Adolescent Health

Question 1

What factors put someone more at risk for developing a gambling problem? (6)

Answer 1

1. Depression2. Loss3. Abuse4. Impulsivity5. Antisocial traits6. Learning disabilities

Question 2

When screening for a gambling problems in adolescents, which questions should you ask?

Answer 2

1. Frequency2. Tendency to gamble more than planned (inability to respect personal limits)3. Hiding gambling behavior from other people (ie. lying)4. How are they doing in school?5. Sleep problems?6. Money or possessions in the home go missing? Theft?7. Substance use?8. Mood?9. Impaired relationships?

Question 3

In which age group is there the highest rate of STIs in Canada?

Answer 3

The highest rates of STIs in Canada are in the 15-24 year age group with girls 15-19 yo having the highest rate for chlamydia and gonorrhea

Question 4

What are components of motivational interviewing? (5)

Answer 4

1. Asking open ended questions: “How does drinking on the weekend affect getting your homework done?”2. Reflective listening: “It sounds like you are very upset about the recent break up with your girlfriend. Are you more likely to drink when you’re upset?”3. Affirmations: “Deciding not to go to that party sounds like a good choice. It may be difficult to avoid drinking if you went.”4. Summary statements: “It is important to be able to hang out with your friends. Are there other activities you do together?”5. Eliciting change talk: “What are some of the things you would like to change?”

Question 5

Which province in Canada actually has a fixed age of consent to medical treatment?

Answer 5

Quebec! Fixed age of consent is 14 yo-for every other province, consent to medical treatment depends on mental capacity, not chronological age

Question 6

What is the definition of:-transgendered-transvestite

Answer 6

-transgendered: a person’s gender does not match their anatomy-transvestite: a person who gets pleasure from dressing in the clothing of the opposite sex

Question 7

What risk factors place LGBT individuals at higher risk of committing suicide? (5)

Answer 7

***2-7x more likely to commit suicide1. Acquisition of gay identity at a young age2. Family conflict`3. Run away or thrown out of home4. Feelings of conflict about own orientation5. Could not disclose orientation to anyone else

Question 8

What advice can you give to a teen who would like to come out to their parents?

Answer 8

1. Explore your parents’ possible reactions by thinking about how they talk about gay people, how they interact with gay people they meet and how they deal with unexpected info2. Introduce the subject of homosexuality by bringing up a book you’re reading reading or something that is in the news and see what your parents have to say3. Consider telling one parent first and then getting their support to tell the other parent4. Role playing can help the teen find the right words to use with their parents so they can avoid sounding like they are communicating bad news5. Reassure your parents that you are the same person you always were6. Not all teens should tell their parents about theiir orientation if there are possible negative repercussions

Question 9

What advice can you give to parents who approach you when their teen has come out?

Answer 9

Teens who have chosen to come out to their parents are likely quite certain about their homosexual orientation and this is probably not “a phase”.-it is important to let your teen know that you still love them while they are dealing with feelings about orientation-referral to Parents and Friends of Lesbians and Gays (PFLAG) (organization that helps parents whose children have come out to them)

Question 10

What percentage of adolescent pregnancies end in induced abortion?

Answer 10

50%

Question 11

Which of the following is false:a. Radioimmunoassays can detect hCG in serum as early as six days postconceptionb. Urine tests used at home/offices/clinics use monoclonal antibodies to detect hcg as early as 10-14 d after ovulationc. The uterus may be palpable above pubic bone after 9-12 wks GA.d. The adolescent pregnancy rate is highest among 15-17 year olds.

Answer 11

D! The adolescent pregnancy rate is highest among 18-19 yo and many of these are PLANNED!-pregnancies among girls

Question 12

In taking a history of the pregnant adolescent, what should you inquire about? (8)

Answer 12

1. How has this pregnancy affected you physically and emotionally?2. What is your knowledge of the options and how do you feel about them?3. Are there any family, cultural or community issues that may play a role in your decision making?4. How does your partner feel about the options and what is his role in your decision-making process?5. Tell me about your support system.6. PMHx?7. High risk health behaviours/substance abuse8. Housing/school status/personal and academic goals**A good thing to say: “When you have an unplanned pregnancy, there is no perfect choice. All you can do is think about what is best for you at this time. No matter what option you choose, it is unlikely that you will feel it is 100% right”

Question 13

What are 3 risks of surgical abortion?

Answer 13

1. Hemorrhage2. Infection3. Uterine perforation

Question 14

Why is it important to provide contraceptive counselling to an already pregnant teenager?

