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• 3 phases
• Early Adolescence
• Middle Adolescence
• Late Adolescence
EARLY MIDDLE LATE
VARIABLE
ADOLESCENCE ADOLESCENCE ADOLESCENCE
Approximate age
10-13 yr 14-17 yr 18-21 yr
range
Sexual maturity
1-2 3-5 5
rating*
•Females: peak
growth velocity,
•Females: menarche (if not
Secondary sex already attained)
characteristics
• Physical
(breast, pubic, •Males: growth spurt,
maturation
axillary hair), start secondary sex
Physical slows
• Increased
of growth spurt characteristics,
lean muscle mass
nocturnal emissions,
in males
•Males: testicular facial and body hair,
enlargement, start voice changes
of genital growth •Change in body
composition
•Acne
EARLY MIDDLE LATE
VARIABLE
ADOLESCENCE ADOLESCENCE ADOLESCENCE
Approximate
10-13 yr 14-17 yr 18-21 yr
age range
•Future-oriented
•Emergence of
with sense of
abstract thought
perspective
(formal operations)
• Concrete •Idealism
•May perceive future
operations •Able to think
implications, but
• Egocentricity things through
may not apply in
• Unable to perceive •independently
decision making
Cognitive and long-term •Improved
•Strong emotions
moral outcome of current impulse control
may drive decision
decisions •Improved
making
• Follow rules to assessment of
•Sense of
avoid risk vs.
invulnerability
punishment •reward
•Growing ability to
•Able to
see others’
distinguish law
•perspectives
from morality
EARLY MIDDLE LATE
VARIABLE
ADOLESCENCE ADOLESCENCE ADOLESCENCE
Approximate
10-13 yr 14-17 yr 18-21 yr
age range
• More stable body
• Preoccupied with
• Concern with image
•
Self- changing body
attractiveness • Attractiveness may
concept/identity • Self-consciousness
Increasing still be of concern •
formation about appearance
introspection Consolidation of
and attractiveness
identity
• Conflicts over •Emotional and
control and physical separation
• Increased need for
independence from family
privacy
• Struggle for •Increased
• Exploration of
Family greater autonomy
dependence/
autonomy •Reestablishment
independence
• Increased of “adult”
boundaries
separation from •relationship with
the parents parents
EARLY MIDDLE LATE
VARIABLE
ADOLESCENCE ADOLESCENCE ADOLESCENCE
Approximate age
10-13 yr 14-17 yr 18-21 yr
range
• Intense peer
group involvement • Peer group and
• Same-sex peer
Peers • Preoccupation values recede in
affiliations
with peer culture • importance
Conformity
• Consolidation of
• Testing ability to sexual identity
•Increased interest
attract partner • Focus on
in sexual anatomy
• Initiation of intimacy and
•Anxieties and
relationships and formation of
Sexual questions about
sexual stable
pubertal changes
activity relationships
•Limited capacity
• Questions of • Planning for
for intimacy
sexual orientation future and
commitment
PHYSICAL DEVELOPMENT
• Puberty
• is the biologic transition from childhood to adulthood
• changes include the appearance of the secondary sexual
characteristics, increase in height, change in body composition,
and development of reproductive capacity
• Production of
• Androgen – dihydroepiandrosterone sulfate (DHEAS)
• GNRH
• LH
• FSH
Sexual Development
• SMR 2 is testicular
enlargement, beginning
as early as 9.5 yr
• Males
• 40-65% breast tissue growth, typically bilateral during SMR 2-3
as a consequence of a relative excess of estrogenic
stimulation
• resolves with ongoing maturation
Tanner (females)
• SMR 2 is the appearance of
breast buds (thelarche), between
8 and 12 yr of age
• Sexual identity
• Gender identity
• Sexual orientation
• Gender variant
• Transgender
• Transsexuals
• Cross dresser/transvestites
• Bigender
• Drag queens/kings
• Queer
PSYCHOSOCIAL ASSESSMENT
• peer relationships • School
• “Do you have a best friend with • “How are your grades this year
whom you can share even the compared with last year?”
most personal secret?”
• personal decisions
• self-image • “Are you feeling pressured to
engage in any behav- ior for which
• “Is there anything you would like to
you do not feel you are ready?”
change about your- self?”
• eating disorder
• depression
• “Do you ever feel that food controls
• “What do you see yourself doing 5 you rather than vice versa?”
yr from now?”
HEADS/SF/FIRST
Home. Space, privacy, frequent geographic moves,
neighborhood.
