adolescence and puberty

Question 1

define adolescence *

Answer 1

the phase between childhood and adulthood

pubertal development might be the start

adulthood is legally, culturally and biologically variable

UN say adult is 18yrs

the definition is extending from 10-20, to 10-25 - this is called the new adolescence

Question 2

why is the definition of adolescence changing *

Answer 2

the milestones that are meant to happen in adolescence ie marriage, childbirth and leaving home are happening at older ages

ie it is taking longer to master the tasks of adolescence

refers to the period of development that occurs between ages 12-18 years.

Question 3

what are the changes that occur in adolesence *

Answer 3

cognitive and emotional changes

• hormone driven
• reasoning gets more abstract/phylosophical - change in cognitive capacity
• greater knowledge/awareness of the world
• identity of self, family, ethnicity develops
• reflective functioning/mentalising - self awareness - see yourself through other people’s eyes

biology

• puberty/endocrine changes
• physical growth

family

• challenging rules
• discipline needs reasoning
• less confiding and intimacy in parents
• develop individualism and autonomy

peers

• peer activities/confiding
• sexual relationships
• peer group influences values and behaviour
• influences the development of mental health difficulties

Question 4

describe adrenarche *

Answer 4

starts female 6-9yrs, males 7-10 ie before puberty

there is a rise in adrenal 19-carbon steroid production, dehydroepiandrosterone (DHEA) and DHEA sulfate - drives hair

purpose is uncertain but it is the precurser to puberty

it is adrenal gland driven

Question 5

describe the hormone pathway in adrenarche *

Answer 5

CRH released from hypothalamus - acts on pit

pit produces ACTH

ACTH acts on the adrenal cortex

cause production of androsteindione and DHEA

leads to development of pubic hair, armpit hair, acne (acne is a testosterone related SE)

Question 6

describe the endocrinology of puberty *

Answer 6

GnRH released from hypothalamus - act on pit

LH and FSH released from pit, act on gonads

gonads produce androgen and sperm in males and oestrogen and ovum production and menarche in females

androgens cause penis development, pubic hair, testes, acne

oestrogen causes development of breasts, ovaries, uterus

Question 7

describe the growth pattern in puberty *

Answer 7

girls grow in early puberty age 12/13

boys grow late puberty age 15

therefore between ages of 12-15 girls are more developed

Question 8

define menache *

Answer 8

first period

Question 9

what are the main female changes in puberty *

Answer 9

breast budding

growth of pubic hair

growth spurt

menache

underarm hair

change in body shape

adult breast size

Question 10

level of puberty at age 13 for girls *

Answer 10

can be prepubertal or fully adult - both are normal

delayed puberty doesnt mean that you have anormal growth

Question 11

changes that happen in puberty in boys *

Answer 11

growth of scrotum and testes

change in voice

lengthening of the penis

growth of pubic hair

growth spurt

change in body shape

growth of facial and underarm hair

Question 12

describe how menarch has changed over time *

Answer 12

age of puberty has reduced

because of nutrition

if overweight there is an earlier puberty - increased leptin = increased stimulatioon of kisspeptin neurons = increased GnRH

however, population studies have suggested body weight at menarche has remained constant

Question 13

psychological changes that occur in puberty *

Answer 13

cognition eg morality/ethics - higehr levels of cognitive ability - piaget’s psychological changes

identity - gender and religion

increased self awareness

affect expression and regulation - learn to recognise and manage emotions

Question 14

social changes that occur in puberty *

Answer 14

family - parents need to give you respect and autonomy, you are less confiding however need good connections and surveillance - the quality of the time becomes more important than the quantity

peers - increased importance, more complex relationships, hierarchial, more sensitive to acceptence and rejection (trigger for mental health), romantic relationships

social role - education, occupation

Question 15

what becomes apparent at puberty socially *

Answer 15

deficits in interpersonal skills

before you are protected by family and understand concrete things

now world becomes more complex so might have subtle communication difficulties that make it difficult for you to communicate with peers and form relationships

