Week 7 Lecture

Thursday, February 27, 2020 9:13 PM

ADOLESCENCE
- Transition from childhood to adulthood
- Age 11-20 years
- Early; 11-14
- Middle; 15-17
- Late; 18-20
- Some function as adolescents into the 20s

Physical Growth
- Rapid growth to physical maturity
- Heart, blood volume, and systolic BP increase
- Heart rate decreases
- Respiratory vital capacity increases
- Change in BMR

Growth & Development

- In general girls begin puberty and reach maturity about 1 1/2 - 2 years
earlier than boys
- Lean body mass, primarily muscle mass increases in both boys and girls
during early puberty
- Height increases in girls during early puberty, whereas boys does not
increase until mid-puberty

Primary Sexual Characteristics

- The primary sexual characteristic in females is the development and
release of an egg, or ovum from the ovaries approximately every 28 days
- The primary sexual characteristic for males is the development of viable
sperm

Tanner Stages
- For females, Tanner Stages describe the development of breast size and
distribution of pubic hair
- For males, testicular volume, scrotal size, size and shape of the penis
Tanner Stages
- For females, Tanner Stages describe the development of breast size and
distribution of pubic hair
- For males, testicular volume, scrotal size, size and shape of the penis
- Sequence is predictable
- Age of occurrence varies

Female Sexual Maturation

- Thelarche (small bud of breast tissue) is the earliest most visible change of
puberty at 7-11 years
- Pubic hair usually follows 2-6 months after thelarche
- Early in puberty there is often an increase in physiologic leukorrhea
associated with uterine development (good anticipatory guidance point)
- Average age of menarche in United States
- 12.55 years for Caucasian
- 12.06 years for African-American
- 12.25 years for Mexican-America
- Initial menstrual periods are usually scanty and irregular they may or may
not be accompanied by ovulation
- Ovulation usually begins 6-14 months after menarche
- In developed countries, the mean age of menarche has gradually
decreased over the past century corresponding to population
improvements in nutrition, sanitation, and control of infectious disease
- Normal increases in weight and fat deposition that accompany puberty
among girls; conflict with cultural norms that emphasize a slender look
- An all too common response to this is engagement in extensive dieting at
a time when nutritional requirements are at a peak
- Health promotion efforts to pubertal growth, eating behaviors, and body
image are important for adolescent girls

Male Sexual Maturation

- First changes in boys are testicular enlargement accompanied by scrotal
looseness
- This occurs around 9 1/2 - 14 years of age
- Early puberty is accompanied by initial appearance of pubic hair
- Mid-puberty sees penile and testicular enlargement, pubic hair growth,
increasing muscularity, early voice changes, facial hair
- Gynecomastia (breast enlargement and tenderness) is common during
puberty and temporary
 - Early puberty is accompanied by initial appearance of pubic hair
- Mid-puberty sees penile and testicular enlargement, pubic hair growth,
increasing muscularity, early voice changes, facial hair
- Gynecomastia (breast enlargement and tenderness) is common during
puberty and temporary
- Height and weight spurts occur at the end of mid-puberty
- Precocious puberty in boys may be a concern if secondary sexual
characteristics occur before age 9
- Concerns occur for boys who exhibit no testicular or scrotal changes by
age 13.5-14
- The ability for penile erection is present at birth but only with pubertal
maturation do boys have seminal emissions
- Nocturnal emissions may occur spontaneously and if they are not
prepared for them they may be troubling or embarrassing
- This is another good place for anticipatory guidance

Development of Sexuality
Sexual Identity
- Critical time in development
- Hormonal, physical, cognitive, and social changes affect sexual
development
- Begin to integrate changes involved with ouberty to develop identities
separate from their families
Sexual Orientation
- Pattern of sexual arousal or romantic attraction towards persons of same,
opposite or both genders
- A developmental process with milestones
- Heterosexual adolescents tend to identify earlier
Body Image
- Early development of secondary characteristics associated with early
sexual activity
Masturbation - opportunity for sexual self exploration
- Boys early adolescence
- Girls may start early but many don't start till after intercourse

