what kİnd of preventive services should be given to adolescents and when? müjgan alikaşifoğlu...

WHAT KİND OF PREVENTIVE SERVICES SHOULD BE GIVEN

TO ADOLESCENTS AND WHEN?

Müjgan AlikaşifoğluProfessor of pediatrics

Cerrahpaşa Medical FacultyDepartment of Pediatrics

Division of Adolescent Medicine

Learning objectives

To understand

• The characteristics of adolescence

• Adolescents special health care needs

• How these special needs can be met?

• From a traditional medical perspective, adolescents enjoy a particularly good state of health.

• Their morbidity rates for certain organic diseases such as heart disease and cancer, which tipically afflict adults, are historically low.

• Likewise, other disorders that may arise during adolescence, such as hypertansion and hyperlipidemia usually cause severe health problems in later life.

• Adolescence, however, is a time of significant change that can lead to emotional disorders and health risk behaviors, some of which may cause serious morbidity and mortality.

• Depression, suicidal ideation, unsafe sexual behaviors, alcohol and drug use, use of tobacco products, and unintentional injuries are just a few of the significant health problems facing adolescents today.

These problems are reflected in the following statistics:Cerrahpasa Health Study

• 61% of high school students are experimental drinkers. • 46% of the students are current drinkers. • 6% of the students are regular drinkers. • 19% of the students reported that they had been really

drunk at least once during their lifetime.• 44% of high school students are experimental smokers. • 23 % of high school students are current smokers.• During the last 12 months preceding the survey 7%

reported that they were involved in a fight which required medical treatment.

• Studies on adolescents health has also shown that there is an intraindividual covariation of adolescent problem behaviours that cluster to form a risk behaviour syndrome.

Smoking+drinking+unsafe sex+ drug use etc

Relationships between smoking, drinking and illicit drug use

Uyuþturucu Kullanma ve Alkol, Sigara Ýliþkisi

7,541 4,406 12,908

6,365 3,752 10,799

Haftadabir alkol

Her günsigara

Exp(B) Lower Upper

95,0% C.I.for EXP(B)

Some conclusion can be drawn from these results:

• The health threats for adolescents today are predominantly behavioral rather than biomedical.

• Today’s adolescents are involved in health behaviors with the potential for serious consequences.

• Many, but not all, adolescents engage in multiple health-risk behaviors simultaneously.

The reasons for these findings are varied and may include adverse societal influences such as;

• unemployement,

• poverty,

• declining availability of parents,

• incresed exposure to violence etc.

• Regardless of the causes, contemporary medicine is faced with a difficult question: how should it respond to the health crisis of today’s youth?

You may question the role of medicine in behavioral health problems

If the aim is to prevent premature death and disability among adults, namely cardiovasculer disease,

This would require targeting services at children and adolescents to prevent smoking, improve eating habits, promote exercise, and identify and treat early onset of hypertansion and hyperlipidemia.

•

WHAT KİND OF PREVENTIVE

SERVICES SHOULD BE GIVEN TO

ADOLESCENTS AND WHEN?

The clinical visit should be accepted an opportunity for health promotion and disease prevention.

• During this visit, physicians will be able to provide health guidance to both adolescents and their parents.

Health screening and evaluation• This visits also provide physicians the

opportunity to identify adolescents who have recently initiated health risk behaviors or who have early stages of physical or emotional disorders.

• Visits to a health care provider should reinforce positive health behavior paterns while discouraging negative behaviors in area such as exercise, nutrition, sexuality, driving, smoking, and relationships.

• WHO describes adolescent as a person who is between the age of 10-19.

• health guidance is offrede to promote the health and well-being of adolescents and their families.

• Screening is offered to identify conditions relatively common to adolescents that cause significant suffering either during adolescence or later in life.

• İmmunizations is offered for the primary prevention of selected infectious diseases.

Health services given to adolescents include:

• Parenting and family adjustment

• Psychosocial adjustment• Intentional and

unintentional injuries• Dietary habits, eating

disorders, and obesity• Physical fitness• Sexual behaviors, STD’s,

and unintended pregnancy• Hypertansion

• Hyperlipidemia• Use of tobacco products• Use of alcohol, other

drugs, and anabolic steroids

• Severe or recurrent depression and suicide

• Physical, sexual, and emotional abuse

• Learning and school problems

• Infectious diseases

• For some health topics, the preventive strategy includes a recommendation for either health guidance, screening, or immunization services.

• Other health topics, however, are addressed by a combination of services.

RECOMMENDATIONS FOR ADOLESCENT PREVENTIVE SERVICES

Recommendations for health guidance

Parents or other adult caregivers of adolescents should receive health guidance at least

• Once during early adolescence,

• Once during middle adolescence,

• Once during late adolescence.


This includes providing information about:• Normative adolescent development, including

information about physical, sexual, and emotional development.

• Sign and symptoms of diseases and emotional distress.

• Parenting behaviors that promote healthy adolescent adjustment.

