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

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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

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Teas

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Spre

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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

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unity

Dis

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to A

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Atti

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Use

Early

Initia

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of A

ntis

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avio

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Peer

Ant

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ehav

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Peer

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Peer

Rew

ards

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Sens

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Z-Sc

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Valu

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• 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