Intimacy
- Intimate relationships begin to emerge in adolescence
- These are emotional attachments between two people characterized by
concern for each other's well-being; a willingness to disclose private
possibly sensitive topics; and a sharing of common interests and activities
-
Intimacy
- Intimate relationships begin to emerge in adolescence
- These are emotional attachments between two people characterized by
concern for each other's well-being; a willingness to disclose private
possibly sensitive topics; and a sharing of common interests and activities
- Developmental course of intimacy:
- First is intimacy through preadolescent and early adolescent
relationships with same gender peers
- Intimate relationships with opposite-sex peers develop relatively late
during adolescence
- Opposite gender friendships may play a more important role in the
development of intimacy in boys than girls who may develop and
experience intimacy with other girls earlier in adolescence

Psychosocial Development
Identity vs. Role Confusion
- Identity; formation of a stable, coherent picture of oneself that includes
integrating one's past and present experiences with a sense of where one
is headed in the future
- Role confusion; failure to establish a sense of identity within society can
lead to role confusion. Role confusion involves the individual not being
sure about themselves or their place in society
Piaget: Emergence of Formal Operational Thought
- Formal operational thinking - ages 11-14
- Thinking is oriented to things and events that they can observe directly
- Abstract terms, possibilities, and hypotheses
- Decision-making abilities increase and they become able to realize
hypothetical risks and benefits to behaviors
- May not use formal operational thought and reasoned decision making all
the time - when faced with time pressure, personal stress or
overwhelming peer pressure, young people abandon rational thought
processes

Adolescent Conceptions of Self

- Adolescent egocentrism
- Self-absorption
- Health-related beliefs
- Imaginary audience
- Personal fable

Changes in Social Cognition

 - Self-absorption
- Health-related beliefs
- Imaginary audience
- Personal fable

Changes in Social Cognition

- Understanding of others' thoughts and feelings
- Mutual role taking - seeing how the thoughts and actions of one person
can influence those of others
- Effect on health-related choices

Development of Value Autonomy

- Struggle to clarify values
- Development of a personal value system
- Gradual process in late adolescence

Moral Development
- Parallels advances in reasoning and social cognition
- Young adolescents function at a conventional level of moral reasoning in
which absolute moral guidelines are seen to emanate from authorities
such as parents or teachers
- Then emergence of elements of principled moral reasoning - question
absolutes and rules and view moral standards as subjective and based on
points of view that are subject to disagreement

Spiritual Development
- Religious beliefs may become more abstract during adolescence
- Late adolescents may reexamine and reevaluate beliefs and values of their
childhood

Achievement
- Development of motives, capabilities, interests, and behaviors
- Progress toward occupational achievement
- Relationship between social class and education and occupational
achievement

Emotional
- Instability - moodiness, rebellion
- Risk-taking behaviors
- Peer relationships important
- Issues of sexuality, body image
Emotional
- Instability - moodiness, rebellion
- Risk-taking behaviors
- Peer relationships important
- Issues of sexuality, body image

Adolescent Health Interview

- Ensure confidentiality & privacy
- Maintain objectivity: be non-judgmental
- Use open-ended questions
- Listen to the adolescent's perspective
- Use language the adolescent will understand

Health Screening - HEEADSSS

- H; Home
- E; Education/employment
- E; Eating
- A; Activities
- D; Drugs
- S; Sexuality
- S; Suicide/depression
- S; Safety

Health Problems of Adolescence

Injuries
- Leading cause of mortality and morbidity - MVAs, falls
- Risk behaviors: not using seat belts, driving after drinking alcohol, not
wearing protective gear during sports, and engaging in physical fights

Workplace Health
- Young workers between the ages of 15-24 years old make up about 15% of
the Canadian workforce
- More likely than adults to be injured on the job
- Lack knowledge & maturity to recognize hazards
- More willing to take on any task
- Less likely to ask questions