Answer 14

To delay future pregnancies OBVI-this is important to know though: 35% of teens who deliver will have another pregnancy within the following 2 years

Question 15

One of your adolescent patients who is pregnant has decided to continue with her pregnancy. She comes to you for advice moving forward. What should you counsel? (4)

Answer 15

1. Refer her to support groups/maternity homes/drop in centers2. Encourage her to continue education to enhance potential for positive maternal and child outcomes and decrease social isolation/depression3. Encourage if appropriate involvement/presence of baby’s father and/or current partner 4. Provide contraceptive counselling

Question 16

One of your adolescent patients who is pregnant decides to terminate the pregnancy. What do you counsel her? (4)

Answer 16

1. Give info about specific details about procedures available2. Anticipatory guidance about common emotional responses: grief, relief, anger3. Refer to appropriate medical/surgical services4. Make f/u appointments to review any possible complications (bleeding/cramps/fever/physical and emotional concerns)

Question 17

Which adolescents are at risk of having unprotected intercourse? (8)

Answer 17

1. Live in group homes/detention centres/street involved2. Substance abuse3. Early puberty4. Hx of sexual abuse5. Moms were adolescent moms6. Experiencing social/family difficulties7. frequent school absenteeism or lacking vocational goals8. Have siblings who were pregnant during adolescence

Question 18

When can emergency contraception be used (ie. timing wise to prevent pregnancy)?

Answer 18

Most effective within 72 hrs but effective up to 120 h

Question 19

What are the 3 forms of emergency contraception available?-which is the preferred method?-rate of pregnancy with use of each?

Answer 19

1. Progestin-only (Plan B)-rate of pregnancy: 1-3%2. Combined hormonal method (Yuzpe)-estrogen + progestin (levonorgestrel)-rate of pregnancy: 3-7%**Preferred: Plan B = more effective and fewer side effects3. Copper IUD insertion-can be used within 120 hr of unprotected sex

Question 20

Without emergency contraception, what percentage of women will become pregnant after a single act of unprotected sexual intercourse during the middle 2 weeks of the menstrual cycle?

Answer 20

8%

Question 21

What are the contraindications to use of emergency contraception?-absolute vs. relative

Answer 21

No absolute contraindications-Relative:1. Already pregnant (ie. will be ineffective)2. Allergy to one of the components of the product

Question 22

What are the contraindications of OCP in adolescents?

Answer 22

1. History of clots: PE, DVT, strokes2. Migraines with neurological symptoms3. Known thrombophilia

Question 23

How can an adolescent get Plan B?-dose?

Answer 23

It is available WITHOUT a doctor’s prescription across Canada! Obtain from pharmacist over the counter.-dose: two pills at once (each = 0.75 mg levonorgestrel)

Question 24

What is the dosing of the combined hormonal regimen for emergency contraception (ie. Yuzpe)?-what if neither Plan B or Yuzpe is available?

Answer 24

High dose norgestrel (250 mcg)-ethinyl estradiol (50 mcg): 1 pill now, then 1 pill 12 hrs later-timing of second dose is super important! Give gravol 1 hr before EC is taken because the estrogen makes people very nauseous-last resort if neither EC methods are available: 4-5 combined low dose OCP pills now, then repeat in 12 hrs

Question 25

What are common adverse effects of Plan B?

Answer 25

Headache, fatigue, nausea, dizziness

Question 26

An adolescent patient comes to you because they took Plan B and then vomited 20 minutes later. She asks if she should take it again. What do you say?

Answer 26

Yes she should! If vomiting occurs within 1 hr of taking emergency contraception, should retake the dose.

Question 27

Are there any pregnancy or teratogenic risks with taking emergency contraception while already pregnant?

Answer 27

Nope!

Question 28

What medications may decrease the effectiveness of combined oral contraceptive or combined hormonal method of emergency contraception? (5)

Answer 28

1. Anti epileptics2. St. John’s Wort3. HIV meds4. Rifampin5. Griseofulvin

Question 29

An adolescent patient comes to you after having unprotected sex. She does not want to take Plan B or Yuzpe and instead requests a copper IUD. -what are the criteria for insertion?-what is your management?

Answer 29

Criteria: should be considered for use up to 7 d after unprotected sexual intercourse for women who are in a stable, mutually monogamous relationship and at low risk for STIs-Management: 1. Exclude existing pregnancy: order pregnancy test2. At time of insertion, endocervical specimens for chlamydia and gonorrhea3. CONSIDER prophylactic antibiotics for both chlamydia and gonorrhea***IUD can be removed during or after the next period

Question 30

An adolescent patient has chosen to take emergency contraception after having unprotected intercourse. She asks you when she can start taking her regular OCP again. She also wants to know when she should come back for follow up. What do you say?

