adenoma, hypothyroidism#

• Local*: Ductal ectasia, papilloma, malignancy

• blood-tinged discharge # due to #8593; TRH

hypersensitivity to estrogens and may require reduction mammoplasty after late adolescence.

Mastodynia, the painful cyclical breast engorgement, during ovulation/ menstruation time is common in late adolescence, which should be treated with analgesics and bra support.

Unilateral breast lumps in adolescence are usually benign, e.g. fibroadenoma (commonest), but rare risk of malignancy must to be excluded by FNAC or biopsy.

Nipple discharge: Transient milky or sticky nipple discharge in adolescent girls is not uncommon due to physical stimulation or drugs, e.g. contraceptives. How­ever, persistent galactorrhea or blood-tinged discharge needs to be investigated for pathological causes (Table 13.6).

D. Menstrual problems: Mean age of menarche in Indian girls is ~12.5 years (10-16 years) and initial cycles for first 12-18 months are often irregular and anovulatory. Menstrual onset, frequency and duration pattern usually correlates well with maternal pattern

Amenorrhea may be primary, i.e. absent menstruation till 16 years of age, despite breast development or secondary, i.e. cessation of menstruation for gt;3 months, after previous regular periods; due to various causes (Table

13.7). Teenage pregnancy is increasingly common and needs to be excluded in cases of secondary amenorrhea. Dysmenorrhea, i.e. lower abdominal pain or cramps during menstruation occurs in ~60% of teen-girls, frequently leading to school absenteeism. Most cases

TABLE 13.7: Causes of amenorrhea

Primary amenorrhea

• Physiological delay

• Undernutrition

• Hypothalamic: GnRH deficiency

• Hypopituitarism

• Gonadal dysgnenesis, e.g. Turner syndrome

• Utero-vaginal anomalies, e.g. imperforate hymen

• Others: Hypothyroidism, cortisol excess, etc.

Secondary amenorrhea

• Pregnancy

• Transient: Dieting, heavy exercise, stress

• Chronic medical illnesses

• Endocrinal: Hypopituitarism, hypothyroidism

• Gonadal: Polycystic ovary, pelvic radiation/surgery

• Utero-vaginal synechiae

• Drugs: Oral contraceptives, phenothiazines

TABLE 13.8: Causes of abnormal uterine bleeding

TABLE 13.9: Causes of vaginal discharge

• Dysfunctional uterine bleeding (DUB)

• Threatened abortion/ectopic pregnancy

• Vaginal infections, trauma or foreign body

• Uterine: Endometriosis, congenital anomalies

• Ovarian: Polycystic ovary, tumors

• Pelvic inflammatory disease

• Systemic bleeding disorders

• Endocrinal: Thyroid or adrenal disorders

• Drugs: Oral contraceptives, aspirin

may be treated with rest and anti-inflammatory agents. Severe or secondary dysmenorrhea after initial painless cycles must be investigated for—(a) pelvic inflammatory disease, (b) endometriosis, (c) intrauterine devices, (d) utero-vaginal anomalies/tumors, and (e) ectopic pregnancy.

Abnormal uterine bleeding may be dysfunctional (no underlying pathology) or secondary (Table 13.8).

Dysfunctional uterine bleeding (DUB) is a diagnosis of exclusion, usually associated with anovulatory cycles without progesterone production and unopposed estro­gen excess. Treatment of severe DUB includes cyclic estrogen-progesterone therapy and iron supplementation. E. Urogenital problems: Urogenital problems are common in adolescence due to increasing genital concerns, local mucosal susceptibility due to hormonal changes and precocious sexual activity.

Physiological leucorrhoea, i.e. thin, mucoid, acidic and non-foul smelling discharge, usually before menstruation, is common in adolescent girls due to high estrogen levels and needs no treatment except reassurance. However, any purulent, bloody or foul smelling discharge or that associated with pruritis or urinary complaints needs evaluation (Table 13.9).

Non-specific vaginosis (NSV) is the commonest cause of pathological vaginal discharge in adolescent girls, due to: (a) inadequate external protection due to lack of labial pad of fat and pubic hair, (b) thin, atrophic, less acidic vaginal epithelium, (c) close proximity with anal orifice, and (d) experimental sexual activity, e.g. masturbation.