Teen Pregnancy
- Incidence
 - Lack knowledge & maturity to recognize hazards
- More willing to take on any task
- Less likely to ask questions

Teen Pregnancy
- Incidence
- 28.2/1000 in females between 15-19
- Rates have been declining for decades
- Medical aspects (less prenatal care)
- Diagnosis
- Negative outcomes:
- Low educational achievement
- Poverty
- Poorer social outcomes
- Adolescents often have unrealistic expectations for the child
- Most teen fathers have a strong emotional commitment to and
interest in their child

Sexually Transmitted Diseases

- Chlamydia
- Genital warts
- Genital herpes
- Gonorrhea
- Pelvic inflammatory disease
- HIV/AIDs
- Hepatitis B

Nursing Considerations
- Obtain a sexual history
- Include uninvited sexual advances
- Use of birth control/STD prevention
- Screening for STDs
- Health guidance re: sexual behaviors
- Birth control information
- Reducing STD risk
- Positive reinforcement for healthy behaviors
- Be sensitive to sexual orientation
- Counseling re: reducing risky sexual behaviors
- Refer to appropriate treatment - eg. Prenatal care
- Reporting of STDs to Public Health, as req'd
 - Positive reinforcement for healthy behaviors
- Be sensitive to sexual orientation
- Counseling re: reducing risky sexual behaviors
- Refer to appropriate treatment - eg. Prenatal care
- Reporting of STDs to Public Health, as req'd

Eating Disorders

Anorexia Nervosa (AN)

- Refusal to maintain normal body weight
- Disturbed body image
- Primarily in adolescent and young adult females (90%)
- Peak age is 13-18 years
- Etiology unclear
- Life threatening
Clinical Manifestations
- Severe weight loss
- Altered metabolic activity
- Amenorrhea (no period)
- Hypothermia
- Bradycardia, hypotension
Therapeutic Management
- Treat life-threatening malnutrition
- Resolution of disturbed patterns of family interactions
- Psychotherapy and behavior modification to correct deficits and
distortions in psychologic functioning
- Long-term management
- 50% of people with AN recover, 30% recover partially, 20% remain
chronically ill

Bulimia
- Binge eating
- Purging behaviors (vomiting, laxatives, diuretics or other medications;
fasting or excessive exercise)
- Weight may be normal or slightly above
- Occurs at slightly older age than AN - 16-17 years
- Psychological issues
Therapeutic Management
- Similar to anorexia management
- Hospitalization to treat potassium depletion, esophageal damage
 - Occurs at slightly older age than AN - 16-17 years
- Psychological issues
Therapeutic Management
- Similar to anorexia management
- Hospitalization to treat potassium depletion, esophageal damage
- Cardiac monitoring
- Behavioral management

Substance Abuse
- Drug abuse, misuse, and addiction
- Voluntary behaviors
- Culturally defined
- Use of drugs for other than acceptable medical purpose
- Drug tolerance and physical dependence
- Involuntary physical responses

Types of Drugs Abused

- Tobacco
- Vaping
- Alcohol
- Cocaine
- Narcotics
- CNS depressants & stimulants
- Hallucinogens
- Inhalants

Cannabis
- Recreational cannabis was legalized by the Canadian Federal gov't on
Oct 17, 2018
- In 2017, one in five grade 7-12 students in ON said they used cannabis at
least once in the previous year
Mechanism of Action
- The endocannabinoid system (ECS) is a biological system composed of
endocannabinoids, which are neurotransmitters that bind to
cannabinoid receptors (CBD1 and CBD2) throughout the vertebrate CNS
(including the brain) and PNS
- Receptors are linked to Gi protein
- Decrease adenylyl cyclase activity
- Prevent activation of various Ca2+ channels and activate K+ influx
- Major effect - decreased cell excitability
- Probably modify responses to various neurotransmitters, and
 (including the brain) and PNS
- Receptors are linked to Gi protein
- Decrease adenylyl cyclase activity
- Prevent activation of various Ca2+ channels and activate K+ influx
- Major effect - decreased cell excitability
- Probably modify responses to various neurotransmitters, and
decrease NT release
How it Works
THC, acting through cannabinoid receptors, also activates the brain's reward
system, which includes regions that govern the response to healthy
pleasurable behaviors such as sex and eating. Like most other drugs that
people misuse, THC stimulates neurons in the reward system to release the
signaling chemical dopamine at levels higher than typically observed in
response to natural stimuli. This flood of dopamine contributes to the
pleasurable "high" that those who use recreational marijuana seek.

