Week 42 (Adolescent Growth and Development)- Lecture Content 1

Pubic Hair- Tanner Staging (Male and Female) 2. Describe the hormonal changes of puberty and relate this with physical examination (Tanner staging), linear growth (timing of growth spurt) and skeletal maturation

** NOTE: 2 has some hair but straight 3 has curls 4 to edge 5. right to edge/ fully developed

Take Home Points

1. Adolescence is a time of rapid psychological and brain development 2. Most morbidity and mortality in adolescents is behavioral and/or developmental 3. Strengths and protective factors are at least as important as risk behaviors and environmental risk factors 4. Children and youth are society's most valuable resources. Our job: Promote the positive development of adolescents into caring, contributing, thriving adults

Treatment of CPP

1. Medroxyprogesterone acetate (DepoProvera®) injections can be given to control menstrual periods and some sexual behaviors, without affecting adult height 2. GnRH Agonists- GnRH stimulates gonadotropin secretion if given in pulses and inhibits it if given continuously • Analogs are true agonists of natural GnRH with substitutions at the 6th amino acid • They inhibit gonadotropin secretion because of prolonged half-life • May cause some regression of secondary sex characteristics - decreased breast size, testicular volume - growth velocity slows - final height improves in selected patients - ? psychosocial benefits E.g. Lupron Depot

4. State the current levels of physical activity in adolescents based on published data

Active healthy kids Canada reporting on Kids activity levels since 2005: D In 2015 - Participaction reporting D - 5-11 yr olds - only 14 % meet 12-17 yr olds - only 5% meet Many Don't meet physical requirements

1. Describe the characteristics of a healthy diet for an adolescent patient, and how that differs from requirements of younger children and adults

Adolescence: Developmental Changes • Puberty: physical transformation from child→adult • Includes: sexual maturation, ↑ height & weight, completion of skeletal growth, changes in body composition • Stages are consistent, but duration & timing different → nutritional needs based *on stage, not age* Cognitive/ emotional changes + Increased needs--> nutritional risk

Protective Factors 4. Describe health risk and protective factors of adolescents in British Columbia

Internal PF: ability to cope with stress, learning and problem-solving skills, coping and emotional regulation skills, social skills, positive outlook on life, Appealing qualities External PF: *CONNECTEDNESS*, Family, School, Caring Adult, Community, Pro-social Peers Even for teens with high risk--> protective factors can buffer risks

6. Describe how clinicians can impact the health of adolescents through engagement of the broader community

Advocate to remove barriers to access exercise Need a multi prong approach- not just kids and parents, but stores, rec centres and everything

2. Identify and describe the impact of chronic health conditions on psychosocial development during adolescents

Chronic Illness impacts yoru identify development because you may have a decreased ability to live independently, decreased independence and family roles • Identity development • Peer relationships • "Visible" vs. "Invisible" disability • Delayed life milestones • Similar or increased risk mental health & substance use disorders vs.. healthy peers • Youth facing multiple adversities are more likely to experience negative outcomes

Treatment of CDGA

Constitutional delay in growth and development Things to Account for • Patient's age (chronological and bone age) and Tanner stage • Coexisting pathology • Compelling psychosocial considerations Treatment of CDGA: BOYS • Best approach is *watchful waiting coupled with explanation of wide variation of pubertal development • 6-month course of low-dose depot testosterone will increase growth rate by about 75% and advance pubic hair by one stage, without deleterious effect on height potential • Usually not initiated before age 13 (minimum bone age 11 - otherwise puberty will not be sustained Treatment of CDGA: GIRLS • Minimum BA=10 to initiate therapy • Most would start at ethinyl estradiol at 2.5 µg/d with max dose of 5 µg/d • Usually not initiated before age 13 (minimum bone age 11 - otherwise puberty will not be sustained)

3. Explain the causes of precocious and delayed puberty from central and gonadal causes- Precocious Puberty

Definitions: • Girls: breast budding or pubic hair before age 8 or menarche before age 10 • Boys: testicular enlargement or pubic hair before age 9

Energy Requirements

Energy Physical activity energy expenditure varies widely - athletes vs "bookworms" High physical activity + growth needs of adolescence may = risk Careful monitoring of weight/height/BMI Sexual development also sensitive to nutrition

Body Composition Changes during Puberty

Females: • ⬇ proportion LM, ⬆ proportion FM • peak needs 10-13 years Males: • ⬆ proportion LM, ⬇ proportion FM • peak needs 12-15 years

Adolescent Brain Development

Functions of the Frontal Lobe *the last part of the brain to mature* • Executive Functions • Insight • Empathy • Impulse Control • Emotional Regulation • Social conduct, rules and laws • Maturity is dynamic • Full maturity: mid-20's You have more developed limbic regions (strong emotions and stress) You have under developed prefrontal regions- so teenagers can make mistakes especially when stressed "Hot" Cognition--> when they're stressed, highly active limbic system, and don't have good executive function

