TUMBUH KEMBANG REMAJA

M Bambang Edi Susyanto

Blok 8 2010

FKIK UMY

REMAJA

bull Periode yang ditandai dengan pertumbuhan dan perkembangan yang cepat dari fisik emosi kognitif dan sosial yang menjembatani masa kanak-kanak dan dewasa

bull Batasan usia relative tidak jelas Merujuk pada periode antara anak-anak dan dewasa ketika perkembangan biopsikososial telah terjadi

bull Umur 11-12 tahun sampai 18-21 tahun

Remaja awal (11-14 tahun)

bull Percepatan pertumbuhan fisik Perempuan biasanya lebih tinggi daripada teman laki-laki sebayanya

bull 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

bull Isu otonomi Pengaruh teman sebaya sangat kuat

bull

Remaja Lanjut (Usia 18-21 tahun)

bull 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

bull 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

bull Biasanya awal pubertas wanita 2 tahun lebih awal

Tanda Pubertas Perempuan

bull Tanda pertama thelarche (perkembangan payudara) dan pada 5 adrenarche (tumbuhnya rambut pubis)

bull Onset perkembangan payudara kadang unilateral biasanya seimbang dalam 6 bulan

bull Sebagian besar menarche terjadi dalam masa 6 bulan masa puncak kecepatan pertambahan tinggi badan

Tanda Pubertas Perempuan

bull Tanda progresi lainnya ndash Breast budingndash Pubic hair growthndash Peak high velocityndash Menarche

bull Pertumbuhan biasanya berhenti 2-3 tahun setelah menarche

bull

Tanda Pubertas Laki-laki

bull Tanda pertama pembesaran testis

bull Tanda lainnya ndash Tumbuhnya rambut pubis ndash Pembesaran penisndash Kecepatan puncak pertambahan tinggindash Pertumbuhan biasanya berhenti 2-3 tahun

setelah puncak kecepatan pertambahan tinggi

Sexual Maturity Rating

bull Dipublikasikan Tanner pada tahun 1962

bull Skala Tanner tingkat perkembangan genital secara klinis

bull Laki-laki pertumbuhan rambut genital dan pubis

bull Perempuan perubahan rambut pubis dan payudara

Pubertas Perempuan

bull Terlalu awal jika perkembangan payudara sebelum usia 8 tahun atau menarke kurang dari 10 tahun

bull Terlalu lambat jika payudara tidak berkembang pada usia 13 tahun atau belum menarke pada usia 16 tahun

bull

Pubertas Laki-laki

bull Terlalu awal jika pembesaran testis (gt25 cm) sebelum usia 9 tahun

bull 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

bull Biasanya 2-4 tahun

bull Perempuan 2 tahun lebih awal

bull Kecepatan tinggi puncak ndash W 115-12 tahunndash L 135-14 tahun

bull Pertambahan BB sampai 2 x

bull Pertambahan TB 15-20

Perkembangan psikososial

bull Mencari jati diri apa yang ingin dilakukan dan kekuatan-kelemahan

bull Periode progresif dan perpisahan dari keluarga

bull Fase-fase perkembangan psikososial--gt

3 fase remaja (lihat bagian depan)

MASALAH-MASALAH REMAJA

bull Morbiditas

bull Mortalitas

Morbiditas

bull Kehamilan yang tak diinginkan

bull Penyakit menular seksual

bull Penyalahgunaan zat

bull Merokok

bull Depresi

bull Psikofifiologis

bull Kekerasan fisik

bull Lari dari rumah

Masalah lain

bull Depresibull Bunuh diri remajabull Penyalahgunaan zatbull Gangguan makanbull Obesitas eksogenbull Kegagalan di sekolahbull Gangguan payudarabull Kelainan ginekologis bull PMS dan Penyakit radang pelvis

Psychological Problems in Adolescence

bull Depression 13 of teens have experienced some symptoms of depression

bull Rates are higher among girls than boys

bull Rates are higher among African-American and Native American teens

bull Additionally lack of popularity rejection death of a loved one contributes

Psychological Problems in Adolescence

bull Teen suicide rate has tripled in last 30 years

bull Annual rate now 122 per 100000 3rd most common cause of death for those age 15-24

bull Successful suicide rate is higher in boys (more lethal means) but girls attempt suicide more often

Teen suicide (contrsquod)

bull Risk factors ndash Depression Social inhibition

Perfectionism

ndash Anxiety Family conflicts romantic rejection

ndash History of drugalcohol abuse gaylesbian orientation

Cluster Suicides

bull 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

bull Schools increasing using crisis teams to counsel students after one student is successful in suicide

