Nice beautiful green coconut palm leaves from a village in Kerala, India.

Tdap vaccine

Tdap vaccine includes standard dose tetanus vaccine, reduced dose diphtheria vaccine and acellular pertusis vaccine. Standard DTP vaccine is not useful for children above 7 years of age.

Hepatitis B vaccination
 
WHO has recommended it for universal immunization.
 
Human papilloma virus vaccine [HPV]
 
16 and 18 are the important types of viruses involved in human cervical cancer. Vaccination of females before onset of sexual activity and before the age of 26 years.  
 
Varicella vaccination
 
If not exposed  earlier or wthin 72 hours of exposure [90 percent efficacy].
 
Japanese B encephalopalitis vaccination
 
Given in endemic areas

Acne – closed and open comedones. Macrolides have a high follicular concentration and are useful in the treatment of acne. Retinoids are also used frequently. Systemic antibiotics are also useful. Systemic retinoids should be used with caution. Comedone extraction is one of the common office procedures.

Hirsuitism if associated with metabolic syndrome should initiate a search for polycstic ovarian syndrome.

Seborrhoeic dermatitis is also androgen dependant and may sometimes be associated with metabolic syndrome.

Psychocutaneous disorders

Dermatitis artefacta
Prurigo nodularis – a form of neurodermatitis

BMI for adults:

Normal BMI: 18 – 25
Overweight: 25 – 30
Obesity: BMI 30 – 40
Morbid obesity: BMI > 40

To avoid obesity, ban eating in front of television. Food should be served only in the dining room. Encourage healthy eating habits and outdoor games. Bariatric surgery is only for the morbidly obese with comorbidity. On the preventive aspect, both low birth weight and high birth weight are to be prevented as they are fore runners of obesity. Obesity is the after effect of easy availability of inexpensive food and sedentary jobs.

Childhood autism was first described by Leo Kanner in 1943. He described 11 children who were “unable to relate” in usual ways to the people and considered it as autistic disturbances of affective contact. The term “autos” means self, and these children have a tendency to morbid self absorption.

Socioemotional reciprocity is the essence of human relationship and autism is a prototype disorder of sociocognitive development.

Prevalence of Autism

Recent studies have shown a prevalence rate 10 – 20 per 10000 children. The sex ratio of boys:girls is 4:1.

Etiology: Biological Factors

Abnormalities have been found in “social brain” – orbito-frontal and medial frontal cortex, superior temporal gyrus and limbic system – especially, reduced amygdala volume.

Relative increase in brain volume has been noted in MRI studies possibly due to failure of synaptic pruning. There is also reduced neuronal size in the hippocampus, amygdala, anterior cingulate cortex and mamillary bodies.

Diagnostic criteria

1. Qualitative impairment in reciprocal social interaction, characterised by:

Failure to develop appropriate peer relationships.
Marked impairment in multiple nonverbal behavior to regulate social interaction.
Lack of social or emotional reciprocity.
Lack of spontaneous seeking to share enjoyment, interests, and achievements with other people.

2. Qualitative impairment in communication as follows:

Delay in, or total lack of, the development of spoken language.
Impairment in the ability to initiate and sustain conversation with others.
Stereotyped or repetitive use of language.
Lack of varied, spontaneous play or social imitation of play.

3. Restricted repetitive and stereotyped behavior:

Stereotyped and repetitive motor mannerisms.
Persistent preoccupation with objects or preoccupation with one interest that is either abnormal in intensity or focus.
Inflexible adherence to specific, non-functional rituals or routines.

Along with the above primary symptoms of autism, these children have also have cognitive delays, motor delays and sensory difficulties.

Abnormalities of motor behaviour include hand flapping, waving in front of the eyes, tip toe walking and echopraxia. Echopraxia is the involuntary repetition or imitation of the observed movements of another individual.

Abnormal reponses to sensory stimuli include hyperacusis, tactile defensiveness – extreme sensitivity to touch or insensitivity to pain – may not cry after a severe injury.