Answer 30

-Can start a new pack of pills the day after she takes EC.-book f/u appointment for 1 wk after her next expected menstrual period. At that appt, can counsel about choices regarding sexual activity, contraception, STI and safer sex.-may need a pregnancy test if next period is more than 1 wk late, unusual, heavy bleeding or pain.

Question 31

What are factors that increase the risk of abuse in youth with disabilities or chronic health conditions?

Answer 31

1. Societal factors:-lack of control over basic aspects of life and feeling of being externally controlled-social isolation by institutionalization, hospitalization, overprotection by families and thus more vulnerable to predators with little chance of detection-social stigma lead young victims to believe they deserve the mistreatment/abuse-sometimes seen as asexual beings and not potential targets for abusers and thus caregivers may not believe victim when abuse is disclosed2. Educational factors-little priority for sex ed for this population-may lack terminology needed to report an abusive situation3. Disability-specific factors-limited mobility/verbal abilities to fight off abuser4. Health care factors-if regular procedures have been performed in a demeaning, insensitive or forcible way, the youth are more likely to tolerate abuse

Question 32

What are some strategies pediatricians should use to prevent the sexual abuse of children and youth with disabilities? (5)

Answer 32

1. Provide early anticipatory guidance on sexuality, personal empowerment and abuse risks2. Interact with schools/communities to enhance/ensure sexual health education for this population3. Ensure thorough screening and monitoring of employees/volunteers in schools/hospitals/etc.4. Promote an institutional culture that promotes patient privacy during office/hospital visit so that child can be empowered5. Advocate for institutional policies that prevent sexual abuse and facilitate a quick intervention if abuse has occurred.

Question 33

What are barriers to health care for street involved youth? (6)

Answer 33

1. Lack money, transportation and knowledge to access appropriate health care2. Issues with trusting adults/authority figures and have worries about confidentiality 3. Youth with child welfare status who have run away from their last placement and individuals with legal problems avoid health care facilities for fear of getting caught4. Need to present health card or have a permanent address5. Perceived need for adult’s consent or involvement6. Difficulties with arranging follow up or affording prescriptions

Question 34

What effects do UVA and UVB have on the skin?

Answer 34

NAME?

Question 35

What characteristics place an individual at higher risk for cutaneous malignant melanoma (CMM)? (6)

Answer 35

1. Light skin color2. Freckles3. Skin moles (high nevus count)4. Easy to burn skin5. Red or blonde hair6. Personal history of CMM or 1st degree relative with CMM

Question 36

Which skin cancer is responsible for 75% of Canadian skin cancer deaths?

Answer 36

Cutaneous malignant melanoma (not the most common type of skin cancer but accounts for most Canadian skin cancer deaths)

Question 37

What factors may be contributing to the increased incidence of cutaneous malignant melanoma?

Answer 37

1. Better disease detection2. More skin exposure with current fashion3. Leisure activities and vacations in sunny areas4. Decrease in ozone layer5. Increased sun seeking behaviour without adequate UVR protection6. Increased popularity of tanning beds

Question 38

Which of the following is false:a. girls are up to 7x more likely to have used artificial tanning devices than boysb. tanning bed use among young girls decreases as they agec. “Extreme” risk taking, poor self esteem and unhealthy lifestyle choices are associated with indoor tanningd. Whether a teen engages in indoor tanning is closely associated with a parent also using indoor tanning

Answer 38

B! Tanning bed use among young girls doubles at age 14 and doubles again at age 17

Question 39

In individuals who begin indoor tanning before age 35, what is the increased risk of developing cutaneous malignant melanoma?

Answer 39

75% increased risk!-early life exposure has been associated with higher risks of CMM

Question 40

What class of carcinogen are tanning beds rated by the WHO?

Answer 40

Class 1 physical carcinogens alongside chemical carcinogens such as cigarettes and asbestos

Question 41

What the 3 most common skin cancers?-fill in the blank:a. Early life UVR exposure increases the risk of developing ___.b. Total or chronic UVR exposure increases the risk of developing ___.c. The most deadly form of skin cancer is ___.

Answer 41

1. Squamous cell carcinoma: chronic/total exposure increases risk2. Basal cell carcinoma: early life UVR exposure increases risk3. Cutaneous malignant melanoma: most deadly

Question 42

What is the most common artificial UVR-exposure side effect?