• İmportance of discussing health-related behaviors with their adolescent, planning family activities, and acting an role models for health-related behaviors.


• Methods for helping their adolescent avoid potentially harmful behaviors such as:

1-Monitoring and managing the adolescent’s use of motor vehicles especially if he or she is a new driver

2-Avoiding having weapons in the home. Parents who have weapons in the home should be advised to make them inaccessible to adolescents.

3-Removing weapons and potentially lethal medications from the homes of adolescents who have suicidal intent.

4-Monitoring their adolescent’s social and recreational activities to restrict sexual behavior and use of tobacco, alcohol, and other drugs.


• All adolescents should receive health guidance annually to promote a beter understanding of their physical growth, psychosocial and psychosexual development, and the importance of becoming actively involved in decisions regarding their health care.


• All adolescents should receive health guidance annually to promote the reduction of injuries.

Health guidance for injury prevention includes:


1-Counseling to avoid the use of alcohol or other substances while using motor or recreational vehicles, or where impaired judgment may lead to injury.


2-Counseling to use safety devices, including seat belts, motorcycle and bicycle helmets, and appropriate athletic protective devices.


3-Counseling to resolve interpersonal conflicts without violence.

4-Counseling to avoid the use of weapons and/or promote weapon safety.

5-Counseling to promote appropriate physical conditioning before exercise


• All adolescent should receive health guidance annually about dietary habits, including the benefits of a healthy diet and ways to achieve a healthy diet and safe weight management.

• All adolescents should receive health guidance annually about the benefits of exercise and should be encouraged to engage in safe exercise on a regular basis.


• All adolescents should receive health guidance annually regarding responsible sexual behaviors, including abstinence, latex condom to prevent STIs and appropriate methods of birth control should be made available with instructions on how to use them effectively.


• Health guidance for sexual responsibility includes:Counseling that abstinence from sexual intercourse is the most effective way to prevent pregnancy and sexually transmissible infections, including HIV infection.Counseling on how HIV is transmitted, on the dangers of the disease, and on the effectiveness of latex condom in preventing STIs, including HIV infection.Counseling to reinforce responsible sexual behavior in adolescents who are not currently sexually active and in those who are using birth control and condoms appropriately.Counseling on the need for adolescents to protect themselves and their partners from pregnancy, STIs, and sexual exploation.


• All adolescents should receive health guidance annually to promote avoidance of tobacco, alcohol and abusable substances, and anabolic steroids.

Recommendations for screening

All adolescents should be screened annually for hypertansion.

• Adolescents with either systolic or diastolic preasures at or above the 90th percentile for gender and age should have blood preasure measurement repeated at three different times within one month, under similar physical conditions, to confirm baseline values.


• Adolescents baseline blood pressure values greater than the 95th percentile for gender and age should have a complete biomedical evaluation to establish treatment options.

• Adolescents with blood pressure values between the 90th and 95th percentile should be assessed for obesity and their blood pressure monitored every six months.

Blood pressure

Normal

Annual control

≥ 90. pers

repeated at three diff times 1 mo

Normal mean value

90-95. pers > 95. pers.

Obese?Other ?

Complate evaluation

Monitor every 6 mo

Recommendations for screeningSelected adolescents should be screened to determine their risk of developing hyperlipidemia and adult coronary heart disease.

• Adolescents whose parents have a serum cholesterol level greater than 240 mg/dl and adolescents who are over 19 years of age should be screened for a total blood cholesterol level at least once.

• Adolescents with an unknown family history or who have multiple risk factors for future cardiovascular disease (e.g.. smoking, hypertansion, obesity, diabetes mellitus) are screened for total serum cholesterol level at least once during adolescence.


• Adolescents with blood cholesterol values less than 170 mg/dl should have the test repeated within five years.

• Those with values between 170 mg/dl and 199 mg/dl should have a repeated test. If the average of the two tests is below 170 mg/dl, total blood cholesterol level should be reassessed within five years.

• A lipoprotein analysis should be done if the average cholesterol value from the two tests is 170 mg/dl or higher, or if the result of the initial test was 200 mg/dl or greater.

Total Cholesterol

< 170mg/dl170-199 mg/dl

≥ 200mg/dl

Repeat within 5 years Repeat immediatelly

lipoprotein analysis

Mean < 170 mg

Mean > 170mg

lipoprotein analysis


• Adolescents who have a parent or grandparent with coronary artery disease, peripheral vascular disease, cerebrovascular disease, or sudden cardiac death at age 55 or younger should be screened with a fasting lipoprotein analysis.


Treatment options are based on the average of two assessments of low-density lipoprotein cholesterol:

• Values below 110 mg/dl are acceptable. • Values between 110-129 mg/dl are borderline. The

lipoprotein status should be re-evaluated in one year.

• Adolescents with values of 130 mg/d lor greater should be referred for further medical evaluation and treatment.