5. Propose how levels of physical activity can be increased in adolescents

GUIDELINE COMPONENTS ORGANIZED SPORT PARTICIPATION - B (77%) ACTIVE TRANSPORTATION - D (25%) ACTIVE PLAY - D+ (37%) Increasing Physical Literacy

GnRH Dependent Precocious Puberty

GnRH-Dependent Precocious Puberty • Idiopathic (75% of girls and <10% of boys) - may be familial • CNS lesions (Hypothalamic hamartoma, optic glioma, congenital defects) • Prolonged exposure to sex hormones: - untreated or poorly controlled CAH - estrogen- and androgen-secreting tumors

Onset of Normal Puberty

• *Reactivation* of the hypothalamic-pituitary- gonadal axis, leading to increased nocturnal pulsatile secretion of LH and early morning secretion of gonadal steroid hormones • Appearance of an LH-predominant response during GnRH stimulation testing • Usually preceded 2-3 years by a rise in adrenal androgen levels (adrenarche), which occurs independently of GnRH

3. Describe the new physical activity guidelines for adolescents

• 60 Min/day of Moderate-Vigorous Intensity - Sweat a little and breathe harder • Vigorous intensity 3 days/wk - Sweat and be out of breath • Activities to strengthen muscle and bone 3days/wk

Normal Onset of Puberty: Boys

• 96% of normal North American boys have onset of puberty between age 9-14 years (mean 11.5) • No significant differences between white and black males • First sign: testicular enlargement (GREATER THAN OR EQUAL TO 4 cc) Pre Pubertal: 1-3 cc Puberty:4-6 cc Adult Normal: 15-25 cm

Adolescent Development and Health: Paradox 1. Describe adolescent psychological development and explain resilience, risk, and protective factors in the adolescent psychosocial history. Describe how to apply positive youth development concepts in interviewing adolescents

• Adolescence should be "healthy" biologically • Major morbidity and mortality in adolescents are related to: - Development & Behaviors - Social Determinants of Health • Health Care Providers have a unique opportunity to make a difference in the future of youth

Early Adulthood 3. Identify and describe salient features in the stages of development during adolescence and young adulthood

• An emerging "fourth demographic" • Developing financial independence • Transitions: School, Employment, Residence, Foster Care System • Ongoing brain development • Medically underserved, high morbidity and mortality

Growth with Central Precocious Puberty 3. Explain the causes of precocious and delayed puberty from central and gonadal causes

• CPP is associated with decreased final height because of premature fusion of epiphyses--> SHORT STATURE • This deficit not as great as previously thought in many children • Adult height lowest in those with the earliest onset of puberty Other side effectsL Co-existing pathology, Psychosocial issues

GnRH-Independent (peripheral) Precocious puberty: Girls DDx

• Exogenous gonadal hormones (BCPs, estrogen creams) • Severe primary hypothyroidism (TSH spillover on FSH receptor) • Ovarian tumors or cysts • Adrenal tumors • McCune-Albright syndrome • Precocious puberty, menarche • Bony lesions - polyostotic fibrous dysplasia • Irregular cafe-au-lait spots • May have other autonomous endocrine tumors - toxic thyroid nodules, pituitary adenomas • May have non-endocrine involvement - hepatobiliary, cardiac

Delayed Puberty Definitions

• Girls: no breast development by age 13 or no menarche by age 16, or absence of menarche within 5 years of pubertal onset • Boys: if no increase in testicular length (>2.5 cm/ volume 4cc) by age 14

Precocious Puberty: DDx 3. Explain the causes of precocious and delayed puberty from central and gonadal causes

• GnRH-dependent (true, central) - always isosexual • GnRH-independent (peripheral) - isosexual - contrasexual

Growth Spurt

• Gonadal steroid hormone-induced increase in GH secretion • Peak growth velocity achieved at age 11.5 in girls and 13.5 in boys • About 15% of adult height is accrued in puberty • 99.0% of final height reached at bone age 15 in girls and 17 in boys

Delayed Puberty: DDx

• Hypergonadotropic conditions - Variants of ovarian and testicular dysgenesis: Turner's, Klinefelters - Gonadal toxins (chemo/radiotherapy) - Enzyme defects (17 α-hydroxylase, 17-ketosteroid reductase) - Androgen insensitivity • Hypogonadotropic conditions - Multiple trophic hormone deficiencies/Isolated GH deficiency - Kallman syndrome (isolated GnRH deficiency) - Systemic conditions, nutritional and psychogenic disorders, increased energy expenditure - Other endocrine causes: hypothyroidism, glucocorticoid excess, hyperprolactinemia - Constitutional delay in growth and development (CDGA)

Adolescent Psychological Development 1. Describe adolescent psychological development and explain resilience, risk, and protective factors in the adolescent psychosocial history. Describe how to apply positive youth development concepts in interviewing adolescents

• Identity: "Who am I?" • Peer & Family Roles: "Where do I fit in?" • Independence (interdependence): "Can I take care of myself?" • Cognition: Concrete ("Here and now") --> Abstract ("My goals, values, future...") • Emotion: "Can I handle these strong (new) feelings?