• Physiological leucorrhoea

• Non-specific vulvovaginitis

• Vulvo-vaginal candidiasis

• Sexually transmitted diseases

• Genital trauma or foreign body

• Urethral prolapse

• Genital tumors

Common microbial etiology of NSV includes fecal pathogens, e.g. enterococci, Staph. aureus, anaerobic pathogens, candida, etc.

Management of these cases include: (a) good peri­neal hygiene, (b) symptomatic treatment, (c) topical antifungal/antibiotic agents, and (d) systemic antibiotics in selected cases. NSV need to be differentiated from more serious STDs with vaginal discharge.

Superficial perineal infections, e.g. intertrigo, fungal infections or pediculosis, etc. are common in both sexes due to poor perineal hygiene, use of tight underwears and sweat-induced moisture. Presence of fungal infection may be confirmed with wet KOH preparation and treated with topical antifungals, e.g. clotrimazole.

Sexually transmitted diseases (STDs) are often under­diagnosed in adolescence and may be acquired by casual contact or genital handling with contaminated fingers. According to the syndromic approach, clinical presentation of STDs may be broadly divided into four groups—(a) vaginal or urethral discharge, (b) ulcerative genital lesion, (c) inguinal lymphadenopathy, and (d) pelvic inflammatory disease (PID).

Although detailed discussion of STDs is beyond the scope of this book, a short summary of common STDs is presented in Table 13.10.

Congenital urogenital tract anomalies, though present since birth, are frequently noticed first time during adolescence due to menstrual problems (imperforate hymen, vaginal septa/atresia and uterine anomalies) and increased genital concerns (epispadias, hypospadias or undescended testes).

TABLE 13.10: Common sexually transmitted diseases in adolescents

*in uncomplicated disease, PID: Pelvic inflammatory disease

13.3 PSYCHOSOCIAL PROBLEMS IN ADOLESCENCE

Adolescents are highly susceptible to behavioral pro­blems due to emotional turmoil and search for the independence, sometimes crossing the social barriers with substantial anti-social dimensions

Prevalence of mental health problems in Indian adole­scents is estimated to be about 10-15%, though many of them remain unrecognized due to ignorance and taboo attached to them. Common psychological problems in this age group may be broadly divided into following categories:

• Adaptive disorders, e.g. depression, suicide, juvenile delinquency, etc.

• Psychosomatic disorders, e.g. anorexia nervosa, bulimia, conversion reactions, etc.

• Disorders of sexuality, e.g. masturbation, pregnancy.

Some common mental health issues in adolescents are discussed as follows:

Anorexia nervosa (AN) is an increasing common behavioral problem in adolescent girls, characterized by:

• Intense fear of obesity despite weight loss,

• Denial of weight loss, even if obvious,

• Refusal to maintain weight above minimal limits,

• Secondary amenorrhea for gt;3 cycles in females.

Epidemiology: AN is estimated to be prevalent in ~1-5% of teen girls, with a female to male ratio of 20:1. Important risk factors for AN include-family history, low-self esteem and preoccupation with self-image.

Clinical manifestations usually begin in adolescence with moderate efforts of dieting to improve the self­appearance, which ultimately progress to severe malnutrition. Two type of dieting efforts prevail- restricted-eating and bulimic-type, i.e. binge-eating with self-induced vomiting. Gradually the patient becomes extremely cachexic with rough and scaly skin, alopecia, constipation and signs of vitamin/mineral deficiency.

More severe cases may also develop complications, e.g. (a) dehydration/dyselectrolytemia, (b) postural hypotension, (c) neuropsychological problems, (d) pancytopenia, and (e) endocrinal problems, e.g. amenorrhea. About 10% of them may even die due to severe dehydration/shock, dyselectrolytemia and anemia.

Management of AN requires a combination of nutri­tional rehabilitation and psychotherapy, e.g. behavioral modification. Pharmacotherapy with antidepressants are useful only in cases with associated depression.

Bulimia nervosa (BN) is a distinct entity from AN, characterized by recurrent episodes of:

• Binge-eating, e.g. compulsive excessive and frequent eating, followed by;

• Inappropriate efforts to control weight gain, e.g. self­induced vomiting or misuse of laxatives, diuretics, enema, etc.

Unlike AN that is common in girls with low self­esteem, BN is more common in girls with impulsive or anti-social personalities like those with history of drug abuse, sexual promiscuity and suicidal attempts and stealing. Electrolyte abnormalities due to excessive vomiting or laxative use is the predominant morbidity in these cases.