Fascination to certain sensory stimuli such as spinning objects is common in autistic children. Some enjoy vestibular sensations such as twirling without becoming dizzy.

Savant skills in autism

10% of people on the autistic spectrum have savant skills. They have high, sometimes prodigious performance on a specific skill in the presence of mild or moderate mental retardation.
e. g. Memorizing lists, calender calculation, drawing skill, musical skill.

Atypical autism

Atypical autism is a type of pervasive developmental disorder that differs from childhood autism either in age of onset or in failing to fulfill all diagnostic criteria. Atypical autism manifests after the age 3 years or there are impairments in communication and stereotyped behaviour, but emotional response to caregivers is not affected.

Differential diagnosis of autism

Two other pervasive developmental disorders which come in the differential diagnosis include:

1. Asperger syndrome

Asperger syndrome was described by Asperger in 1944. It is characterized by the same kind of impairment of social activities and stereotyped features of behaviour as is described in autistic children.
There is no delay of speech and cognitive development. The condition occurs predominantly in boys (8:1).

2. Rett’s syndrome

Rett’s syndrome has been described only in girls. Normal early development is followed by partial or complete loss of speech and of skills in locomotion and use of hands, together with deceleration in head growth. Onset of Rett’s syndrome is between 7 and 24 months of age. Loss of purposive hand movements, hand-wringing stereotypies, and hyperventilation are the importan features of Rett’s syndrome. Motor functioning is more affected in middle childhood and muscles are hypotonic. Kyphoscoliosis and spasticity in the lower limbs occurs in majority of cases.

Other differential diagnoses of autism include selective mutism, receptive language disorders, expressive language disorders, mental retardation and obsessive compulsive disorder.

Assessment of autism

Developmental history is essential. Assessment of intelligence, self help skills and pre academic skills helps in planning the remedial training programs. Structured interviews like Autism Diagnostic Interview (ADI) and unstructured behavioral scales like Childhood Autism Rating Scale (CARS) and structured behavioral observation scales like Autism Diagnostic Observation Scale (ADOS)
help in arriving at a correct diagnosis.

Behavioural Analysis

Behavioural analysis should be done using ABC chart (antecedent, behaviour, consequence). Determine child’s current developmental level, strengths and weaknesses, likes and dislikes.

Treatment of autism

Early and intensive intervention is essential for successful management of autism. Medication is needed for children with aggressive behaviour. Behaviour modification programmes and social skills training and speech stimulation programs helps in improving the socioemotional reciprocity as well as communication skills of these children and helps in alleviating the stereotyped behaviours.

Conclusion

Identifying children with autism and initiating intensive, early ntervention during the preschool years, results in improved outcomes.

Why We Are Concerned About Adolescence?

Adolescence represents high risk period in human life cycle and requires special attention by everyone involved in health care. Importance should be given to the nutrition and physical growth. An adolescent is under lots of pressure from parents, teachers, peer
group and the society. Adolescence is viewed as a period of stress. About to 10 to 20 % of adolescents experience severe emotional reactivity. They show impulsive behavior and rebelliousness. Personality development is completed during adolescence. It is also the time for deciding the future career. Hence proper scientific guidance is necessary during adolescence to lead them towards successful adulthood.

Stress in Adolescence

Teenagers experience strong feelings of anxiety, confusion, pressure to succeed, financial uncertainty, and other fears while growing up. Stress is a normal universal human experience and proper management of stress in adolescents is highly essential for success in life. Common causes of stress include exam related stress, other school related stress, personal stress and family related stress.