Question 16

wider social influences in adolesence *

Answer 16

school

work

culture - teen subculture, migration/culture

social influences eg unemployment, poverty/affluence, housing, neighbourhood effects

social media

Question 17

describe the effect of social media on mental health *

Answer 17

it isnt the time that you spend on it

it is whether it is beiung used as cyber bullying, stopping you sleep or exercise

Question 18

describe the development of the brain in adolescence *

Answer 18

there is cortical thickening and then thinning in adolesence

there is a cross over from grey to white matter - this is pruning

the neurons that are used dominate, those that are not are pruned

Question 19

effect of developmental change in brain on behaviour *

Answer 19

there is a mismatch

there is a period where the dopaminergic/opiodinergic activity ie sensation seeking is ahead of the regulatory/cognitive control to think rationally

therefore it isnt that more risks are taken in adolesence its just that there is a miscalculation of risks

these behaviours might continue into adolesence

Question 20

incidence of mental health disorders in children

Answer 20

1/10 children aged 5-10 - most are neurodevelopmental disorders rather than emotional

1/2 of mental health disorders are established by 14

3/4 by 24

some are episodic and relapsing, rather than chronic and persistant

Question 21

describe the association between comparing self on social media and psychiatric disorder *

Answer 21

of people who compare themselves on social media there is a higher proportion of people with psychiatric disorder than not

this is even more common in girls

Question 22

when do emotional disorders emerge *

Answer 22

in teenage years

Question 23

how does mental health disease relate to the burden of disease globally *

Answer 23

it is the dominant disease in terms of burden

Question 24

define the features of anorexia *

Answer 24

restriction of energy intake relatuve to the requirements leading to significantly low body weight for the person in the context of age, sex and developmental trajectory and physical health

psychopathy - intense fear of ganing weight or becoming fat, or persistant behaviour that interfers with weight gain

disturbance in experience of weight/shape - undue influence of weight or shape on self-evaluation or persistant lack of recognition of seriousness of low weight

weight loss is self induced

endocrine disturbance - amenorrhoea, or delayed growth and puberty - not necessary for diagnosis

dont have to be able to articulate why acting in certain way - drs can infer by the fact they are avoiding calorie dense food

subtypes - restricting v binge eating/purge - they have different prognosises

Question 25

describe the formulation framework to determine the cause of anorexia \*

Answer 25

look at predisposing (background factors that increase the risk), precipitating (the trigger), perpetuating (what keeps it going), protective features (tell you about the prognosis) and determine if they are bioological, family or systemic factors (or can be individual/psychological/social) eg genetic risk is predisposing family precipitating is systemic precipitating there is not 1 cause and it is different for each person

Question 26

example of predisposing factors \*

Answer 26

bullying, genetics

Question 27

describe the genetic contribution to anorexia nervosa \*

Answer 27

there are psychological risks cognitive style risks metabolic risks ie there is a psychosomatic risk profile ie the hertability is multideterminant - about 50-70% we can modify some of the factors but mainly have to work with the non-heritable ones these are the non-shared factors (ie things that only effect the individual, not other people in their system)

Question 28

what are precipiatitating factors \*

Answer 28

interpersonal things

Question 29

what are perpetuating factors \*

Answer 29

people's responses to you determine the outcome so need to involve family in treatment perpetuating factors are the things that can be modified in treatment

Question 30

summarise the aetiology of anorexia nervosa (

Answer 30

they go through prenatal, childhood, adolesence, adulthood genetic factors, traits and cognitive style (obsessionality, perfectionism, deficits in social cognition, inflexibility), hormones, puberty (brain development, hormones, stressful life events, cultural values) being female traits lead to dieting and weight loss perhaps higher social class leads to starvation induced changes eg aberrent reward response to starvation syndrome which increases anxiety, depression and obsessionality

Question 31

describe the fact that anorexia nervosa is on a scale of being normal \*

Answer 31

\>50% girls feel fat a lot of girls diet only a small amount of people want to put on weight boys ahve the same feeling but are less inclined to diet - perhaps because less influenced by social media boys have a stringer wish to gain muscle - this is body dysmorphic disorder the feeling of being fat is present across cultures and countries