Warning signs of suicide

bull Direct or indirect talk of suicidebull School difficulties writing a willbull Giving stuff away arranging for pet

carebull Change in appetite general

depressionbull Changes in behavior preoccupation

with death in art music or literature

Indikator remaja berisiko tinggi

1 Penurunan kemampuan belajar

2 Absen sekolah yang berlebihan

3 Keluhan psikosomatik yang seringmenetap

4 Perubahan kebiasaan tidur atau makan

5 Kesulitan konsentrasi atau kebosanan yang menetap

6 Tanda dan gejala stres atau kecemasan

Indikator remaja berisiko tinggi

7 Menarik diri atau berpindah kelompok8 Perilaku menentang atau kekerasan yang

hebat dan atau perubahan kepribadian yang radikal

9 Konflik dengan orang tua10 Perilaku seksual yang berlebihan11 Konflik dengan hukum12 Memperlihatkan pikiran bunuh diri13 Penyalahgunaan obat dan alkohol14 Melarikan diri dari rumah

Gejala psikofisiologis

bull Reaksi konversi perasaan tidak menyenangkan dikomunikasikan dengan gejala fisik ldquoperolehan sekunderrdquo

bull Riwayat dan temuan fisik tidak konsisten dengan konsep anatomi dan fisiologis

bull Cenderung mempunyai OT yang overprotektif dan menjadi semakin tergantung pada OT

Terapi gejala psikofisiologi

bull Jelaskan hubungan antara penyebab fisik dari nyeri emosional atau penyebab emosional dari nyeri fisik

bull Memberi dorongan untuk mengerti bahwa gejala dapat menetap

bull Membantu pasien meneruskan aktivitas harian yang normal

bull Obat-obatan jarang membantubull Dokter suportif dan tidak menduga bahwa

nyeri tidak benar-benar terjadi

KLINIK REMAJA

Sikap Dokter Dalam Menghadapi Pasien Remaja

bull Dokter tampil jujur sederhana tidak perlu tampil ldquoprofesionalrdquo berlebihan

bull Remaja kurang PD dokter hati-hati

bull Sensitif terhadap tingkat perkembangan

Pemberian pelayanan kesehatan

bull 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

bull Beritahu remaja dan orang tuanya tentang kerahasiaan yang akan dijaga

bull Waktu adekuat

bull Yakinkan bahwa dokter tidak akan mencampuri kehidupan pribadi remaja tetapi merupakan hal penting untuk kesehatannya

What are The importan Aspects of an Adolescent History

bull HEADSSS untuk melacak informasi psikososial yang penting dari pasien remaja

bull H Homehealthbull E EducationEmploymentEatingbull A ActivitiesAspirationAffiliationbull D Drugsbull S Sexbull S SleepSuicidebull S Shoplifting

How to Talk to Teens about Puberty

1048708 Be open and honest

1048708 Treat the teen with respect

1048708 Talk directly to the teen

1048708 Begin conversation with least

threatening topics

1048708 Provide confidentiality

Wawancara

Wawancara terpimpinPenilaian tugas-tugas psikoperkembanganPemeriksaan sistemik meliputi 1 Nutrisi2 Tidur3 Perawatan diri pengetahuan ttg

pemeriksaan sendiri 4 Olah raga5 Hubungan keluarga dan sahabat6 Teman sebaya

Wawancara

7 Sekolah8 Minat pendidikan dan pekerjaan 9 Tembakau10 Penyalahgunaan zat11 Seksualitas12 Kesehatan mental

Usahakan pasien mendapat kesan tertarik dan seperti mempunyai ldquodokternyardquo sendiri

LAMPIRAN

PHYSIOLOGY OF PUBERTYPhysical 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 25 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 134 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 25 SD below the mean and is considered to have delayed puberty

- By this definition 06 of the healthy population are classified as having constitutional delay in growth and adolescence

CASE

bull 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

bull 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)

bull 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 15 to 35 year period

bull 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 124 to 128 years of age African-American girls are maturing earlier

bull 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 115 years

bull 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 135 and 17 years of age Growth of the penis reaches a SMR (Tanner) stage V between 125 and 165 years of age Nocturnal emissions (wet dreams) may first appear during SMR stage III

bull 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

bull 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

bull 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

bull 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

bull 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)

bull

bull 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

bull 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

bull 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 50ile of the patients actual height)

bull 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 (Klinefelters syndrome)

