M. Bambang Edi Susyanto Blok 8 2010 FKIK UMY TUMBUH KEMBANG REMAJA M. Bambang Edi Susyanto Blok 8 2010 FKIK UMY

REMAJA Periode yang ditandai dengan pertumbuhan dan perkembangan yang cepat dari fisik, emosi, kognitif dan sosial yang menjembatani masa kanak-kanak dan dewasa Batasan usia relative tidak jelas. Merujuk pada periode antara anak-anak dan dewasa, ketika perkembangan biopsikososial telah terjadi Umur 11-12 tahun sampai 18-21 tahun

Remaja awal (11-14 tahun) Percepatan pertumbuhan fisik. Perempuan biasanya lebih tinggi daripada teman laki-laki sebayanya. Isu penting : perubahan fisik yang luar biasa cepat (apakah saya normal?) dan kemandirian

Remaja Tengah (15-17 tahun)  Pubertas biasanya hampir tuntas, sehingga perhatian remaja terfokus pada identitas pribadi dan aliansi dengan teman sebayanya. Isu otonomi. Pengaruh teman sebaya sangat kuat  

Remaja Lanjut (Usia 18-21 tahun) Perhatian remaja beralih pada masa depan mereka. Keterlibatan dengan teman sebaya biasanya tidak lagi dengan suatu kelompok saja. Mulai ada komitmen dalam hubungan antar personal. Berfikir formal dan konseptual.

FISIOLOGI PUBERTAS

Pubertas Peralihan dari imaturitas seksual ke masa potensial subur yang berhubungan dengan munculnya tanda kelamin sekunder. Jadi awal dan akhir pubertas lebih jelas daripada awal dan akhir remaja Biasanya awal pubertas wanita 2 tahun lebih awal

Tanda Pubertas Perempuan Tanda pertama : thelarche (perkembangan payudara) dan pada !5% adrenarche (tumbuhnya rambut pubis) Onset perkembangan payudara kadang unilateral, biasanya seimbang dalam 6 bulan Sebagian besar menarche terjadi dalam masa 6 bulan masa puncak kecepatan pertambahan tinggi badan

Tanda Pubertas Perempuan Tanda progresi lainnya : Breast buding Pubic hair growth Peak high velocity Menarche Pertumbuhan biasanya berhenti 2-3 tahun setelah menarche

Tanda Pubertas Laki-laki Tanda pertama : pembesaran testis Tanda lainnya : Tumbuhnya rambut pubis Pembesaran penis Kecepatan puncak pertambahan tinggi Pertumbuhan biasanya berhenti 2-3 tahun setelah puncak kecepatan pertambahan tinggi

Sexual Maturity Rating Dipublikasikan Tanner pada tahun 1962 Skala Tanner : tingkat perkembangan genital secara klinis Laki-laki : pertumbuhan rambut genital dan pubis Perempuan : perubahan rambut pubis dan payudara

Pubertas Perempuan Terlalu awal jika perkembangan payudara sebelum usia 8 tahun atau menarke kurang dari 10 tahun Terlalu lambat jika payudara tidak berkembang pada usia 13 tahun atau belum menarke pada usia 16 tahun  

Pubertas Laki-laki Terlalu awal jika pembesaran testis (>2,5 cm) sebelum usia 9 tahun Terlalu lambat jika pembesaran testis tidak terjadi hingga usia 14 tahun

Pertumbuhan fisik Pertumbuhan fisik dan perkembangan fisik : hasil aktivasi aksis hipotalamus-hipofisis-gonad Pubertas : inhibisi GnRH di hipotalamus hilang - produksi dan pelepasan pulsatil gonadotropin, luteinizing hormone (LH) dan follicle stimulating hormone (FSH) Awal dan tengah masa remaja : kenaikan frekuensi dan amplitudo  stimulasi gonad  produksi estrogen atau testosteron

Pertumbuhan fisik Wanita : FSH  stimulasi maturasi ovarium, fungsi sel granulosa dan sekresi estradiol awal : inhibisi pelepasan LH dan FSH lalu : perangsang LH dan FSH  siklis LH  ovulasi, pembentukan korpus luteum dan sekresi progesteron

Pertumbuhan fisik Pria LH stimulasi sel interstitial testis  testosteron  selama pubertas testosteron sirkulasi = 20 kali lipat  staudium fisik dan maturasi tulang rangka FSH  pembentukan spermatosit

