Adolescence is one of the most beautiful and poignant phases of one’s
life; yet it is also one of the most difficult and turbulent phase. It
is a time of growth, experience, and fulfillment associated with leaps
and falls; a period when new relationships are made and old ones tested
and strengthened. This is precisely that time when the individual yearns
to touch the sky, rebels, and also starts risk-taking behavior with
potentially serious consequences. Pediatricians, as gatekeepers, have
the pleasant yet challenging responsibility of making this journey
better and easier for teenagers, their parents and teachers.
Pediatrician can be a person whom adolescents can trust and confide in,
someone who can guide, and is non-judgmental.
And to accomplish this task we need to equip
ourselves.
Role of Pediatricians in Adolescent Health
India is currently in an enviable position as far as
the distribution of its population is concerned. The adolescents (age
10-19 y) [1] constitute almost one-fifth of the total population. At the
time when most of the developed nations are reeling under the strain of
looking after their predominantly elderly people, India has the
advantage of a large proportion of young and potentially productive
people. This huge number (253 million) [2], however, puts forth another
demand – that of guiding and channelizing them! Who is the right person
for this task?
The cut-off for pediatric patients has traditionally
been 12 years. With time and experience, it has become increasingly
clear that this definition is not practical. Pediatricians take care of
health of children right from the time of birth. The children’s little
world is shaken by the storm called ‘adolescence’, and they are often
shunted to a physician. Take a look at the physician’s clinic. Mostly
elderly patients, long queues, quick dispersal from the doctor’s chamber
and uninspiring interior – a patient used to the colorful and informal
atmosphere of a pediatrician’s office is confused and scared. To top it,
the uncertainty of meeting a new doctor puts them into apprehensive
state.
The physical changes during adolescence are alien and
scary. A lot of confusion exists about what is normal and what is
abnormal. The brain is undergoing pruning and restructuring. While the
amygdala or the emotional and impulsive brain is developing fast, the
cognitive brain is lagging behind. The last to mature is the prefrontal
cortex. This gives rise to uncontrolled anxiety, bouts of aggression,
poor impulse control, and frequent mood changes [3]. Peers and peer
pressure dictate their lifestyle and decision-making. The predominant
concrete thinking of early adolescence (10-13 y) becomes abstract by
late adolescence (17-19 y). Adolescents are frequently mis-understood.
The general perception is that they are rude, noisy and self-centered.
But the fact is that they are confused and vulnerable behind their tough
facade. The characteristic developmental stage is responsible for high
risk behaviors such as rash driving, unsafe sexual practices,
malnutrition, violence, addictions, and mental and psychosocial problems
[4]. Parents of adolescents are in their late thirties or forties. They
find it challenging to handle their adolescent children. The guidance
from elders is missing due to the changing family structure. They want
information and some guidelines to deal with the situation. A
pediatrician can be the right person to make the parents aware that
their child is growing and changing. The laws of nature can be explained
to them well in advance, when the child enters into adolescence (around
the age of 10 y). Pediatricians can be the advocates of adolescents as
they have rapport with both the important parties, the parents as well
as the adolescents – a unique opportunity! Besides, talking to
adolescents is refreshing and rewarding. It can lend a fresh and
interesting component to our practice.
Challenges
However, most of the pediatricians find it difficult
to deal with adolescents in their clinics. There are multitudes of
reasons:
1. Pediatricians are often not trained to handle
adolescents and their parents.
2. As individuals, we can be prejudiced and
judgmental. This attitude is a strict no-no for adolescent practice.
3. ‘Time’ is the greatest constraint. Adolescent
care is time consuming. Sparing a lot of time for one patient is
difficult.
4. The decor is meant for little children –
colorful and loud. Children are crying in the waiting rooms;
vaccines are being given. An already anxious adolescent might become
more apprehensive in such atmosphere. They might feel out of place
and unsure of being understood in such a clinic!
What can we do?
A few simple steps can help:
• Giving a separate time slot by appointment.
• If possible, make a separate waiting area,
which will appeal to them.
• Giving them an Adolescent Card containing
growth charts [height, weight and body mass index (BMI)],
immunization schedule, Sexual maturity rating (SMR) charts, and
yearly columns highlighting the need for regular visits.
• Training at undergraduate, postgraduate and
office practice levels.
• The most important thing is to change our own
attitude towards them. Non-judgmental attitudes with active
listening, no preaching, responding (and not reacting), and ensuring
confidentiality are all the prerequisites of a good adolescent
ambassador.
Important areas to be addressed
1. During the first visit, it is important to
develop a warm, comfortable rapport with the adolescent. An
empathetic attitude, active listening and eye contact are necessary.
A thorough HEEADSSS assessment [H- Home
(information about home, family); E- Education/ Employment;
E- Eating or dietary history; A- Activities
including exercise, hobbies, screen time, media usage, etc.;
D- Exposure to Drugs/ addiction; S- Sexual
history; S- Suicidal ideation or self harm behaviors;
S- Safety] [5], measurement of height, weight and BMI,
and record of immunization status will allow the pediatrician to get
the required basic information, and will also relax the adolescent.
2. Height, weight and BMI should be plotted on
adolescent growth charts. Target height can be calculated using
mid-parental height. Any deviation from normal should be noted.