Symptoms of stress

An adolescent under stress may present with emotional, behavioural or
psychosomatic symptoms. Deterioration in scholastic performance and lack of concentration in studies are common presentations of a student under stress. And hence, any adolescent presenting with forgetfulness and scholastic backwardness needs individualised evaluation to find out the underlying stress. Anxiety, depression and even deliberate self harm can occur in an adolescent under stress. Stress can lead an adolescent towards alcohol or other substance abuse.
Psychosomatic symptoms are quite common and it manifests in the form of somatoform disorders in adolescents. The common somatoform disorders seen in adolescents include pain disorder, somatoform autonomic dysfunction and conversion disorders.

How to prevent stress related problems in adolescents

Role of family members

Adolescence is a period of growth and change. So it is essential that parents are always willing to support them and guide them in the correct direction. Parents should give them all the love, care and affection they wish for. Recognize their good deeds and complement
them. Parents should also point out their mistakes and motivate them to excel in life. Express concern, but not criticism. Be a good role model and friend.

Responsibilities of Adolescents

Use adolescence as a time of training by accepting more responsibility for doing the duties in the best way. Peer group pressure is significant during this period. It is not just something to be used as an excuse when someone gets into trouble! Be assertive to avoid unwanted peer pressure, as well as negative influences by media. Peer group can have
tremendous influence on your life, so be friendly with positive people and be a positive person yourself. Try to be empathetic with parents and teachers. Improve the study skills and be a motivated student.

Management of Stress

Role of experts in Adolescent Guidance

Individualized detailed evaluation after establishing good rapport is essential to find out the underlying stress in adolescents. They need counseling to improve self esteem and motivation. Associated learning problems should be managed with individualised remedial training programmes. Family guidance is also an essential aspect of the
management of stress in adolescents. Life skills training helps adolescents to deal effectively with demands and challenges of everyday life.

Conclusion

Adolescence is the period of prime importance in the life of a person. Hence care of adolescents is the need of the hour. Its the duty of the parents, teachers and health professionals to guide adolescents towards excellence in life.

Normal and Pathological Anxiety

Normal anxiety is a diffuse unpleasant vague sense of apprehension often accompanied by autonomic symptoms. It enables a person to take measures to deal with a threat. Pathological anxiety is an inappropriate response to a given stimulus and it will hinder developmentally appropriate adaptive behavior.

Anxiety Disorders

The common anxiety disorders seen in adolescents are panic disorder, generalized anxiety disorder, obsessive compulsive disorder, specific phobia and social phobia.
In panic disorder, the individual experiences recurrent unexpected panic attacks characterized by discrete periods of intense fear associated with palpitation, sweating, trembling, chest discomfort, abdominal distress or dizziness and fear of impending death. Usually there will be a precipitating stress. Panic disorder may or may not be associated with agoraphobia.
In generalized anxiety disorder (GAD), there is free floating anxiety about a number of events or activities. The adolescents with GAD can have restlessness, difficulty in concentration, muscle tension, irritability, autonomic overactivity, recurrent somatic symptoms or sleep disturbance.
Obsessive compulsive disorder is characterized by recurrent obsessions and compulsions causing marked distress and significantly interfering with the normal routine activities, academic functioning and social relationships.
Adolescents with specific phobia will have marked and persistent fear cued by the presence or anticipation of a specific object or situation. Exposure to the phobic stimulus invariably provokes immediate anxiety response. In social phobia there is marked and persistent fear of one or more social situations in which the person is exposed to unfamiliar people or to possible scrutiny by others. The exposure to the feared situation provokes anxiety and the feared social situations are usually avoided.

Treatment of anxiety disorders

Anxiety disorders, if diagnosed early, can be managed effectively by psychological therapies such as cognitive behaviour therapy, relaxation therapy, desensitization ( for phobias), insight oriented psychotherapy, family therapy etc. In severe cases, pharmacotherapy may be indicated.

Conclusion

Anxiety Disorders will cause deterioration in the academic performance of adolescents. If untreated, it can lead to substance abuse, depression, deliberate self harm or even hypertension and heart disease in future. Early diagnosis and management of Anxiety Disorders is essential for guiding the adolescents towards excellence in life.