Lonjakan pertumbuhan Biasanya 2-4 tahun Perempuan 2 tahun lebih awal Kecepatan tinggi puncak W : 11,5-12 tahun L : 13,5-14 tahun Pertambahan BB : sampai 2 x Pertambahan TB : 15-20 %

Perkembangan psikososial Mencari jati diri, apa yang ingin dilakukan dan kekuatan-kelemahan Periode progresif dan perpisahan dari keluarga Fase-fase perkembangan psikososial--> 3 fase remaja (lihat bagian depan)

MASALAH-MASALAH REMAJA Morbiditas Mortalitas

Morbiditas Kehamilan yang tak diinginkan Penyakit menular seksual Penyalahgunaan zat Merokok Depresi Psikofifiologis Kekerasan fisik Lari dari rumah

Masalah lain Depresi Bunuh diri remaja Penyalahgunaan zat Gangguan makan Obesitas eksogen Kegagalan di sekolah Gangguan payudara Kelainan ginekologis PMS dan Penyakit radang pelvis

Psychological Problems in Adolescence Depression: 1/3 of teens have experienced some symptoms of depression Rates are higher among girls than boys Rates are higher among African-American and Native American teens Additionally, lack of popularity, rejection, death of a loved one contributes

Psychological Problems in Adolescence Teen suicide: rate has tripled in last 30 years Annual rate now 12.2 per 100,000, 3rd most common cause of death for those age 15-24 Successful suicide rate is higher in boys (more lethal means) but girls attempt suicide more often.

Teen suicide (cont’d) Risk factors: Depression, Social inhibition, Perfectionism Anxiety, Family conflicts, romantic rejection History of drug/alcohol abuse, gay/lesbian orientation

Cluster Suicides One suicide in a teen community leads to attempts by others to kill themselves, especially if the first suicide is high profile and well publicized Schools increasing using crisis teams to counsel students after one student is successful in suicide

Warning signs of suicide Direct or indirect talk of suicide School difficulties, writing a will Giving stuff away, arranging for pet care Change in appetite, general depression Changes in behavior, preoccupation with death in art, music, or literature

Indikator remaja berisiko tinggi Penurunan kemampuan belajar Absen sekolah yang berlebihan Keluhan psikosomatik yang sering/menetap Perubahan kebiasaan tidur atau makan Kesulitan konsentrasi atau kebosanan yang menetap Tanda dan gejala stres atau kecemasan

Indikator remaja berisiko tinggi 7. Menarik diri atau berpindah kelompok 8. Perilaku menentang atau kekerasan yang hebat dan atau perubahan kepribadian yang radikal 9. Konflik dengan orang tua 10. Perilaku seksual yang berlebihan 11. Konflik dengan hukum 12. Memperlihatkan pikiran bunuh diri 13. Penyalahgunaan obat dan alkohol 14. Melarikan diri dari rumah

Gejala psikofisiologis Reaksi konversi : perasaan tidak menyenangkan dikomunikasikan dengan gejala fisik  “perolehan sekunder” Riwayat dan temuan fisik tidak konsisten dengan konsep anatomi dan fisiologis Cenderung mempunyai OT yang overprotektif dan menjadi semakin tergantung pada OT

Terapi gejala psikofisiologi Jelaskan : hubungan antara penyebab fisik dari nyeri emosional atau penyebab emosional dari nyeri fisik Memberi dorongan untuk mengerti bahwa gejala dapat menetap Membantu pasien meneruskan aktivitas harian yang normal Obat-obatan jarang membantu Dokter suportif dan tidak menduga bahwa nyeri tidak benar-benar terjadi

KLINIK REMAJA

Sikap Dokter Dalam Menghadapi Pasien Remaja Dokter tampil jujur, sederhana, tidak perlu tampil “profesional” berlebihan Remaja kurang PD  dokter hati-hati Sensitif terhadap tingkat perkembangan

Pemberian pelayanan kesehatan Membangun hubungan saling percaya merupakan dasar dalam pemenuhan kebutuhan pelayanan kesehatan pasien remaja  pasien tidak bohong / memberikan informasi yang penting untuk diagnosis dan terapi yang tepat

Kerahasiaan Beritahu remaja dan orang tuanya tentang kerahasiaan yang akan dijaga Waktu adekuat Yakinkan bahwa dokter tidak akan mencampuri kehidupan pribadi remaja, tetapi merupakan hal penting untuk kesehatannya