Physical Changes of Puberty 1. Physical Changes of Puberty 2. Describe the hormonal changes of puberty and relate this with physical examination (Tanner staging), linear growth (timing of growth spurt) and skeletal maturation

• In ~85% of girls, breast development (thelarche) is the first outward sign of puberty • In the remainder, it is the appearance of pubic hair (pubarche) • In nearly all boys, testicular enlargement (gonadarche) to a volume >4 cc is the first sign of puberty • Family history is often revealing

Premature Thelarche

• May appear at any age, usually <5 years • Often asymmetrical, may regress • Etiology unknown, ? transient ovarian follicle • May be first sign of true precocious puberty • May be associated with "smoldering early puberty" • Generally benign if bone age not advancing

Investigations for Precocious Puberty

• Measure height and growth velocity carefully • Bone age • TSH • LH, FSH, DHEAS, estradiol or testosterone not always helpful, 17-OHP, Other tests to determine • GnRH stimulation test, looking for a rise of LH to 6-8 U/L • If central precocious puberty: MRI head

Gynecomastia

• Observed in 65% of normal boys at Tanner 4 • Resolves in 75% within a year • More noticeable in obese boys • Consider possibility of Klinefelter syndrome • Also consider medications, marijuana

Nutrients for Adolescents

• Risk for multiple micronutrient deficiencies (why?): • Calcium (peak bone mass 30-35 yr) • Iron (⬆ blood volume + menses) • Zinc for creation of new tissue • B vitamins (energy metabolism) • Vitamin D • Risk of overconsumption of energy ➜ obesity ➜ chronic disease

2. Describe common consequences of poor diet quality in adolescents and propose approaches to screening

• Separation from parents, influence of peers • Development of abstract (as opposed to concrete) and complex thinking • Emerging independence - economic, social, emotional SCREENING- RISK FACTORS • Skipping meals • Meals away from home • Alcohol • Body image

GnRH-Independent (peripheral) Precocious puberty: Boys DDx

• Untreated congenital adrenal hyperplasia • Exogenous gonadal hormones (anabolic steroids) • hCG-secreting dysgerminoma/hepatoma (LH receptor) • Testicular tumors • Adrenal tumors • Testotoxicosis (autonomous LH receptor)

Premature Adrenarche

• Usually warrants some investigation • May also have body odor, axillary hair, acne,hirsutism, acanthosis nigricans • R/O non-classical or late-onset 21- hydroxylase deficiency • Generally benign if bone age not advancing • Associated with later development of PCOS (polycystic ovarian syndrome) in many girls

Normal Pubertal Progression in boys

• Voice breaks around age 13 • Axillary, facial hair appear about age 14 • Gynecomastia frequent at Tanner 4 • Peak growth velocity at Tanner 4 • Continued virilization into late teens

Timing Of Female Puberty 2. Describe the hormonal changes of puberty and relate this with physical examination (Tanner staging), linear growth (timing of growth spurt) and skeletal maturation

• White North American girls: - thelarche between age at 10 - pubarche between age mean 10.5 Black and Asian girls--> earlier maturation • Peak growth velocity at Tanner 3 • Mean growth after menarche ~3 cm (range 0-6)

Examination for Precocious Puberty

•Follow growth velocity carefully • Tanner staging of breasts and pubic hair individually in girls • Tanner staging of genitals and pubic hair individually in boys • Look for evidence of isosexual pubertal development - breast tissue, vaginal mucosal pinkening, mucoid discharge in girls - testicular and phallic enlargement and scrotal thinning in boys - acne, body odor, pubic and axillary hair in both • Look for evidence of contrasexual pubertal development *particularly worrisome* - clitoromegaly or hirsutism in girls - gynecomastia in boys • Look for evidence of other disease processes - CNS disease or abnormalities - cafe-au-lait spots or other neurocutaneous lesions - endocrine disease

SSHADESSS

Strength based assessment

The five "C"s of Positive youth development 1. Describe adolescent psychological development and explain resilience, risk, and protective factors in the adolescent psychosocial history. Describe how to apply positive youth development concepts in interviewing adolescents

The 6th: "Contribution"