Education/School. Frequent school changes, repetition of a
grade/ in each subject, teachers’ reports, vocational goals, after-
school educational clubs (language, speech, math, etc.), learning
disabilities
Abuse. Physical, sexual, emotional, verbal abuse; parental
discipline
Drugs. Tobacco, alcohol, marijuana, inhalants, “club drugs,”
“rave” parties, others. Drug of choice, age at initiation, frequency,
mode of intake, rituals, alone or with peers, quit methods, and
number of attempts
Safety. Seat belts, helmets, sports safety measures, hazardous
activities, driving while intoxicated
Sexuality/Sexual Identity. Reproductive health (use of
contraceptives, presence of sexually transmitted infections,
feelings, pregnancy)
HEADS/SF/FIRST
Family and Friends. Family: Family constellation, genogram, single/
married/separated/divorced/blended family, family occupations and shifts;
history of addiction in 1st- and 2nd-degree relatives, parental attitude toward
alcohol and drugs, parental rules; chronically ill physically or mentally challenged
parent. Friends: peer cliques and configuration (“preppies,” “jocks,” “nerds,”
“computer geeks,” cheerleaders), gang or cult affiliation
SOCIAL FACTORS
Poverty
Limited access to “adolescent friendly” healthcare services
Adolescent health-seeking behaviors (forgoing care because of
confidentiality concerns or denial of health problem)
Sexual abuse and violence
Homelessness
Young adolescent females with older male partners
Epidemiology
Pathogenesis
HIV
• HIV screening should be discussed and offered to all adolescents ≥15 yr in healthcare
settings, unless identified at an earlier age with HIV risk factors
Routine Laboratory Screening Recommendations for Sexually Transmitted
Infections in Sexually Active Adolescents and Young Adults
SYPHILIS
• Syphilis screening should be offered to sexually active adolescents reporting risk factors
• The majority of U.S. syphilis cases occurring among young MSM and many early
syphilis cases are identified from correctional facilities
• Providers should consult with their local health department regarding local syphilis
prevalence and associated risk factors that are associated
with syphilis acquisition
HEPATITIS C VIRUS
• Screening adolescents for hepatitis C virus who report risk factors, i.e., injection drug
use, MSM, received blood products or organ donation before 1992, received clotting
factor concentrates before 1987, long-term hemodialysis, or high prevalence setting, i.e.,
correctional facilities or STD clinics
Definitions, Etiology, and
Clinical Manifestations
of STI
Urethritis
• Trichomoniasis
• Caused by protozoan T. vaginalis. Infected females may
present with symptoms characte ized by a diffuse,
malodorous, yellow-green vaginal discharge with vulvar
irritation or may be diagnosed by screening an
asymptomatic patient.
Cervicitis
• (1) a purulent or
mucopurulent endocervical
exudate visible in the
endocervical canal or on an
endocervical swab specimen
commonly referred to as
mucopurulent cervicitis or
cervicitis
• (2) sustained endocervical bleeding easily induced by
gentle passage of a cotton swab through the cervical os
signifying friability
Pelvic Inflammatory Disease
• encompasses a spectrum of inflammatory disorders of the
female upper genital tract, including endometritis, salpingitis,
tuboovarian abscess, and pelvic peritonitis, usually in
combination
Number of
Usually multiple Usually single Multiple
lesions
Unilateral or bilateral
First-time infections
painful adenopathy in
Inguinal may cause
Usually mild and >50%
lymphadenopat constitutional
minimally tender Inguinal bubo
hy symptoms and
formation and rupture
lymphadenopathy
may occur
HERPES
SIGNS/SYMPT
SIMPLEX SYPHILIS (PRIMARY) CHANCROID
OMS
VIRUS
Detection of
HSV by culture Identification Treponema
Detection of
Definitive or PCR from pallidum, from a chancre or
Haemophilus ducreyi by
diagnosis ulcer scraping lymph node aspirate, on dark-
culture
or aspiration of field microscopy
vesicle fluid
Genital Lesions and Ectoparasites
• present as outgrowths on the surface of the epithelium and
other limited epidermal lesions
For pregnancy:
Azithromycin 1 g orally once
Alternative regimens:
Erythromycin base 500 mg orally 4 times a day for
Azithromycin 1 g orally
7 days or
Chlamydia trachomatis once
or
Doxycycline 100 mg
Erythromycin ethylsuccinate 800 mg orally 4 times
orally twice daily for 7 days
a day
for 7 days or
Levofloxacin 500 mg orally once daily for 7 days or
Ofloxacin 300 mg orally twice a day for 7 days
Treponema pallidum
Penicillin allergy: doxycycline 100 mg
(primary and Benzathine penicillin G
orally twice daily for 14 days. Limited
secondary syphilis or 2.4 million units IM in 1
data suggest ceftriaxone 1-2 g daily
early latent syphilis, dose
either IM or IV for 10-14 days.
