M K C Nair
Department of Pediatrics & Epidemiology, Medical College Campus, Thiruvananthapuram, Kerala.

Corresponding Author: Dr. M K C Nair, MD, PhD, M.Med.Sc., MBA, MA, DCH, FIAP, FIACAM, PG Diploma in Counseling & Ultrasonography, Professor of Pediatrics & Epidemiology; Director, Child Development Centre, Medical College Campus, Thiruvananthapuram, Kerala. Phone: 9447121689. Email: cdcmkc@gmail.com

ABSTRACT

We need more and more general practitioners getting interested in adolescent pediatrics as a sub-specialty, for overall improvement in providing adolescent care and counseling.

Counseling is required for non-assertive adolescents and those who have scholastic backwardness, adjustment difficulties, specific behavioural problems, personality disorders and mood disorders. Adolescent depression with possible associated suicidal ideation, need special mention because of the fact that majority of them may not look depressed at all and because early detection and intervention – both medical and psychological – would give excellent results. Aim of adolescent counseling would be maintaining the client’s adaptive patterns, modifying maladaptive patterns and enhancing motivation of the client.

The goals of adolescent counseling would be resolution of problems, improving personal effectiveness, decision making – avoiding impulsive actions, reducing possibility of error, modification of behaviour – removal of undesirable behaviour, promoting mental health – through differentiating “normal” & “abnormal”. We need to create a safe and predictable holding environment for the adolescent’s concerns, affect and behaviours; by creating clear and consistent boundaries within the individual relationship; built through appropriate consistent limit setting; helping adolescent to internalize limits and improve self regulation of impulses and affect and accepting clients experience without judgment.

Many have wondered whether the concept of an adolescent pediatrician/physician would survive as an independent self sustained professional. I see a parallel with the Neonatologists in India, the majority of who are still practicing pediatricians with special interest in neonatology, but there are also many full-time qualified neonatologists with a DM or a Fellowship in neonatology. We need more and more general practitioners getting interested in adolescent pediatrics as a sub-specialty, for overall improvement in providing adolescent care and counseling. Yet qualification is essential for growth of the specialty and hence in the last few years, Child Development Centre’s single minded focus have been on producing over 600 qualified adolescent specialists with a PG Diploma in Adolescent Paediatrics from the University of Kerala, as a distance education program, with MBBS as the minimum qualification.

Our basic MBBS / paediatric / internal medicine training is adequate to deal with the majority of problems that we would see in day-to-day clinical practice. You would observe that the medical problems identified among higher secondary school children in Thiruvananthapuram district namely; headache, refractory error, urinary tract infection, dandruff, acne, allergic rhinitis and dysmenorrhoea / leucorrhoea in girls are problems that can be tackled by a trained MBBS doctor. However, in order to organize an adolescent office practice, it is essential to undergo a training program and at present the only option is the PG Diploma in Adolescent Pediatrics (distance education course of University of Kerala) conducted at CDC, Thiruvananthapuram. This course involves 80 hours sessions (only 10 days) with discussions on the following common medical issues that may come up in office practice, namely; anemia, iodine deficiency, under nutrition, overweight& obesity, body image problems, life style diseases, poly cystic ovarian syndrome (PCOS), acne & other cosmetology issues, dandruff & seborrhoea, dental caries & problems, genito urinary infections, sexually transmitted infections, sexual abuse/empowerment issues, teenage pregnancy/contraceptives, pelvic inflammatory disease, drug therapy and individual counseling for mental health issues.

Adolescent Counseling

Counseling is required for non-assertive adolescents and those who have scholastic backwardness, adjustment difficulties, specific behavioural problems, personality disorders and mood disorders. Adolescent depression with possible associated suicidal ideation, need special mention because of the fact that majority of them may not look depressed at all and because early detection and intervention – both medical and psychological – would give excellent results. Aim of adolescent counseling would be maintaining the client’s adaptive patterns, modifying maladaptive patterns and enhancing motivation of the client.

The goals of adolescent counseling would be resolution of problems, improving personal effectiveness, decision making – avoiding impulsive actions, reducing possibility of error, modification of behaviour – removal of undesirable behaviour, promoting mental health – through differentiating “normal” & “abnormal”. We need to create a safe and predictable holding environment for the adolescent’s concerns, affect and behaviours; by creating clear and consistent boundaries within the individual relationship; built through appropriate consistent limit setting; helping adolescent to internalize limits and improve self regulation of impulses and affect and accepting clients experience without judgment.