Question 32

what are the proportions of girls with unhealthy eating behaviour \*

Answer 32

30-50% dislike weight etc 10% of these have severe dieting and unhealthy behaviour eg laxatives 1-2% of them have anorexia/bulieia - it is hard to knwo what the threshold of normal is 20% of girls have obesity

Question 33

what can be used to predict eating problems \*

Answer 33

it is associatyed with: * Earlier pubertal maturation, & higher body fat - the thin and the overweight are those at most risk * Concurrent psychological problem e.g. depression - hating the world is a risk factor but need to determine why that has become about food (usually it is because of poor body image) * Poor body image * Specific cognitive phenotypes

Question 34

describe the neurophysiology of anorexia nervosa - executive functioning deficits \*

Answer 34

thinks that borderline autistic traits increase risk of AN because world narrows to be focused on food etc however - we all become narrow minded and focussed when starved so difficult to know if narrow minded because starved or because you are predisposed to it people have weak central coherence ie global processing difficulties - they dont see the big picture and have coherent fixed thinking

Question 35

describe why there is an incidence in obesity and eating disorders \*

Answer 35

the things that drive obesity also drive eating disorders - ie dieting and body image/satisfaction

Question 36

treatment for eating disorders \*

Answer 36

when pts have parental/carer support they should have an anorexia focused family therapy - either in conjoint, separated, or multifamily format as 1st line as an out patient or if too sick as a day patient following a \<3wk admission for medical stabalisation if needed For abnormal eating attitudes and depression: cognitive behavioural therapy.

Question 37

prognosis for anorexia

Answer 37

About 40% respond to first line interventions alone Up to 80% recover overall within 5 years when you add something in Around 30% develop binge eating at some point during recovery Around 20% run a more chronic course then can doe - higehr death rate than T1DM/asthma Mortality e.g. at 20 years: 5-10% of which 1 in 5 is suicide Duration of illness predicts recovery therefore adolescent onset better prognosis because earlier help seeking Early treatment response is the only robust predictor of outcome but more extreme social difficulties are a factor

Question 38

what are the 2 ways to classify depression \*

Answer 38

dimension - an increase of symptoms means an increase in impairment category - whether the disorder is present or not

Question 39

symptoms of depression \*

Answer 39

affective - low mood/saddness, loss of enjoyment (anhedonia), loss of energy, irritability leads to changed in: * biological - appetite/weight, sleep * concentration * cognitive - pessimism/guilt/self blame * self esteem/confidence * libido * psychomotor agitation/retardation * self harm/suicide have to have a collection of the symptoms in order to have a disorder

Question 40

what is necessary to 'have' depression \*

Answer 40

need a collection of the symptoms they need to be pervasive - feel the same whereever the situation, even if masked impairing fuinction present for at least 2 wks the symptoms and impairment determine whether you have mild/moderate/severe

Question 41

what are the differnet types of depression \*

Answer 41

Depressive episode - 20% people have an episode, 50% of these people have a recurring episode Recurrent depression - between episodes there are periods of remission Dysthymia - consistently low mood but gets better/worse over time Bipolar depression - be down then up Psychotic depression - hallucinations Atypical depression Seasonal affective disorder (SAD) ?Inflammatory subtype

Question 42

problems associated with depression \*

Answer 42

increased risk of self harm association with anxiety disorders, eating disorders, conduct problems, systems missuse familial aggregation (genetic and learning) - the influence of environment

Question 43

what are the 2 types of pre-pubertal depression \*

Answer 43

1 * more common * present with co-morbid behavioural problems, parental criminality, parental substance misuse and family discord * course resembles that of people with conduct disorder * there is no increased risk of recurrence in adult life - more likely to go into conduct disorder pattern 2 * less common * highly familial - multigenerational loading for depression * high rates of anxiety and bipolar disorder * social withdrawal * recur in adolesence and adulthood

Question 44

describe adolescent depressive disorder \*

Answer 44

irritability instead of sadness/low mood especially in boys somatic complaints and social withdrawal are common - feel bad feeling in stomach, gut extension of forebrain so have feelings there psychotic symptoms are rare before mid-adolescence

