Paradox and Policy in Adolescent Health
Professor George PattonDirector of Adolescent Health Research
Centre for Adolescent Health
AUSTRALIAN PRIMARY HEALTH CARE RESEARCH INSTITUTE Aug 2009
Paradox in adolescent healthPuberty Adolescent health mattersData driven responses
Four ideas
A paradox in adolescent health?PubertyAdolescent health mattersData driven responses
Stronger, faster, fitter, smarterbut
morbidity and mortality worsen?
Australian Child and Adolescent Mortality
0102030405060708090
1 to 4 5 to 9 10 to 14 15 to 18 19 to 24
Age groups
deat
hs/1
00,0
00 p
a
MaleFemale
Current Policy Emphasis
M a le D A L Y s in H ig h In c o m e
0
2
4
6
8
10
12
14
1 0 to 1 4 15 -19 20 -24
DAL
Ys/1
00 In ju ryC hro n ic D isIn fec t io us
F e m a le D A L Y s H ig h In c o m e
0
2
4
6
8
10
12
1 0 to 1 4 15 -19 20 -2 4
DAL
Ys/1
00 In ju ryC hro n ic D isIn fec t io usM a te rn a l
Chronic Disease and Injury Dominate Adolescent Morbidity
The paradox….. Health problems increase post-puberty• Importance is greatest in high income
countries• Social context matters
A paradox in adolescent health?PubertyAdolescent health mattersData driven responses
8 9 10 11 12 13 14 15 16 17 18 years
adrenarche
Pubertal Cascade
? HPA axis
8 9 10 11 12 13 14 15 16 17 18 years
adrenarche
Pubertal Cascade
gonadarche
? HPA axis
HPG axis
8 9 10 11 12 13 14 15 16 17 18 years
adrenarche
Pubertal Cascade
gonadarche
Growth spurt
HPA axis
HPG axis
GH/somatomedin axis
Oxytocin system ?
But that’s not all that is happening……..
Frontal grey matter volume
210
215
220
225
230
235
240
4 6 8 10 12 14 16 18 20 22
Adolescent brain development
Prefrontal cortex maturation • extends into the third decad
• impulse control• planning• emotional regulation
‘Adult’ problems emerge• Depression - anxiety syndromes• Deliberate self-harm • Substance abuse • Eating & body image disorders • Psychotic symptoms• Functional somatic disorders & Pain
syndromes eg migraine• Range of physical health problems
I
II
III
IV
V
Early
Mid
Late
Mental disorders commoner from puberty• Depression - anxiety syndromes• Deliberate self-harm • Substance abuse • Eating disorders• Dysmorphophobia• Psychotic symptoms• Functional somatic disorders• Pain syndromes eg migraine
Substance abuse & pubertal stage (ages 12-15 years)
0
5
10
15
20
25
30
35
I/II III IV/V
12 yrs13 yrs14 yrs15 yrs
Mental disorders commoner from puberty• Depression - anxiety syndromes• Deliberate self-harm • Substance abuse • Eating disorders• Dysmorphophobia• Psychotic symptoms• Functional somatic disorders• Pain syndromes eg migraine
Deliberate self harm by early and late pubertal stage
0
2
4
6
8
10
I-III IV/V I-III IV/V
%
M ales Females
Depressive symptoms & pubertal stage in girls
0
5
10
15
20
25
30
35
40
I/II III IV/V
Wave 1Wave 2Wave 3
Tanner stage
%
So is depression all that changes?
A paradox in adolescent health?Puberty
Adolescent health mattersData driven responses
Victorian Adolescent Health Cohort Study
1 2 3 4 5 6 7 8 914 yrs 17 yrs 21 yrs 24 yrs 28 yrs
90% 88% 87% 83% 81% 78% 81% 78% 77%
Does ‘sensible’ teen drinking protect against later harmful drinking?
Is there a safe level of teen drinking?