In order to achieve such a therapeutic alliance, the counselor has to be constructive in approach and have qualities of listening more – talking less, empathy not sympathy, professionalism, patience, effective communication, accepting adolescent’s freedom and maintaining confidentiality at all times.

Conditions to be present for Effective Counseling – Carl Rogers

  • Two persons to be in psychological contact
  • The first, the client, is in a state of incongruence, vulnerable & anxious
  • The second, the counselor, is congruent or integrated in the relationship
  • The counselor experiences unconditional regard for the client
  • The counselor experiences an empathic understanding of the client’s internal frame of reference and endeavours to communicate this experience to the client.
  • However, the above same is only to a minimal degree achieved.

Approaches to Adolescent Counseling

  • Cognitive Approach: Cognition means knowing: The process of counseling is the curing of unreason by reason ie., to help clients eliminate most emotional disturbances by learning to think rationally, to help them get rid off illogical, irrational ideas and attitudes and substitute logical rational ideas and attitudes.
  • Affective Approach: Affect means feeling: This approach focuses attention to what is going on inside the individual, and particularly what he / she is experiencing at a given time. Best example would be “Client cantered approach of Rogers”, focusing on elimination of “defence mechanisms” developed out of perception of threat, insecurity, inadequacy and worthlessness
  • Behavioural Approach: Conation means doing: This approach is characterized by a; focus on overt and specified behaviour, precise and well spelt out target behaviours called goals, formulation of a specific & objective treatment procedure to the problem at hand and an objective assessment of the outcome of counseling in terms of the degree of approximation to the target behaviour.

All adolescents need support and guidance. But some young people whose adolescence is marked by more serious struggles may require help from outside the family and it is usually the parents who would be the first to notice such changes in their adolescents. Parents will be troubled by confrontational nature of some of the adolescent behaviours. It is not an easy job to decide where to draw the limits and where to give in. Hence there is no tailor made solutions to these problems. We need to develop strategies in dealing with our adolescents, at times through trial and error, through experience and at times adopting the practices. Once we start feeling happy and contented, we get a tremendous desire to help others and who other than general practitioners /family physicians have the best opportunity to help our adolescents and their parents, if only we understand the basics of mental health counseling.

Adolescent mental health

These have to be addressed by the general practitioners / pediatrician / physician, because there are far too many adolescents with behavioural and emotional problems in the community and only limited number of psychiatrists and trained clinical psychologists available. We have to recognize early signs of psychosocial problems for better results and the pediatrician, who have been seeing the child and who knows the family well for a long time, would be the ideal person to do so. Both parents and children have to be made comfortable in a non- stigmatizing service delivery system. Many of the adult psychiatric disorders have their onset in adolescence.

Anxiety Disorders: Anyone can have anxiety but it would be called anxiety disorder only when it is associated with (i) history of real or perceived catastrophic trauma like death of parents, (ii) intrusive recollection of the traumatic event with (iii) autonomic arousal symptoms like sweating and palpitation and all resulting in (iv) avoidance of the situation. The drug of choice in general practice is the antidepressant (SSRI) – Fluoxetine (10-20mg/ day) to be given along with breakfast for 6 months.

Conduct Disorder: Although behavioural problems are common among school age children it becomes a disorder like oppositional defiant disorder (ODD) in the younger age group and conduct disorder (CD) in the older age group, only when it is associated with significant (i) dissocial (ii) defiant and (iii) aggressive behaviour. The drug of choice in general practice is Sodium valproate – 20mg/kg/day (1st line) or Risperidone 1-2mg/day (2nd line).

Mood Disorders: Mood disorders both depression and manias are increasingly being recognized among adolescents. Depression is now much more common than ever and it is one disorder that could be easily handled by a trained pediatrician. The adolescent may not look depressed always, instead may try to cover-up depression by showing over activity. Important clinical features of depression include; (i) persistent low mood out of proportion to the cause associated (ii) not able to enjoy what he/ she used to enjoy (iii) biological symptoms like disturbance in appetite, sleep and libido and (iv) avoiding usual social responsibilities.