What are The importan Aspects of an Adolescent History ? HEADSSS untuk melacak informasi psikososial yang penting dari pasien remaja. H : Home/health E : Education/Employment/Eating A : Activities?Aspiration/Affiliation D : Drugs S : Sex S : Sleep/Suicide S : Shoplifting

How to Talk to Teens about Puberty 􀂄 Be open and honest 􀂄 Treat the teen with respect 􀂄 Talk directly to the teen 􀂄 Begin conversation with least threatening topics 􀂄 Provide confidentiality

Wawancara Wawancara terpimpin Penilaian tugas-tugas psikoperkembangan Pemeriksaan sistemik meliputi : Nutrisi Tidur Perawatan diri, pengetahuan ttg pemeriksaan sendiri Olah raga Hubungan keluarga dan sahabat Teman sebaya

Wawancara 7. Sekolah 8. Minat pendidikan dan pekerjaan 9. Tembakau 10. Penyalahgunaan zat 11. Seksualitas 12. Kesehatan mental Usahakan pasien mendapat kesan, tertarik dan seperti mempunyai “dokternya” sendiri

LAMPIRAN

PHYSIOLOGY OF PUBERTY Physical Changes of Puberty (Tanner) A PHYSIOLOGY OF PUBERTY Physical Changes of Puberty (Tanner) A. Female : The first sign is an increase in growth velocity pubertal growth spurt; - Breast development is the first sign of puberty noted by most examiners. - Increased estrogen secretion at the time of menarche. - Other features reflecting estrogen action include enlargement of the labia minora and majora, dulling of the vaginal mucosa (reddish), and production of aclear or slightly whitish vaginal secretion prior to menarche.

Pubic hair development is determined chiefly by adrenal and ovarian androgen secretion. Stages of breast development (Marshall and Tanner). Stage B1: Preadolescent; elevation of papilla only. Stage B2: Breast bud stage; elevation of breast and papilla as a small mound, and enlargement of areolar diameter. Stage B3: Further enlargement of breast and areola, with no separation of their contours. Stage B4: Projection of areola and papilla to form a secondary mound above the level of the breast. Stage B5: Mature stage; projection of papilla only, owing to recession of the areola to the general contour of the breast.

Stages of female pubic hair dev. (Marshall and Tanner). Stage P1: Preadolescent; the vellus over the area is no further developed than that over the anterior abdominal wall, ie, no pubic hair. Stage P2: Sparse growth of long, slightly pigmented, downy hair, straight or only slightly curled, appearing chiefly along the labia  difficult to see on photographs and is subtle. Stage P3: Hair is considerably darker, coarser, and curlier. The hair spreads sparsely over the junction of the labia majora. Stage P4: Hair is now adult in type, there is no spread to the medial surface of the thighs. Stage P5: Hair is adult in quantity and type, distributed as an inverse triangle of the classic feminine pattern  inverse triangle.

B. Male Changes: The first sign of normal puberty in boys is usually  increase in the size of the testes to over 2.5 cm in the longest diameter Pubic hair development is caused by adrenal and testicular androgens The appearance of spermatozoa in early morning urinary specimens (spermarche) occurs at a mean chronologic age of 13.4 years; this usually occurs at gonadal stage 3-4 and pubic hair stage 2-4.

Stages of male genital and pubic hair development ( Marshall and Tanner) Genital: Stage G1: Preadolescent. Testes, scrotum, and penis are about the same size and proportion as in early childhood. Stage G2: The scrotum and testes have enlarged, and there is a change in the texture and some reddening of the scrotal skin. There is no enlargement of the penis. Stage G3: Growth of the penis has occurred, at first mainly in length but with some increase in breadth; further growth of testes and scrotum. Stage G4: Penis further enlarged in length and girth with development of glans. Testes and scrotum further enlarged. The scrotal skin has further darkened. Stage G5: Genitalia adult in size and shape. No further enlargement takes place after stage G5 is reached.

Pubic hair: Stage P1: Preadolescent. The vellus is no further developed than that over the abdominal wall, ie, no pubic hair. Stage P2: Sparse growth of long, slightly pigmented, downy hair, straight or only slightly curled, appearing chiefly at the base of the penis. This is subtle. Stage P3: Hair is considerably darker, coarser, and curlier and spreads sparsely. Stage P4: Hair is now adult in type, but the area it covers is still considerably smaller than in most adults. There is no spread to the medial surface of the thighs. Stage P5: Hair is adult in quantity and type, distributed as an inverse triangle. Spread is to the medial surface of the thighs but not up the linea alba. Most men will have further spread of pubic hair.