Teen drinking groups• Started after 18 years• Teen drinker - never risky• Teen drinker - risky at 1 wave• Teen drinker – risky at 2+ waves
Males
0 . 0 0
0 . 2 0
0 . 4 0
0 . 6 0
0 . 8 0 A l c o h o l u s e d i s o r d e r
0 . 0 0
0 . 1 0
0 . 2 0
0 . 3 0
0 . 4 0
0 . 5 0 H i g h - r i s k a l c o h o l u s e
0 . 0 0
0 . 1 0
0 . 2 0
0 . 3 0 A l c o h o l - r e l a t e d s e x u a l b e h a v i o r
Prev
alen
ce
Nondrinker
0 2+
Waves
2001 Short Term NHMRC Guidelines
1
2001 Long Term NHMRC Guidelines
2007NHMRC Guidelines
Nondrinker
0
Waves
Nondrinker
0 2+
Waves
1 2+1
Predicting Post-natal Depression from Teen Psychiatric Morbidity
0
5
10
15
20
25
30
Persisting Intermittent None
Odd Ratio 3.3 (1.2, 9.4)
A paradox in adolescent health?PubertyAdolescent health mattersData driven responses
NU
MB
ER O
F A
DO
LESC
ENTS
Risk FactorsHigh Risk
Population approaches
Symptomatic
Clinical/Individual Clinical/Individual InterventionsInterventions
Modifiable Risk factors
Protective factors
Community Perceived drug availability Favourable drug use norms Community transitions & mobility Community disorganisation
Encouragement & reward for involvement Opportunity for community involvement
School Academic failure Low school commitment
Opportunities and rewards for school involvement
Family Family conflict Poor discipline History of antisocial behaviour Poor management Favourable parental views on drugs and antisocial behaviour
Family attachment Opportunities and rewards for family involvement
Peer individual
Attitudes to drug use Friends’ drug use Perceived risks associated with drug use Sensation seeking Attitudes to antisocial behaviour Rebelliousness Gang involvement Reported antisocial behaviour
Social skills Belief in the moral order
Modifiable Risk factors
Protective factors
Community Perceived drug availability Favourable drug use norms Community transitions & mobility Community disorganisation
Encouragement & reward for involvement Opportunity for community involvement
School Academic failure Low school commitment
Opportunities and rewards for school involvement
Family Family conflict Poor discipline History of antisocial behaviour Poor management Favourable parental views on drugs and antisocial behaviour
Family attachment Opportunities and rewards for family involvement
Peer individual
Attitudes to drug use Friends’ drug use Perceived risks associated with drug use Sensation seeking Attitudes to antisocial behaviour Rebelliousness Gang involvement
Social skills Belief in the moral order
Risk factors & substance use
0102030405060708090
100
0-1 2-3 4-6 7-9 >=10
Risk factors
% alcohol
cigarettes
marijuana
other drugs
Risk factors & anti-social behaviour
0
10
20
30
40
50
0-1 2-3 4-6 7-9 >=10
Risk factors
% suspended from school
sold illegal drugs
attacked someone
carried a w eapon
Risk factors & psychosocial problems
0
10
20
30
40
50
0-1 2-3 4-6 7-9 >=10
Risk factors
%
depressivesymptomatology
deliberate self harm
homelessness
early sexual activity
Protective factors & psychosocial problems
0
10
20
30
40
50
0-1 2-3 4-6 7-10
Protective factors
%
depressivesymptomatology
deliberate self harm
homelessness
early sexual activity
“For a dozen formative
years children spend almost
half their waking hours in schools”
Gatehouse: a semi-structured process
Assess social environment
School action team
Best practice at multiple levels
Types of bullying
0102030405060
Teas
ing
Spre
adin
gru
mou
rs
Del
iber
atel
yle
ft ou
t
Phys
ical
lyth
reat
ened
or h
urt
Comparison
School X
05
101520253035404550
Teachersdon't notice
me
Fewchances to
planactivities
Teachersnot fair
Too muchschoolwork
Don't helpothers
Comparison
School X
Gatehouse: a semi-structured process
Assess social environment
School action team
Best practice at multiple levels
Gatehouse: a semi-structured process
Assess social environment
School action team
Best practice at multiple levels
Baseline: year 8 students (13-14 yo)
2 years: year 8 students (13-14 yo)
4 years: year 8 students (13-14 yo)
Neighbourhood Risk Factor Profile,
-1.00
-0.80
-0.60
-0.40
-0.20
0.00
0.20
0.40
0.60
0.80
1.00Co
mm
unity
Dis
orga
niza
tion
Low
Nei
ghbo
rhoo
d A
ttach
men
t
Tran
sitio
ns a
nd M
obilit
y
Perc
eive
d A
vaila
bility
ATO
D
Law
s an
d No
rms
Poor
Fam
ily M
anag
emen
t
Poor
Fam
ily D
isci
plin
e
Fam
ily C
onfli
ct
Fam
. Attd
. Fav
orab
le A
TOD
Fam
ily H
isto
ry o
f Ant
isoc
ial B
ehav
ior
Low
Aca
dem
ic A
chie
vem
ent
Low
Sch
ool C
omm
itmen
t
Ant
isoc
ial B
ehav
ior
Attd
s. F
avor
able
to A
ntis
ocia
l Beh
avio
r
Atti
tude
s Fa
vora
ble
to A
TOD
Use
Early
Initia
tion
of A
ntis
ocia
l Beh
avio
r
Peer
Ant
isoc
ial B
ehav
ior
Peer
ATO
D Us
e
Peer
Rew
ards
for A
ntis
ocia
l Beh
avio
r
Rebe
llious
ness
Sens
atio
n Se
ekin
g
Z-Sc
ore
Valu
e
• Pubertal transitions in health• Sexual & reproductive health • Mental health • Substance use• Chronic conditions• Youth friendly primary care services
2007 Lancet Series in Adolescent Health
A Healthy A Healthy Start to LifeStart to Life
Health in Health in AdolescenceAdolescence
Whole of government approach
No systematic national adolescent health data
No mechanism for coordination across sectors
Balance between prevention and health care
Use available resources & systems
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