The bio-psycho-social model for depression denotes that there are neurotransmitters involved and hence drug therapy is of prime importance. Cognition or the thought process as such, primarily affects mood and hence the primary defect is in the thought process – called cognitive error. The thought process may be irrational, illogical and unrealistic. There may be over generalization, maximization of negatives, minimization of positives, etc… necessitating counseling or psychotherapy by trained clinical psychologists. The support of family and friends becomes crucial in maintaining positive results of therapy. The drug of choice in general practice is the antidepressant (SSRI) – Fluoxetine (10-20mg/day) to be given along with breakfast for 6 months.

Psychosis: Psychosis and its variant forms are serious psychiatric disorders to be managed primarily by psychiatrists, yet the pediatrician has a huge role in early diagnosis. The significant clinical symptoms are; (i) hallucinations (seeing, hearing, smelling or feeling-touch, unreal things/events), (ii) delusions (unshakable false belief) and (iii) catatonic symptoms in severe cases. The drug of choice in general practice is Risperidone 2 – 4mg/day, to be used only in consultation with a Psychiatrist.

Adolescent reproductive health

Adolescents in India form one of the largest groups with an unmet need for reproductive health services. A neglected, yet promising, population for identification of reproductive health needs is the out of school adolescent girls.  Targeting this population should be rewarding both in terms of understanding their needs and introducing targeted interventions. There are differences in the way these needs are met for adolescents from different socioeconomic strata of society, as well as for those living in urban and rural areas. Adolescents should be able to protect themselves from unwanted sex, unplanned pregnancy, early childbearing, unsafe abortion, domestic sexual violence and sexually transmitted infections (STIs). With practically no information about issues related to the normal physiology of growing up and the gender relations within societies, they are highly prone to risky behaviours and diseases including sexually transmitted infections and HIV/AIDS. The three major areas to be focused would be (a) menstrual disorders, (b) reproductive tract infections and (c) Polycystic Ovary Syndrome (PCOS).

a) Menstrual disorders: Menstrual disorders are a common problem in adolescents the world over. Menstrual disorders form the commonest gynecological complaint (45-58%) among adolescents, yet are often overlooked. Though the onset of menstruation is part of the normal maturation process, variability in menstrual cycle characteristics and menstrual disorders are common. The common menstrual disorders reported in adolescents are amenorrhea, abnormal/excessive uterine bleeding, dysmenorrhea and premenstrual syndrome which can be effectively diagnosed and treated in the adolescent population. In a CDC study conducted among higher secondary students in Thiruvananthapuram corporation area, menstrual disorders were reported in 21.1% of the girls. The most frequently reported problem during menstruation was dysmenorrhoea (72.4%) followed by oligomenorrhea (11.3%). Only 11.5 % of the girls who had menstrual problems sought treatment and majority from a gynecologist. As the pain is prostaglandin mediated the drug of choice for significant dysmenorrhoea is the anti- prostaglandin drug Mefenamic Acid 250 – 500mg tds depending on the age and weight of the adolescent girl.

b) Reproductive Tract Infections: Prevalence of Reproductive Tract Infections (RTIs) among adolescents is determined by a number of factors. Lack of menstrual and personal hygiene is found to be associated with RTIs, which are preventable and treatable. They are responsible for causing serious consequences of infertility, ectopic pregnancy, wastage, low birth weight, etc… As the adolescents are important target group for prevention of RTIs, assessment of the problem among them is urgently needed. Reproductive-tract infections (RTIs), including bacterial vaginosis and candidiasis are common among adolescents and young adults. Evidence associating bacterial vaginosis with serious medical complications during pregnancy has accumulated. These associations include premature rupture of membranes, chorioamnionitis, amniotic fluid infection, premature labour and delivery, and post-partal endometritis.