Causes of Short Staturebull I Constitutional Short Staturebull II Primordial Dwarfism (intrauterine growth retardation)bull III Endocrine Causesbull A Growth Hormone Deficiencybull 1 Congenitalbull 2 Acquiredbull a HypothalamicPituitary Tumorsbull b Head Traumabull c CNS infectionsbull d Psychosocial Dwarfismbull 3 Laron Dwarfismbull 4 Hypothyroidismbull 5 Syndromes of Short Staturebull a Turner Syndrome (gonadal dysgenesis)bull b Noonans Syndromebull c Prader-Willi Syndromebull

Causes of Short Stature

bull IV Chronic Diseasebull A Heart Diseasebull B Pulmonarybull 1 Cystic Fibrosisbull 2 Asthmabull C GI Disordersbull D Hepatic Diseasebull E Renalbull V Iatrogenicbull A Corticosteroids anabolic steroidsbull B ADHD meds

bull Causes of Delayed Pubertybull I Constitutional Delay in Growth and Maturationbull II Hypogonadotropic hypogonadismbull A Central nervous system disordersbull 1 Tumors bull a Craniopharyngiomasbull b Gliomasbull c Germinomasbull 2 Radiation Therapybull 3 Congenital Malformationsbull

Causes of Delayed Puberty

bull B Isolated Growth Hormone Deficiencybull 1 Kallmanns Syndromebull C Miscellaneous Disordersbull 1 Prader-Willi Syndromebull 2 Hypothyroidismbull 3 Malnutritionbull 4 Anorexia Nervosabull 5 Exercise amenorrheabull 6 Cushingsbull 7 Diabetesbull

Causes of Delayed Puberty

bull III Hypergonadotropic hypogonadism

bull A Turner Syndrome

bull B XX and XY gonadal dysgenesis

bull C Polycystic ovary Syndrome

bull D Noonans 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- Kallmanns 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 Klinefelters syndrome Other forms of primary testicular failureAnorchia or

cryptorchism- Females Turners syndromeOther forms of primary ovarian failure Pseudo-Turners

syndrome- Noonans 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 2512 years of age with idiopathic true precocious

13412-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 (-45 SD) and a weight of 286 kg (-3 SD) The patient had early stage 2 breast development There was no pubic hair Karyotype was 46XX Bone age was 10 years After administration of GnRH LH and FSH rose in a pubertal pattern Estradiol was 40 pgmL She has since spontaneously progressed through pubertal development

• TUMBUH KEMBANG REMAJA
• REMAJA
• Remaja awal (11-14 tahun)
• Remaja Tengah (15-17 tahun)
• Remaja Lanjut (Usia 18-21 tahun)
• FISIOLOGI PUBERTAS
• Pubertas
• Tanda Pubertas Perempuan
• Slide 9
• Tanda Pubertas Laki-laki
• Sexual Maturity Rating
• Pubertas Perempuan
• Pubertas Laki-laki
• Pertumbuhan fisik
• Slide 15
• Slide 16
• Lonjakan pertumbuhan
• Perkembangan psikososial
• MASALAH-MASALAH REMAJA
• Morbiditas
• Masalah lain
• Psychological Problems in Adolescence
• Slide 23
• Teen suicide (contrsquod)
• Cluster Suicides
• Warning signs of suicide
• Indikator remaja berisiko tinggi
• Slide 28
• Gejala psikofisiologis
• Terapi gejala psikofisiologi
• KLINIK REMAJA
• Sikap Dokter Dalam Menghadapi Pasien Remaja
• Pemberian pelayanan kesehatan
• Kerahasiaan
• What are The importan Aspects of an Adolescent History
• How to Talk to Teens about Puberty
• Wawancara
• Slide 38
• LAMPIRAN
• 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
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• CASE
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Causes of Short Stature
• Slide 65
• Slide 66
• Causes of Delayed Puberty
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73