i.e., infection <12 mo)
Benzathine penicillin G
Treponema pallidum
7.2 million units total, Penicillin allergy: doxycycline 100 mg
(late latent syphilis or
administered as 3 doses orally twice daily for 28 days with
syphilis of unknown
of 2.4 million units IM close serologic and clinical follow-up
duration)
each at 1 wk intervals
ALTERNATIVE REGIMENS
RECOMMENDED
PATHOGEN AND SPECIAL
REGIMENS
CONSIDERATIONS
Azithromycin 1 g orally in
a single dose or
Ceftriaxone 250 mg IM in
Haemophilus ducreyi a single dose or
(chancroid: genital Ciprofloxacin 500 mg
ulcers, orally twice a day for 3
lymphadenopathy) days or
Erythromycin base 500
mg orally 3 times a day
for 7 days
Alternative: erythromycin
Chlamydia trachomatis base 500 mg orally 4
serovars L1, L2, or L3 Doxycycline 100 mg orally times a day for 21 days
(lymphogranuloma twice daily for 21 days or
venereum) Azithromycin 1 g orally
once a week for 3 wk
Management Guidelines for Uncomplicated Miscellaneous Sexually Transmitted
Infections in Adolescents and Adults
ALTERNATIVE
PATHOGEN RECOMMENDED REGIMENS REGIMENS AND SPECIAL
CONSIDERATIONS
Patient-applied:
Podofilox 0.5% solution or gel self-applied to
warts twice daily for 3 consecutive days each wk followed by 4 days
of no therapy. May be repeated for up to 4 cycles.
or
Imiquimod 3.75% cream or 5% cream self-
applied to warts at bedtime 3 times wkly for
up to 16 wk; wash off after 6-10 hr or
Human Sinecatechins 15% ointment self-applied 3 times daily for up to 16
papillomaviruses wk. Do not wash off after use
external genital Provider-administered:
warts Cryotherapy with liquid nitrogen or cryoprobe.
Repeat applications every 1-2 wk or
Trichloroacetic acid (TCA) or bichloracetic acid (BCA) 80-90%. A
small amount should be applied only to the warts and allowed to
dry, at which time a white “frosting” develops. Can be repeated
weekly
or
Surgical removal either by tangential scissor
excision, tangential shave excision, curettage, or electrosurgery
Management Guidelines for Uncomplicated Genital Warts and Genital Herpes in
Adolescents and Adults
Treat for 7-10 days with 1 of the
following: Acyclovir 400 mg orally 3
times daily
or Consider extending
Herpes simplex virus
Acyclovir 200 mg orally 5 times daily treatment if healing is
(genital herpes): First
or incomplete after 10
clinical episode
Valacyclovir 1 g orally twice daily days of therapy
or
Famciclovir 250 mg orally 3 times
daily
Management Guidelines for Uncomplicated Genital Warts and
Genital Herpes in Adolescents and Adults
Before or
Time of day After school
during school
Whiskey,
Marijuana, Hallucinogens, opiates,
Type of drug
beer, wine amphetamines cocaine,
barbiturates
Stages of Adolescent Substance Abuse
STAGE DESCRIPTION
Potential for abuse
• Decreased impulse control
• Need for immediate gratification •
1
Available drugs, alcohol, inhalants • Need for peer acceptance
Regular use: seeking the euphoria
• Use of other drugs, e.g., stimulants, LSD,
3 sedatives • Behavioral changes and some consequences
• Increased frequency of
use; use alone
• Buying or stealing drugs
• Have you ever ridden in a Car driven by someone (including yourself) who
was high or had been using alcohol or drugs?
• Do you ever use alcohol or drugs to Relax, feel better about yourself or fit in?
• Do you ever use alcohol or drugs while you are by yourself (Alone)?
• Do you ever Forget things you did while using alcohol or drugs?
• Do your Family or Friends ever tell you that you should cut down on your
drinking or drug use?
• Have you ever gotten into Trouble while you were using alcohol or drugs?
The Most Common Toxic Syndromes
ANTICHOLINERGIC SYNDROMES
SYMPATHOMIMETIC SYNDROMES
CHOLINERGIC SYNDROMES
FDA-
STUDIED IN
THERAPY APPROVED AVAILABILITY
NAME STRENGTHS ADOLESCENT QUIT DATE
BRAND ADULT *
S
DOSING
Nicotrol
Inhaler 4 mg 6-16 cartridges a day for up to 12 wks Rx No
Inhaler
• Subcutaneous: in minutes
• snorting: 30 minutes
• euphoria, diminution in pain, flushing of the skin, and pinpoint
pupils
• Loss of libido
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