Although early detection and treatment of RTIs can prevent and minimize the severity of long-term sequel, many infections go unnoticed. Utilization of specialized services for the management of RTIs is often low, because these infections are frequently asymptomatic or produce vague, non-specific symptoms. Further, the socio-cultural norms, values and taboos also prevent the women from seeking health care for RTIs. A CDC study among 427 adolescent girls, reproductive tract infections were observed by local clinical examination among 15.7% and the same was confirmed by laboratory diagnosis among 11.7%. As Candida infection is the predominant cause for genital itching with discharge, the drug of choice for unmarried adolescent girls is Fluconazole 150mg single dose, that may be repeated in severe infections.

c) Polycystic Ovary Syndrome: Although PCOS, the commonest cause for infertility later on, is reported to be a growing problem among the adolescent girls, not much data are available on the prevalence of PCOS in South India, especially among the adolescent and young adults. The clinical signs and symptoms of PCOS namely; obesity, menstrual irregularities, dirty black pigmentation of neck and undue midline hair growth, begin during the teenage years around menarche. As there is a normal period of anovulation following menarche in adolescent girls, it is often difficult to differentiate normal menstrual patterns from chronic anovulation. Also, it is very difficult to diagnose PCOS in teenage girls as they often experience irregular or absent menses and acne. Hence PCOS is rarely diagnosed in the early teenage years and the hyperandrogenic effects usually progress slowly over time.

In a CDC study of 136 adolescent girls from a cohort of 301 girls between 15 and 17 years of age with confirmed menstrual irregularity, with or without ultrasound diagnosed polycystic ovaries were assessed in detail after a gap of 2 years. Of the 136 cases reported, 36.0% cases were found to have PCOS and 63.9% cases were normal. The results of this study support screening for menstrual irregularity, obesity and clinical hyperandrogenism (increased hair growth at chin, chest and lower abdomen) for early diagnosis of PCOS in an effort to improve the reproductive health of adolescent girls.

The mainstay of management is consistent and continuous weight reduction program. Even 5% weight loss cause resumption of menses and lower androgen levels. Estrogen – Progesterone Pill regularizes periods and combats mild hirsuitism. Oral Contraceptive (Ethinyl estradiol) with Antiandrogen (Cyproterone acetate 2mg) for 6 -12 cycles only at a time is indicated when a combination of hirsuitism, acne and seborrhea occur together. Insulin sensitizing agents (Metformin 1gm daily), helps the body utilize insulin more efficiently by effects on glucose metabolism in severe case of Acanthosis Nigricans. As a significant contributor to infertility later on adolescent PCOD  should  be  detected  in adolescence and at least during premarital counseling.

Pre-marital Counseling

Premarital counseling should be offered to any adolescent over 18 years of age and should emphasize on the following;

  1. Ideal age for marriage is between 20 and 30 years, though many are not lucky enough to get the right partner by then.
  2. Once married, do not delay the first pregnancy unless you are below 21.
  3. Do not forget a medical and gynecological check-up before marriage (to detect menstrual abnormalities, PCOD and vaginal infections) and obtain adequate information on contraceptives both conventional and emergency contraceptives.
  4. Rule out sexually transmitted diseases
  5. Avoid drugs during 2nd half of menstrual cycle as fertilization occurs around 14th day.
  6. Remember that perinatal intake of folic acid could prevent neural tube defects in the baby.
  7. Avoid intrauterine infections to prevent low birth weight, small head, deafness, cataract, various birth defects. Avoid Toxoplasmosis by not eating improperly cooked meat and avoiding contact with cat faces during gardening. Rubella (German measles) could be avoided by taking MMR vaccine at 15 months of age and Rubella vaccine at adolescence or even later.
  8. Sexuality education is a must to avoid marital disharmony.

Sexuality is a boon given to mankind alone by the almighty. It is the sum total of one’s thinking, behaviour and attitude. Sexuality is becoming comfortable with one’s own body, emotions and feelings. To develop a positive sexuality concept one has to free the mind from all fears, misconceptions, myths and complexes. Evolving healthy sexuality has to be a lifelong process.

End Note

Author Information

Dr. M K C Nair, MD, PhD, M.Med.Sc., MBA, MA, DCH, FIAP, FIACAM,
PG Diploma in Counseling & Ultrasonography,
Professor of Pediatrics & Epidemiology;
Director, Child Development Centre,
Medical College Campus, Thiruvananthapuram, Kerala.   

Conflict of Interest: None declared

References

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  3. MKC Nair, Mini K Paul, Babu George. Counselling.In: Bhave’s Text Book of Adolescent Medicine. Eds .Swati Y Bhave, MKC Nair, A Parthasarathy, PSN Menon, Donald Gradanus. Published by Jaypee  Br o t h e r s  Medical Publishers Limited, New Delhi, 2006; p837-843.
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