LDL

<110mg/dl

110-129 mg/dl

≥130 mg/dl

Normal

Repeat within 1 year

Complate evaluation

Recommendations for screeningAll adolescents should be screened annually for eating disorders and obesity by determining weight and stature, and asking about body image and dieting patterns.

• Adolescents should be assessed for organic disease, anorexia nevroza, or bulimia if any of the following are found:1-Weight loss greater than 10% of previous weight2-Recurrent dieting when not overweight3-Use of self-induced emesis, laxatives, starvation, or diuretics to lose weight4-Distored body image5-Body mass index below the fifth percentile.


• Adolescents with a BMI between the 85th and 94th percentile are at risk for becoming overweight.

A dietary and health assessment to determine psychosocial morbidity and risk for future cardiovascular disease should be performed on such youths if any one of the following is identified:

1-If BMI has increased by two or more units during the previous 12 months

2- If there is a family history of premature heart disease, obesity, hypertansion, or diabetes mellitus.

3- If express concern about their weight4- If have elevated serum cholesterol levels or

blood pressure.• If this assessment is negative, these

adolescents should be provided general dietary and exercise counseling and monitored annually.


• All adolescents should be asked annually about their use of tobacco products, including cigarettes and smokeless tobacco.

Adolescents who use tobacco products should be assessed further to determine their pattern of use.

A cessation plan should be provided for adolescents who use tobacco products.


All adolescents should be asked annually about their use of alcohol and other abusabale substances, and about their use of over-the-counter of prescription drugs for nonmedical purposes, including anabolic steroids.


Adolescents who report any use of alcohol or other drugs or inappropriate use of medicines during the past year should be assessed further regarding

• Family history, • Circumtances surrounding use, • Amount and frequency of use, • Attitudes and motivation about use, • Use of other drugs and • The adequacy of physical, psychosocial, and

school functioning


Adolescents whose substance use endangers their health should be referred for counseling and mental health treatment, as appropriate.Adolescents who use anabolic steroids should be counseled to stop.Adolescents who use alcohol or other drugs should also be asked about their sexual behavior and their use of tobacco products.


All adolescents should be asked annually about involvement in sexual behaviors that may result in unintended pregnancy and STIs, including HIV.

• Sexually active adolescents should be asked about their use and motivation to use condoms and contraseptive methods, their sexual orientation, the number of sexual partner they have had in the past six months and their history of prior STIs.

• Adolescents at risk for pregnancy, STIs, or sexual exploation should be counselted on how to reduce this risk.


• Adolescents at risk for HIV infection should be offered confidential HIV screening with ELISA and confirmatory test.Risk status includes:

• Having used intravenous drugs, • Having had other STIs, • Having lived in an area with a high prevalence of STIs and HIV

infection, • Having had more than one sexual partner in the last six months, • Having exchanged sex for drugs or money, • Being male and having engaged in sex with other males or, having

had a sexual partner who is at risk for HIV infection.The frequency of screening for HIV infection should be determined by the risk factors of the individual.

Recommendations for screening• All adolescents should be asked annually about behaviors or

emotions that indicate recurrent or severe depression or risk of suicide.Screening for depression or suicidal risk should be performed on adolescents who exhibit cumulative risk as determined by:

• Declining school grades, • Chronic melancholy, • Family disfunction, • Homosexual orientation, • History of physical or sexual abuse, • Alcohol or other drug use, • Previous suicide attempt, • Suicidal plans.


If suicidal risk is suspected, adolescents should be evaluated immediately.

They should be referred to a psychiatrist or they should be hospitalized.


• All adolescents should be asked annually about a history of emotional, physical, and sexual abuse.If abuse is suspected, adolescents should be assesses to determine the circumtances surrounding abuse and the presence of physical, emotional, and psychosocial consequences, including involvement in health-risk behaviors.Adolescents who report emotional or psychosocial sequela should be referred to a psychiatrist for evaluation and treatment


All adolescents should be asked annually about learning or school problems.

Adolescents who report • A history of truancy, • Repeated absences, • Poor or declining performance should be assessed

for the presence of conditions that could interfere with school success.


These include: • Learning disability, • Attention deficit hyperactivity disorder, • Medical problems, • Sexual abuse, • Family dysfunction, • Mental disorder, • Alcohol or other drug use.


• Adolescents should receive a tuberculin skin test if they have been exposed to active tuberculosis

Recommendations for immunizations

• All adolescents should receive a Td vaccine

• All adolescents should receive a second trivalent MMR vaccination unless they had a history of the diseases or there is documentations of two vaccinations earlier during childhood.

Recommendations for immunizations

• All adolescents should be vaccinated against hepatitis B and hepatitis A viruses unless they had history of the diseases or there are documentations of three vaccinations for hepatitis B and two vaccinations for hepatitis A earlier during childhood.

• All adolescents should be asked about chicken pox history and if they did not have a history of the disease, they should vaccinated against varicella virus.

Thank you

what kİnd of preventive services should be given to adolescents and when? müjgan alikaşifoğlu...

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