REMAJA

bull Periode yang ditandai dengan pertumbuhan dan perkembangan yang cepat dari fisik emosi kognitif dan sosial yang menjembatani masa kanak-kanak dan dewasa

bull Batasan usia relative tidak jelas Merujuk pada periode antara anak-anak dan dewasa ketika perkembangan biopsikososial telah terjadi

bull Umur 11-12 tahun sampai 18-21 tahun

Remaja awal (11-14 tahun)

bull Percepatan pertumbuhan fisik Perempuan biasanya lebih tinggi daripada teman laki-laki sebayanya

bull 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

bull Isu otonomi Pengaruh teman sebaya sangat kuat

bull

Remaja Lanjut (Usia 18-21 tahun)

bull 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

bull 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

bull Biasanya awal pubertas wanita 2 tahun lebih awal

Tanda Pubertas Perempuan

bull Tanda pertama thelarche (perkembangan payudara) dan pada 5 adrenarche (tumbuhnya rambut pubis)

bull Onset perkembangan payudara kadang unilateral biasanya seimbang dalam 6 bulan

bull Sebagian besar menarche terjadi dalam masa 6 bulan masa puncak kecepatan pertambahan tinggi badan

Tanda Pubertas Perempuan

bull Tanda progresi lainnya ndash Breast budingndash Pubic hair growthndash Peak high velocityndash Menarche

bull Pertumbuhan biasanya berhenti 2-3 tahun setelah menarche

bull

Tanda Pubertas Laki-laki

bull Tanda pertama pembesaran testis

bull Tanda lainnya ndash Tumbuhnya rambut pubis ndash Pembesaran penisndash Kecepatan puncak pertambahan tinggindash Pertumbuhan biasanya berhenti 2-3 tahun

setelah puncak kecepatan pertambahan tinggi

Sexual Maturity Rating

bull Dipublikasikan Tanner pada tahun 1962

bull Skala Tanner tingkat perkembangan genital secara klinis

bull Laki-laki pertumbuhan rambut genital dan pubis

bull Perempuan perubahan rambut pubis dan payudara

Pubertas Perempuan

bull Terlalu awal jika perkembangan payudara sebelum usia 8 tahun atau menarke kurang dari 10 tahun

bull Terlalu lambat jika payudara tidak berkembang pada usia 13 tahun atau belum menarke pada usia 16 tahun

bull

Pubertas Laki-laki

bull Terlalu awal jika pembesaran testis (gt25 cm) sebelum usia 9 tahun

bull 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

bull Biasanya 2-4 tahun

bull Perempuan 2 tahun lebih awal

bull Kecepatan tinggi puncak ndash W 115-12 tahunndash L 135-14 tahun

bull Pertambahan BB sampai 2 x

bull Pertambahan TB 15-20

Perkembangan psikososial

bull Mencari jati diri apa yang ingin dilakukan dan kekuatan-kelemahan

bull Periode progresif dan perpisahan dari keluarga

bull Fase-fase perkembangan psikososial--gt

3 fase remaja (lihat bagian depan)

MASALAH-MASALAH REMAJA

bull Morbiditas

bull Mortalitas

Morbiditas

bull Kehamilan yang tak diinginkan

bull Penyakit menular seksual

bull Penyalahgunaan zat

bull Merokok

bull Depresi

bull Psikofifiologis

bull Kekerasan fisik

bull Lari dari rumah

Masalah lain

bull Depresibull Bunuh diri remajabull Penyalahgunaan zatbull Gangguan makanbull Obesitas eksogenbull Kegagalan di sekolahbull Gangguan payudarabull Kelainan ginekologis bull PMS dan Penyakit radang pelvis

Psychological Problems in Adolescence

bull Depression 13 of teens have experienced some symptoms of depression

bull Rates are higher among girls than boys

bull Rates are higher among African-American and Native American teens

bull Additionally lack of popularity rejection death of a loved one contributes

Psychological Problems in Adolescence

bull Teen suicide rate has tripled in last 30 years

bull Annual rate now 122 per 100000 3rd most common cause of death for those age 15-24

bull Successful suicide rate is higher in boys (more lethal means) but girls attempt suicide more often

Teen suicide (contrsquod)

bull Risk factors ndash Depression Social inhibition

Perfectionism

ndash Anxiety Family conflicts romantic rejection

ndash History of drugalcohol abuse gaylesbian orientation

Cluster Suicides

bull 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

bull Schools increasing using crisis teams to counsel students after one student is successful in suicide

Warning signs of suicide

bull Direct or indirect talk of suicidebull School difficulties writing a willbull Giving stuff away arranging for pet

carebull Change in appetite general

depressionbull Changes in behavior preoccupation

with death in art music or literature

Indikator remaja berisiko tinggi

1 Penurunan kemampuan belajar

2 Absen sekolah yang berlebihan

3 Keluhan psikosomatik yang seringmenetap

4 Perubahan kebiasaan tidur atau makan

5 Kesulitan konsentrasi atau kebosanan yang menetap

6 Tanda dan gejala stres atau kecemasan

Indikator remaja berisiko tinggi

7 Menarik diri atau berpindah kelompok8 Perilaku menentang atau kekerasan yang

hebat dan atau perubahan kepribadian yang radikal

9 Konflik dengan orang tua10 Perilaku seksual yang berlebihan11 Konflik dengan hukum12 Memperlihatkan pikiran bunuh diri13 Penyalahgunaan obat dan alkohol14 Melarikan diri dari rumah