Pharmacologic Effects
- CNS - general
- Drowsiness
- Impairment of short-term memory
- Low dose - mild euphoria, relaxation, increased sociability, decreased
anxiety
- High dose - dysphoria, increased anxiety, sensory distortion and
hallucinations
- Neuromuscular
- Central and peripherally mediated antispasmicity
- Cardiovascular
- Tachycardia
- Increased myocardial oxygen demand
- Respiratory
- Bronchodilation; decreased airway resistance
- Bronchial irritation; particulate fraction of cannabis smoke
- Cannabis smoke similar to tobacco smoke
- Eye
- Decreased IOP at doses that produce CNS effects
- Acute effects
- Pain perception lowered
- Antinauseant and antiemetic effects, increased appetite
- Anticonvulsant effects

Routes and Effects

 - Acute effects
- Pain perception lowered
- Antinauseant and antiemetic effects, increased appetite
- Anticonvulsant effects

Routes and Effects

- Inhaled
- THC and other chemicals in the plant pass from the lungs into the
bloodstream, which rapidly carries them throughout the body to
the brain
- The person begins to experience effects almost immediately
- 1 to 3 hour duration
- Ingested
- In edibles these effects are somewhat delayed and usually appear
after 30mins to 1 hour; because the drug must first pass through
the digestive sysem (passes through liver so less into bloodstream)
- Significantly less THC into the bloodstream than smoking an
equivalent amount of the plant
- Because of the delayed effects, people may inadvertently consume
more THC than they intend to
- Duration may last for many hours depending on dose taken

Risks of Use
- Trying cannabis is unlikely to cause serious problems in most people, but
even occasional use can be harmful
- Youth who use cannabis at a young age, often, and over the long-term,
are at risk of long-term health and social problems
- Harm to the brain, such as problems with memory, concentration,
thinking, learning, handling emotions, and decision-making
- Research shows that cannabis use can affect normal brain functioning in
youth and young adults up to age 25 and may alter brain development
- Problems with academic progress, such as impact on learning and
attention, difficulty with completing school work, lower school
performance, and increased risk of dropping out of high school
- Mental health problems, such as psychosis or schizophrenia and
possibly, depression, anxiety, and suicide, especially if there's a personal
or family history of mental illness
- Difficulties with relationships, such as conflicts at home, school, or work
- Physical health problems, such as lung and respiratory problems from
smoking cannabis
- Addiction, such as difficulty controlling how much or how often the
 or family history of mental illness
- Difficulties with relationships, such as conflicts at home, school, or work
- Physical health problems, such as lung and respiratory problems from
smoking cannabis
- Addiction, such as difficulty controlling how much or how often the
person uses it, even when it’s causing them challenges in their life.
Cannabis can be especially addicting for youth

Fentanyl - "National Health Crisis"

- Synthetic opioid - 100x more toxic than morphine
- Death rates from overdose rising (naloxone is antidote)
- Calls for government action - provincial & federal

Nursing Considerations
- Counseling re: risks
- Screening (identification of behaviors)
- Acute care
- Long-term management
- Family needs/family support
- Prevention
- Advocacy

Childhood Depression
School-age and adolescence
Depression may be:
- Temporary
- Responses to chronic stress and loss
Characteristics of children with depression:
- Can manifest differently in children/adolescents than adults
- Sad facial expression, flat affect
- Poor school performance
- Withdrawal
- Aggressive or disruptive behavior
- Physical complaints
- Low self-esteem, suicidal ideation