Answer 42

Erythema and sunburn

Question 43

What are adolescent traits that support the fact that they should not be deemed as culpable as adults in punishment for crimes? (3)

Answer 43

1. Unformed character2. Susceptibility of peer influence3. Diminished decision making capacity**Prefrontal cortex does not fully mature until wel beyond age 18 and thus executive functions are still developing in adolescents

Question 44

What are the benefits for adolescents in juvenile vs. adult facilities in the youth justice system?

Answer 44

NAME?

Question 45

What are the principles of family based therapy for anorexia nervosa? What are the main advantages? (3)

Answer 45

***Studies have shown that FBT is the most effective treatment for children/teens with AN-Parents are given the responsibility to return their child to physical health = patient is treated as outpatient by interdiscplinary team-Main advantages:1. Child gets to stay in their own environment to allow ongoing connection to friends/family/activities2. Parents are empowered as they learn that they have the ability to help their child3. Scarce inpatient resources can be directed to people whose eating disorder cannot be managed as an outpatient

Question 46

You have just diagnosed a child with anorexia nervosa and there are limited subspecialty services in your area. You would like to begin family-based treatment while they wait for subspecialty referral. What counselling will you provide to the parents?

Answer 46

1. Let the parents know that the ED is not their fault and they are not to blame for their child’s illness but they do need to take responsibility to ensure that their child gets well2. Do not dwell on the cause of the symptoms: ED is both genetic and environmental 3. Tell them their child is unable to care for him or herself and has been overwhelmeed by a powerful illness = parents should take charge of their child’s eating/exercise to ensure weight restoration4. Expect the child to become angry and defiant with refeeding5. Recommend resources: “Help your teenager beat an eating disorder” book by Lock and Le Grange6. Parents are well within their authority to impose behavioural consequences (such as withdrawal of activities) to affect their child’s choices.-behavioural modification strategies (rewarding desirable behaviours, consequences for undesirable behaviours) can be useful7. Encourage parents or siblings to do something fun with the patient after the meal to help them distract themselves from “feeling fat”8. Enforce 3 meals and 2-3 snacks per day (work with a dietician) and these MUST be supervised by parent8. Parents can be angry at the eating disorder, NOT at their child who is suffering with an eating disorder.

Question 47

What are some strategies to build rapport with an ED patient in early management?

Answer 47

1. Always start the visit by chatting alone with the teenager to let them know you value them as a person. Ask about other areas of life first to deliver the message that not everything is about their weight.2. Try to find the few things that are unpleasant for the patient about their ED: ie. bothersome symptoms such as hair thinning, always feeling cold, preoccupation with weight/shape that has affected their ability to relax or think about other things**Emphasize to the teenager that physical health and weight restoration are not negotiable and that parents/doctors are working together to make sure that this happens but try to help them understand why these changes are needed-remind them that parents and doctors are working together to fight the eating disorder, not to fight him/her.

Question 48

What is the goal of weight gain in treating a patient with an eating disorder?

Answer 48

0.2-0.5 kg/week

Question 49

A family is undergoing family-based treatment with you for their daughter who has an eating disorder. They are struggling to gain her cooperation since they are very busy to enforce refeeding. Furthermore, parents are separated. They also wonder whether they should remove her from school. What are your recommendations?

Answer 49

-for many parents, a leave of absence or reduced hours at work is needed to ensure adequate supervision of nutrition = write them a letter to their employer-continue schooling for the child but if there is concern the child is not eating their lunch, parents may need to bring the child home for lunch-reinforce the need to stop all physical activity as the refeeding process gets started-reinforce to parents that the time commitment and intense supervision required at the beginning of treatment is time well spent and offers the child the best chance of complete recovery-reinforce that the illness has affected the child’s ability to adequately care for themselves and that without the parents being a united front and taking charge, recovery will not occur.

Question 50

What monitoring should be done at every visit for a patient with an eating disorder? (3)

Answer 50

1. Urine sample2. Weight check3. Orthostatic vitals

Question 51

What are the health care goals for transition to adult care planning in youth with chronic illnesses? (4)

Answer 51

1. Adolescent involvement in management of the condition2. Adolescent and family understanding of the condition3. Understanding of personal potential for activity, education, recreation and vocation4. The attainment of self-esteem and self-confidence

Question 52

What is a transition program that can help a youth with chronic illness transition into adult health care system?

