adolescence and puberty Flashcards
define adolescence *
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
why is the definition of adolescence changing *
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.
what are the changes that occur in adolesence *
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
describe adrenarche *
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
describe the hormone pathway in adrenarche *
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)
describe the endocrinology of puberty *
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
describe the growth pattern in puberty *
girls grow in early puberty age 12/13
boys grow late puberty age 15
therefore between ages of 12-15 girls are more developed
define menache *
first period
what are the main female changes in puberty *
breast budding
growth of pubic hair
growth spurt
menache
underarm hair
change in body shape
adult breast size
level of puberty at age 13 for girls *
can be prepubertal or fully adult - both are normal
delayed puberty doesnt mean that you have anormal growth
changes that happen in puberty in boys *
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
describe how menarch has changed over time *
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
psychological changes that occur in puberty *
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
social changes that occur in puberty *
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
what becomes apparent at puberty socially *
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
wider social influences in adolesence *
school
work
culture - teen subculture, migration/culture
social influences eg unemployment, poverty/affluence, housing, neighbourhood effects
social media
describe the effect of social media on mental health *
it isnt the time that you spend on it
it is whether it is beiung used as cyber bullying, stopping you sleep or exercise
describe the development of the brain in adolescence *
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
effect of developmental change in brain on behaviour *
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
incidence of mental health disorders in children
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
describe the association between comparing self on social media and psychiatric disorder *
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
when do emotional disorders emerge *
in teenage years
how does mental health disease relate to the burden of disease globally *
it is the dominant disease in terms of burden
define the features of anorexia *
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
describe the formulation framework to determine the cause of anorexia *
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
example of predisposing factors *
bullying, genetics
describe the genetic contribution to anorexia nervosa *
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)
what are precipiatitating factors *
interpersonal things
what are perpetuating factors *
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
summarise the aetiology of anorexia nervosa (
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
describe the fact that anorexia nervosa is on a scale of being normal *
>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
what are the proportions of girls with unhealthy eating behaviour *
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
what can be used to predict eating problems *
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
describe the neurophysiology of anorexia nervosa - executive functioning deficits *
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
describe why there is an incidence in obesity and eating disorders *
the things that drive obesity also drive eating disorders - ie dieting and body image/satisfaction
treatment for eating disorders *
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.
prognosis for anorexia
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
what are the 2 ways to classify depression *
dimension - an increase of symptoms means an increase in impairment
category - whether the disorder is present or not
symptoms of depression *
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
what is necessary to ‘have’ depression *
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
what are the differnet types of depression *
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
problems associated with depression *
increased risk of self harm
association with anxiety disorders, eating disorders, conduct problems, systems missuse
familial aggregation (genetic and learning) - the influence of environment
what are the 2 types of pre-pubertal depression *
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
describe adolescent depressive disorder *
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
outcome of adolescent depressive disorder *
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
causes of depression *
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
treatment of mild depression *
cognitive behavioural therapy
interpersonal psychotherapy for adolescents
brief psychosocial intervention - supportive therapy
family intervention for associated family problems
treatment of moderate-severe depression *
antidepressants eg SSRIs - fluoxetine
could be antidepressant and cognitive behavioural therapy
combined has the highest rate of symptomatic remission
what is conduct disorder *
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
what are the types of conduct disorders *
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 )
what is the epidemiology of CD
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
aetiology of CD*
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
intervention for CD (
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
prognosis of CD *
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
hormones involved in growth *
androgens and somatotrophin
how does puberty start *
either:
- Maturation of the CNS affecting GnRH neurones (increased pulsatile release)
- Altered set point to gonadal steroid negative feedback
how does puberty affect anorexia in girls *
in puberty there is increased adiposity causing an increase in negative attitudes in white people, less so in afrocaribbean people
prognosis of depressive disorder *
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)
developmental considerations for CD *
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.
epidemiology of conduct disorder
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