DELAYED PUBERTY OR ABSENT PUBERTY (Sexual Infantilism) Any girl of 13 or boy of 14 years of age with no signs of pubertal development falls more than 2.5 SD below the mean and is considered to have delayed puberty By this definition, 0.6% of the healthy population are classified as having constitutional delay in growth and adolescence.

CASE This is a 15 year old boy who is seen by his primary care physician for short stature and delayed sexual development. His past medical history is unremarkable except for asthma during early childhood, which has been well controlled. He is currently on no medications. He is an average student currently in the 9th grade and is the smallest in his class. He has been harassed by older classmates because of his size. His parents are concerned because Jim is becoming withdrawn and a "loner".

Females initially show a deposition of adipose tissue and widening of the pelvis and changes in the contour of the hips. The first clinical sign is thelarche (the appearance of breast buds) and adrenarche (the appearance of dark straight pubic hair over the mons veneris, also called the mons pubis).

These changes identify a SMR stage (or Tanner stage) II (see tables 1 and 2). Breast development over the next 4 years will proceed from breast stage II (secondary mound of breast tissue to adult breast stage V). Development of pubic hair starts about 1 year after breast budding and may take place over a 1.5 to 3.5 year period. During SMR stage 3, girls experience a very rapid increase in their height. The peak of their height growth (PHV=peak height velocity) should take place before the onset of menarche in most girls. Menarche occurs six months after the PHV and just prior to stage IV of breast development. Most western girls achieve their menarche around 12.4 to 12.8 years of age. African-American girls are maturing earlier.

Puberty in boys also follows a regular sequence of events, but lacks the clear cut landmarks such as breast development and menarche. In the male, the pubertal growth spurt is a late event starting about two years later than in females. The onset of pubertal changes however, are only about 6 months later than in females (see tables 2 and 3). Enlargement of the testes indicates the transition from genital stage I to Stage II, beginning at an average age of 11.5 years.

Penile growth occurs about one year later Penile growth occurs about one year later. This is usually preceded by the appearance of pubic hair at the base of the phallus progressing through pubic hair stages II to V. Pubic hair stage III is followed by the appearance of axillary and facial hair growth. Testicular growth is completed anytime between 13.5 and 17 years of age. Growth of the penis reaches a SMR (Tanner) stage V between 12.5 and 16.5 years of age. Nocturnal emissions (wet dreams) may first appear during SMR stage III.

There is a common misconception that the difference between the onset of puberty in males and females is 2 years. This applies only to the growth spurt and not to pubertal (SMR) changes.

The patient described above is not only short statured but is delayed in his pubertal development. On the basis of the physical findings described, he would fit a presumptive diagnosis of constitutional delay of growth and maturation

Boys with a constitutional delay of growth and maturation, usually have a normal birth weight and length, and progress along their normal growth centile for the first several years of life, following which, they begin to deviate and grow at or below the 3rd percentile throughout childhood.

At the time when normal puberty should begin, there is often a marked fall off in growth (pre-adolescent dip) due to a diminished secretion of growth hormone. This transient fall in growth hormone is probably due to failure of sex hormone production and stimulation.

Skeletal maturation is usually delayed Skeletal maturation is usually delayed. When the bone age eventually reaches the skeletal age when puberty is expected, it is likely that early signs of sexual maturation will also appear, which is the stage of testicular enlargement (SMR genital stage II).

Often a familial pattern of pubertal delay is reported Often a familial pattern of pubertal delay is reported. The incidence of affected males is about 10%. Patients with constitutional delay in growth and maturation usually do not reach their "mid parent" or predicted height. Catch up growth is largely dependent upon the delay of bone maturation at the time of diagnosis, indicating that there may be a genetic or familial component to their short stature.

In most males, a watch and wait approach is indicated for six to twelve months. The patient presented could have been prescribed a short term course of testosterone or gonadotropins in order to stimulate sexual maturation and growth hormone production. In general, such treatment has been reserved for teenagers with significant behavior or psychological (self image) problems due to their delayed puberty.

In most cases, the evaluation of a patient suspected of delayed sexual maturity can be conservative. A thorough family history, physical examination, and assessment of sexual maturity stage will often show signs of early pubertal changes. The bone age is usually delayed and reflects the physical delays and the height age of the patient (the age corresponding to the 50%ile of the patient's actual height).