Management includes a combination of nutritional monitoring, psychological support and antidepressants. Substance abuse: Although experimental substance abuse may be considered as part of normal psychosocial development, habitual or compulsive abuse among adolescents has shown a distinctly upward trend during recent years.

Commonly used substances in India are alcohol, nicotine and volatile substances, e.g. spirit and shoe polish. Drug abuse due to other agents, e.g. hallucinogens (LSD or ecstasy), barbiturates, opiates and cocaine is rising; as also the use of anabolic steroids to enhance atheletic performance.

Risk factors for substance abuse include—(a) social and peer pressure, (b) emotional stress, (c) low-self-esteem, (d) family maladjustments, and (e) lack of inhibitory influences. Role of unknown genetic or biological factors has been postulated in cases with severe substance abuse or dependence.

Clinically, substance abuse should always be suspected in any adolescent with unexplained: (a) abnormal behavior, e.g. depression or mood elevation, (b) physical signs, e.g. respiratory depression, coma, papillary abnormalities, and (c) superficial indicators, e.g. unexplained needle marks or breath odor.

Management of these cases includes: (a) treatment of acute episodes with specific antidotes and supportive measures, (b) enrolment in long-term detoxification programs, (c) psychological evaluation and counseling of patient and family, (d) elimination of precipitating factors, and (e) rehabilitation in the school, family or workplace.

Masturbation, i.e. stimulation of one's own genitals to derive pleasure, is not an uncommon behavior even in pre-adolescents but becomes more common in adolescence with an incidence of as high as 90% in boys and 30% in girls. It may also be a manifestation of sexual abuse or exposure to explicit sexual material/events.

However, compulsive, intense masturbation that disturbs other activities, inter-personal relationships or involves use of objects/public display is not normative and needs counseling. Parents must be counselled about normal nature of this act. Moral lectures or punishment only intensifies this behavior. Behavioral therapy is

indicated only in rare selected cases with compulsive acts, leading to development of guilt and anxiety in adolescents and their parents.

Teen pregnancy is estimated to account for ~15% of all pregnancies in India and often get underreported.

Epidemiologically, three important risk factors for teen pregnancy in India are—(a) early marriage as a prevalent social custom in many backward regions, (b) experimental tendencies in adolescents (unwed mothers), and (c) inadequate sexual education or awareness about contraceptive methods.

Consequences of teen pregnancy are disastrous not only to mother but also to family and offspring (Table 13.11). Maternal and infant mortality rates in teen mothers are ~2-3 times higher than in general population.

Prevention: Although legal barriers for early/childhood marriages are already in place in India, important preventive measures against teen-pregnancies include-

(a) social reforms and community-awareness campaigns to discourage child marriages, (b) adolescent counseling at every contact level, regarding hazards and protection methods, (c) changes in adolescent-parent communication ties, (d) promotion of female literacy, and (e) easy and confidential availability of birth control education, devices and obstetrical care.

Teen-suicide: Suicide is the third leading cause of adolescent mortality in India and the fifth leading cause, globally.

Adolescents are at risk for suicide or attempted suicide due to cognitive immaturity and impulsivity. Successful attempts are more common in boys while failed attempts are more common in girls.

Adjustment disorders, anxiety and depression, sub­stance abuse, physical/sexual abuse and parent-child conflict are common causes of suicide in adolescents.

Family history of suicide and non-suicidal self-injury behavior, i.e. deliberate destruction or alteration of body

TABLE 13.11: Consequences of teen-pregnancy

Maternal (high maternal mortality)

• General: Undernutrition, anemia, osteoporosis

• Local: Vaginal infections and STDs

• Psychological: Distress, depression and suicides

Obstetrical

• Cephalopelvic disproportion

• Peurperal sepsis

• Birth-canal trauma

Neonatal (high perinatal/infant mortality)

• Abortions and stillbirths

• Prematurity and low birth weight

• Neonatal sepsis

Socioeconomic

• Social ostracization

• Economic drawbacks

• Increased cost of health care tissue without suicidal intent to cope with mental distress or secure attention are important risk factors for suicide in teens.

Many scoring systems have been developed to assess the risk of self-inflicted injury or suicides in teens, which can be used to identify high-risk cases and refer them for mental health support. HEEADSSS screening, a useful tool to assess psychosocial history in adolescents may also be used to identify high-risk cases (Ch 13.4).

13.4