3. Immunization charts should be updated. Tdap
booster, Human papilloma virus (HPV) vaccine, Typhoid vaccine as
well as other catch up vaccines (Hepatitis A, Hepatitis B,
Chickenpox, MMR etc.) are advised as needed [6].
4. Routine general examination should be done,
especially for blood pressure, pallor, acne, goiter, gynecomastia
etc.
5. SMR staging using Tanner’s charts.
6. Any specific issue, such as scholastic
problem, behavioral problem, relationship issues should be
addressed.
7. These visits can be used to impart
anticipatory guidance regarding media, addictions, attractions,
individual variations in growth, and emotional management. The ten
Life Skills recommended by WHO (self awareness, empathy, problem
solving, decision making, critical thinking, creative thinking,
coping with stress, coping with emotions, effective communication
and interpersonal relationship) are very useful to get these things
across to them.
8. Paren‘teen’ing: "There isn’t any
formula or method of parenting. You learn to love by loving (Aldous
Huxley)." One night a man had a dream. He dreamed he was walking
along the beach with God. Across the sky flashed scenes from his
life. For each scene, he noticed two sets of footprints in the sand;
one belonging to him and the other to God. When the last scene of
his life flashed before him, he looked back at the footprints in the
sand. He noticed that many times along the path of his life, there
was only one set of footprints. He also noticed that it happened at
the very lowest and saddest times in his life. This really bothered
him and he questioned God about it. "God, you said that once I
decided to follow you, you’d walk with me all the way. But I noticed
that during the most troublesome times in my life, there is only one
set of footprints. I don’t understand why when I needed you most you
would leave me."
The God replied, "My precious, precious child; I
love you and I would never leave you. During your times of trial and
suffering, when you see only one set of footprints, it was then that
I carried you."
Moral of the story…Let the adolescents overcome
the period of crisis on their own. Let us, as parents, be with them,
without their knowledge, and pay attention to them without being
indulgent.
Pediatricians and parents need to work together for
the adolescents’ well being. Parents need to be informed about normal
adolescent growth and development, normal range of variations, handling
day-to-day frictions with adolescents, as well as the importance of
imparting gradual and watchful independence to the children. The
importance of effective communication cannot be overemphasized. What an
adolescent needs is PITA-G …Pyaar (love),
Interaction, Time, Anushaasan (discipline), and
a Guru (teacher).
Parents are the role models. Their dietary habits,
attempts at physical fitness, manner of behaving with the partner,
language – and so many other things are imbibed by the adolescents. The
parents must empower the adolescents to ‘say no’ and to ‘accept no.’
Parents must be aware that problems like declining scholastic
performance, isolation, adolescent keeping quiet at dinner time,
frequent expressions like ‘I want to die’, cash in the house getting
stolen, addiction, rash driving, criminal activities, and attempt to
suicide need urgent attention. Indian Academy of Pediatrics (IAP) Action
Plan titled ‘Parenteening’ will address various aspects of parenting of
adolescents.
Overlooking the health of adolescents is a key reason
for unmet goals in the area of adult health. Adolescence is a
significant opportunity to improve the health of a child in the second
decade of his life. IAP has come forward to design such an initiative to
address healthcare concerns among adolescents while suggesting
preventive measures to help protect them from diseases. Healthy,
educated adolescents will grow into a resource pool of valuable
individuals with the potential to contribute to the betterment of their
families, communities and country.
The Indian Academy of Pediatrics has launched ACE
(Adolescent Care Endeavour) 10/10, a major
healthcare initiative aimed at adolescents. The ACE 10/10 initiative
aims to create ‘Adolescent Ambassadors’ (kishore doot) in
the pediatricians’ community across each state for influencing the care
and health needs of adolescents. The program will impart training to
pediatricians across all the states, with the expertise from our own
Adolescent Health Academy, with a view to impacting the well-being of
adolescents in the country.
The ten teen parenting essentials that the ACE 10/10
program recommends are:
1. Ensure regular sound sleep of 8 hours every
night.
2. Encourage eating balanced food and wholesome
breakfast. This would include inculcating the habit of drinking at
least 6-8 glasses of water/day, consumption of plenty of vegetables,
salads and fruits, and discouraging foods high in sugar, fat and
salt.
3. Ensure 60 minutes of daily physical
activities.
4. Ensure annual health check up to monitor
growth and development and psychological assessment.
5. Vaccinate boys and girls with Tdap vaccine and
girls (10-12 y) with HPV vaccine.
6. Monitor school performance and studies.
7. Ensure communication and use teachable
moments.
8. Monitor digital media usage every day and
teach healthy use of media.
9. Know and stay connected with the friends of
the adolescent.
10. Be observant of change in the behavior/mood.
Healthy parenting is the PULSE of adolescent
care which demands Parents’ Unconditional Love,
Support and Encouragement.
With 1 in 5 people in India being adolescents, there
is a need is to ensure that the foundations laid during adolescence are
strong enough as they are the future of the country. What takes place
during the adolescent period affects health during the adult years and
even influences the wellbeing of the next generation. Pediatricians, as
trusted advisors to parents, play an important role in developing
Adole‘sense’. I am sure that the ‘Adolescent Ambassadors’ program will
catalyze the collective strength of pediatricians as key influencers to
effect an impactful change in the health and well-being of adolescents
as a significant segment of our society.
References