Answer 52

On-Trac transition framework = begins at around 10 yo and has clinical pathways based on stage of transition to support the youth and family

Question 53

What factors make separation and independence more difficult for adolescents with chronic conditions and their parents? (4)

Answer 53

1. Adolescent’s need for treatment2. Parental overprotection3. Physical appearance that is more youthful than the adolescent’s chronological age4. Limited physical freedom

Question 54

What are risk factors associated with dieting and unhealthy weight control behaviours in teenagers?-individual factors (8)-family factors (5)-environmental factors (4)-other factors (2)

Answer 54

Individual factors:1. Female2. Overweight and obesity3. Body image dissatisfaction and distortion4. Low self esteem5. Low sense of control over life6. Psychiatric symptoms: depression/anxiety7. Vegetarianism8. Early pubertyFamily factors:1. low family connectedness2. Absence of positive adult role models3. Parental dieting4. Parental endorsement or encouragement to diet5. Parental criticism of child’s weightEnvironmental factors:1. Weight-related teasing2. Poor involvement in school3. Peer group endorsement of dieting4. Involvement in weight related sportsOther factors:1. Chronic illnesses: diabetes2. Smoking/substance use/unprotected sex

Question 55

What are some methods you can employ for a teenager with a chronic illness to help them gain independence and assertiveness? (3)

Answer 55

1. Preparing parents for separation from their teenager2. Make teenager aware of treatment choices and encourage active discussion and participation in decision making (ie. pill or liquid med?)3. Help teenager learn self care skills to gain self-esteem and autonomy (if they need help, recommend they seek a caregiver who is not a family member)

Question 56

What are the goals of providing health care to youths with chronic health conditions? (7)

Answer 56

1. Optical medical control2. Adolescent involvement in management of condition3. Adolescent and family understanding of the condition4. Acknowledge of personal potential for activity, education, recreation and functioning5. Completion of adolescent developmental tasks6. Attainment of self esteem 7. Acknowledge of personal potential for a vocation or career

Question 57

You are about to embark on transitioning the care of a 17 yo patient of yours with a chronic illness to the adult world. What steps do you take?

Answer 57

1. Make contact with adult health care provider2. Discuss the transfer with the family well in advance (ie. at 10-12 yo)3. Give the teen a copy of the transfer summary4. Follow up with the patient and facility to ensure that the transfer has gone smoothly

Question 58

Which population has a disproportionate share of firearm injuries in the pediatric population?-most common cause of firearm death in this population?

Answer 58

Adolescent males = 98% of all firearm deaths among 15-19 yo-15-19 yo males are more likely to die from firearm injuries than cancer, falls, fires and drowning combined-most common cause of firearm death in adolescent males: suicide

Question 59

What are the current Canadian federal gun control laws?

Answer 59

1. Screening process before purchase of firearm2. All firearm owners must be licensed.3. All firearms must be registered4. All firearms must be kept in a locked container, unloaded and separate from ammunition

Question 60

Which of the following is false:a. The presence of a firearm in the home has not been shown to increase rates of homicide and suicideb. Presence of a firearm in the home was found to be a strongly positive risk factor for completed adolescent suicidec. Firearm ownership is correlated with increased suicide rates for some but not all age groupsd. Handgun related homicides now account for 2/3s of firearm homicides (rifles/shotguns make up the rest of the 1/3)

Answer 60

A! It HAS been shown to increase rates of homicide and suicide!-for C, this is true: increased suicide rates for 15-24 yo and 65-84 yo but not other age groups (?impulsivity, depression, alcohol/substances)

Question 61

What is the 2nd most common cause of enucleation secondary to trauma?

Answer 61

Air gun injuries

Question 62

What are 3 possible safety device features for guns?

Answer 62

1. Personalization device: allow only the owner to fire the gun2. Loaded chamber indicators: show the gun is loaded3. Magazine safeties: keeps a semiautomatic gun from firing when the ammunition magazine is removed even if there is a bullet left in the chamber

Question 63

True or false: children’s firearm safety education programs are effective in reducing firearm injury rates in children.-reasons for why or why not? (2)

Answer 63

FALSE. There has been no evidence so far that these programs help. Lots of studies have shown they don’t make a difference and that if a kid sees a gun, 50% will touch it, 50% will not regardless of whether they’ve been educated or not.Reasons why not:1. Firearm safety education for children may increase their comfort level around guns (especially ones that include gun handling techniques)2. Parents may have false sense of security and reduce their supervision or use of safe storage practices if they think their child learned gun safety at school

Question 64

When a facility admits a youth to care, when should a medical evaluation of each individual be performed?

Answer 64

Within 72 hrs of admission

Question 65

What are the goals of intake assessment for a youth newly admitted to a facility for short-term placement? (3)

Answer 65

1. Medical evaluation within 72 hrs of admission2. Full medical, psychiatric, behavioural history to determine whether the youth is a danger to themselves or others3. Assess for s/s of withdrawal in youth with history of recent substance use