Question 45

outcome of adolescent depressive disorder \*

Answer 45

short term - high rates of persistence and recurrance - 20% in 1yr long term - 50% continuity into adulthood, 2-7x increased risk as an adult, impairment of relationships/education in adulthood

Question 46

causes of depression \*

Answer 46

biological changes - genetics, puberty, brain growth, endocrine change in female risk low mood social changes - peer, family, social world life events - losses these all feed into psychological/cognitive emotional changes - more advanced and efficient, more intense/fluctuant mood, self concept/autonomy cause a vulnerability to depression life events eg exams, adversities

Question 47

treatment of mild depression \*

Answer 47

cognitive behavioural therapy interpersonal psychotherapy for adolescents brief psychosocial intervention - supportive therapy family intervention for associated family problems

Question 48

treatment of moderate-severe depression \*

Answer 48

antidepressants eg SSRIs - fluoxetine could be antidepressant and cognitive behavioural therapy combined has the highest rate of symptomatic remission

Question 49

what is conduct disorder \*

Answer 49

repetitive and persistant (\>6months) pattern of antisocial behaviours at frequency and severity beyond age appropriate behaviours: * Oppositional behaviour, defiance * Tantrums * Excessive levels of fighting or bullying, assault * Running away from home * Truancy * Cruelty to animals * Stealing * Destructiveness to property * Fire-setting

Question 50

what are the types of conduct disorders \*

Answer 50

CD confined to family setting unsocialised CD socialised CD oppositional CD depressive CD hyperkinetic CD (depends on whether you do it on your own/in peer group - unsocialised is worse prognosis )

Question 51

what is the epidemiology of CD

Answer 51

about 5% of 5-19yr odlds had CD, higher in boys, increases with age, more common in urban than rural communities either adolescent limited or life course persistant

Question 52

aetiology of CD\*

Answer 52

child factors - eg ADHD, educational drop out due to unrecognised learning disabilities, impulsivity, difficut temprement family factors - inadequate parenting, discord, lack warmth, inconsistent discipline, coercive interaction, aggression environmental factors eg inner city/access to specific peer gps - gang culture genetic - weak

Question 53

intervention for CD (

Answer 53

targeted at major modifyable risk factors - should begin early managing underlying hyperactivity parenting programs cognitive problem solving skills training interventions at school - restorative justice intervention multisystemic therapy

Question 54

prognosis of CD \*

Answer 54

40% of 7 and 8 year olds with CD became recidivist delinquents as teenagers. Over 90% of recidivist juvenile delinquents had conduct disorder as children. Predictor of * Antisocial PD in adulthood (~50%) * Alcoholism & drug dependence * Unemployment and relationship difficulties * Intergenerational transmission

Question 55

hormones involved in growth \*

Answer 55

androgens and somatotrophin

Question 56

how does puberty start \*

Answer 56

either: * Maturation of the CNS affecting GnRH neurones (increased pulsatile release) * Altered set point to gonadal steroid negative feedback

Question 57

how does puberty affect anorexia in girls \*

Answer 57

in puberty there is increased adiposity causing an increase in negative attitudes in white people, less so in afrocaribbean people

Question 58

prognosis of depressive disorder \*

Answer 58

Major depression: Duration In specialist CAMHS settings: 6-9 months Primary care: 2-3 months High risk recurrence Prepubertal onset – better prognosis Small number in adolescence – bipolar (mania, hypomania)

Question 59

developmental considerations for CD \*

Answer 59

Changes in family relationships – less direct surveillance, physical closeness, joint activities Peers – increased involvement with peers; may amplify antisocial behavior Experimentation and risk taking – rule violation, drugs & alcohol, petty offending frequent.

Question 60

epidemiology of conduct disorder

Answer 60

4% at ages 5-10 years; 6% at ages 10-15 years; overall 5% at ages 5-15 years. Higher in deprived inner-city areas Boys: girls 3:1 Age of onset may vary Associated with: * Larger family size * lower socio-economic status