Therapeutic Management
- Treatment is highly individualized
- Takes place in outpatient setting if appropriate (less constrictive)
- Counselling, psychotherapy, family therapy, cognitive therapy,
Therapeutic Management
- Treatment is highly individualized
- Takes place in outpatient setting if appropriate (less constrictive)
- Counselling, psychotherapy, family therapy, cognitive therapy,
education, environment improvement, pharmacotherapy
- Pharmacotherapy
- SSRIs - eg fluoxatine, tricyclic antidepressants

Nursing Care
- Screening for signs of depression
- Make appropriate referrals
- Educate family re:
- Depression
- Antidepressants (must be at therapeutic level for 2-4 weeks to be
effective)
- Monitoring for side effects of medication (link to suicide ideation)
- Suicidal ideation

Suicide
- Second leading cause of death in teens in Canada
- Males > females
- Etiology
- Mental health problems
- Substance abuse (mostly alcohol)
- LGBT youth
- Victims of abuse
- Chronic illness and/or disability
- Inuit and First Nations youth
- Difficult home situation; conflict with parents
- Availability of firearms in home
- Family protective factors
Self-harm
- Direct intentional damage to one's body without the intent to die
Suicide
- Deliberate act of self-injury with the intent that the injury results in
death
Suicidal ideation
- Preoccupation with thougts about suicide and may be a precursor
Suicide attempt
 - Deliberate act of self-injury with the intent that the injury results in
death
Suicidal ideation
- Preoccupation with thougts about suicide and may be a precursor
Suicide attempt
- Intent to cause injury or death
Parasuicide
- Behavior range
Often is an impulsive act, related to some crisis
Methods:
- Most common attempt is overdose
- Most common completed suicides; firearms
- In Canada, males most likely to use hanging
- Females most likely to use overdose

Nursing Care
Prevention
- Anticipatory guidance to parents and adolescence - develop protective
factors
- Screening for risk factors, warning signs
Screening for suicidality
- Ask direct questions
- In the case of suicide confidentiality cannot be honoured
- Support systems for clients who have frequent suicidal thoughts
SLAP assessment
- Specificity, lethality, accessibility and proximity
Ensure client's safety
- Refer immediately
- Monitor client closely
- Maintain caring relationship

Mental Health of Refugee Children

Background: Experience of Syrian Refugee Children
- Experienced high levels of trauma: 79% had experienced a death in the
family; 60% had seen someone get kicked, shot at, or physically hurt;
and 30% had themselves been kicked at, shot at, or physically hurt
- Many have been unable to attend school in past year or more
- At risk for a range of mental health issues: PTSD, behavioral problems
such as aggression, depression, anxiety
- More likely to have poor school performance or drop out
 and 30% had themselves been kicked at, shot at, or physically hurt
- Many have been unable to attend school in past year or more
- At risk for a range of mental health issues: PTSD, behavioral problems
such as aggression, depression, anxiety
- More likely to have poor school performance or drop out

Individual Factors
- Exposure to violence
- Migration journey & postmigration experiences
- Girls at higher risk in some studies
- Physical, developmental, psychological disorders

Family Factors
- Exposure to violence
- Family composition; bereavement
- Separation from family increases risk; single mother families
- Family functioning - communication
- Higher socioeconomic status & education may be protective

Community Factors
Social support
- Acceptance vs discrimination
- Sense of safety, school belonging
- Presence of family connections
- Learning of language
- Parent/child cultural conflict increases risk

Societal Factors
- Ethnicity, religion
- Resettlement process - location, time
- Immigration process

Recommendations
- Health professionals assess refugees' challenges and advocate for
services/policies
- Access to physical & psychological health services
- Community resources to help integrate families
- Prioritize reunion of families
- Specific support for unaccompanied children
- Stable settlement in host countries - support for employment,
education, housing
- Access to physical & psychological health services
- Community resources to help integrate families
- Prioritize reunion of families
- Specific support for unaccompanied children
- Stable settlement in host countries - support for employment,
education, housing
- Reduce inequities in access to resources