Gonadotropins usually reflect the sexual maturity status of the patient. A chromosomal karyotype is indicated for all short statured girls who are delayed (for possible Turner syndrome) and for boys who are tall with small soft testes with or without delayed sexual maturity (Klinefelter's syndrome).

Causes of Short Stature I. Constitutional Short Stature II. Primordial Dwarfism (intrauterine growth retardation) III. Endocrine Causes A. Growth Hormone Deficiency 1. Congenital 2. Acquired a. Hypothalamic/Pituitary Tumors b. Head Trauma c. CNS infections d. Psychosocial Dwarfism 3. Laron Dwarfism 4. Hypothyroidism 5. Syndromes of Short Stature a. Turner Syndrome (gonadal dysgenesis) b. Noonan's Syndrome c. Prader-Willi Syndrome

Causes of Short Stature IV. Chronic Disease A. Heart Disease B. Pulmonary 1. Cystic Fibrosis 2. Asthma C. GI Disorders D. Hepatic Disease E. Renal V. Iatrogenic A. Corticosteroids, anabolic steroids B. ADHD meds

Causes of Delayed Puberty I. Constitutional Delay in Growth and Maturation II. Hypogonadotropic hypogonadism A. Central nervous system disorders 1. Tumors a. Craniopharyngiomas b. Gliomas c. Germinomas 2. Radiation Therapy 3. Congenital Malformations

Causes of Delayed Puberty B. Isolated Growth Hormone Deficiency 1. Kallmann's Syndrome C. Miscellaneous Disorders 1. Prader-Willi Syndrome 2. Hypothyroidism 3. Malnutrition 4. Anorexia Nervosa 5. Exercise amenorrhea 6. Cushing's 7. Diabetes

Causes of Delayed Puberty III. Hypergonadotropic hypogonadism A. Turner Syndrome B. XX and XY gonadal dysgenesis C. Polycystic ovary Syndrome D. Noonan's Syndrome

Classification of delayed puberty. Constitutional delay in growth and adolescence Hypogonadotropic hypogonadism Central nervous system disorders Tumors Other acquired disorders Congenital disorders Isolated gonadotropin deficiency Kallmann's syndrome Gonadotropin deficiency with normal sense of smellMultiple pituitary hormonal deficiencies Miscellaneous disorders Prader-Willi syndrome Laurence-Moon, Bardet-Biedl syndromes Chronic disease Weight loss Anorexia nervosa Increased physical activity in female athletes Hypothyroidism Hypergonadotropic hypogonadism Males: Klinefelter's syndrome, Other forms of primary testicular failure,Anorchia or cryptorchism Females: Turner's syndrome,Other forms of primary ovarian failure, Pseudo-Turner's syndrome, Noonan's syndrome XX and XY gonadal dysgenesis

PRECOCIOUS PUBERTY (Sexual Precocity) - The appearance of secondary sexual development before the age of 7 years in Caucasian girls and 6 years in African-American girls; 9 years in boys of either race constitutes precocious sexual development. When the cause is premature activation of the hypothalamic-pituitary axis, the diagnosis is complete (true) precocious puberty; If ectopic gonadotropin secretion occurs in boys or autonomous sex steroid secretion occurs in either sex, the diagnosis is incomplete precocious puberty. In all forms of sexual precocity, there is an increase in growth velocity, somatic development, and skeletal maturation

Classification of precocious puberty. Central (complete or true) isosexual precocious puberty Constitutional Idiopathic Central nervous system disorders Following androgen exposure Incomplete isosexual precocious puberty Males Gonadotropin-secreting tumors Excessive androgen production Premature Leydig and germinal cell maturation Females ovarian cysts Estrogen-secreting neoplasms Males and females Severe hypothyroidism McCune-Albright syndrome Sexual precocity due to gonadotropin or sex steroid exposure Variation in pubertal development Premature thelarche Premature menarche Premature pubarche Adolescent gynecomastia

Boy 25/12 years of age with idiopathic true precocious

134/12-year-old girl with constitutional delay in growth and puberty 134/12-year-old girl with constitutional delay in growth and puberty. History : normal growth rate but short stature at all ages. Physical examination : height of 138 cm (-4.5 SD) and a weight of 28.6 kg (-3 SD). The patient had early stage 2 breast development. There was no pubic hair. Karyotype was 46,XX. Bone age was 10 years. After administration of GnRH, LH and FSH rose in a pubertal pattern. Estradiol was 40 pg/mL. She has since spontaneously progressed through pubertal development.