Gejala psikofisiologis

bull Reaksi konversi perasaan tidak menyenangkan dikomunikasikan dengan gejala fisik ldquoperolehan sekunderrdquo

bull Riwayat dan temuan fisik tidak konsisten dengan konsep anatomi dan fisiologis

bull Cenderung mempunyai OT yang overprotektif dan menjadi semakin tergantung pada OT

Terapi gejala psikofisiologi

bull Jelaskan hubungan antara penyebab fisik dari nyeri emosional atau penyebab emosional dari nyeri fisik

bull Memberi dorongan untuk mengerti bahwa gejala dapat menetap

bull Membantu pasien meneruskan aktivitas harian yang normal

bull Obat-obatan jarang membantubull Dokter suportif dan tidak menduga bahwa

nyeri tidak benar-benar terjadi

KLINIK REMAJA

Sikap Dokter Dalam Menghadapi Pasien Remaja

bull Dokter tampil jujur sederhana tidak perlu tampil ldquoprofesionalrdquo berlebihan

bull Remaja kurang PD dokter hati-hati

bull Sensitif terhadap tingkat perkembangan

Pemberian pelayanan kesehatan

bull 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

bull Beritahu remaja dan orang tuanya tentang kerahasiaan yang akan dijaga

bull Waktu adekuat

bull Yakinkan bahwa dokter tidak akan mencampuri kehidupan pribadi remaja tetapi merupakan hal penting untuk kesehatannya

What are The importan Aspects of an Adolescent History

bull HEADSSS untuk melacak informasi psikososial yang penting dari pasien remaja

bull H Homehealthbull E EducationEmploymentEatingbull A ActivitiesAspirationAffiliationbull D Drugsbull S Sexbull S SleepSuicidebull S Shoplifting

How to Talk to Teens about Puberty

1048708 Be open and honest

1048708 Treat the teen with respect

1048708 Talk directly to the teen

1048708 Begin conversation with least

threatening topics

1048708 Provide confidentiality

Wawancara

Wawancara terpimpinPenilaian tugas-tugas psikoperkembanganPemeriksaan sistemik meliputi 1 Nutrisi2 Tidur3 Perawatan diri pengetahuan ttg

pemeriksaan sendiri 4 Olah raga5 Hubungan keluarga dan sahabat6 Teman sebaya

Wawancara

7 Sekolah8 Minat pendidikan dan pekerjaan 9 Tembakau10 Penyalahgunaan zat11 Seksualitas12 Kesehatan mental

Usahakan pasien mendapat kesan tertarik dan seperti mempunyai ldquodokternyardquo sendiri

LAMPIRAN

PHYSIOLOGY OF PUBERTYPhysical 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 25 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 134 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 25 SD below the mean and is considered to have delayed puberty

- By this definition 06 of the healthy population are classified as having constitutional delay in growth and adolescence

CASE

bull 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

bull 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)

bull 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 15 to 35 year period

bull 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 124 to 128 years of age African-American girls are maturing earlier

bull 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 115 years

bull 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 135 and 17 years of age Growth of the penis reaches a SMR (Tanner) stage V between 125 and 165 years of age Nocturnal emissions (wet dreams) may first appear during SMR stage III

bull 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

bull 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

bull 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

bull 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

bull 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)

bull

bull 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

bull 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

bull 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 50ile of the patients actual height)

bull 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 (Klinefelters syndrome)

Causes of Short Staturebull I Constitutional Short Staturebull II Primordial Dwarfism (intrauterine growth retardation)bull III Endocrine Causesbull A Growth Hormone Deficiencybull 1 Congenitalbull 2 Acquiredbull a HypothalamicPituitary Tumorsbull b Head Traumabull c CNS infectionsbull d Psychosocial Dwarfismbull 3 Laron Dwarfismbull 4 Hypothyroidismbull 5 Syndromes of Short Staturebull a Turner Syndrome (gonadal dysgenesis)bull b Noonans Syndromebull c Prader-Willi Syndromebull

Causes of Short Stature

bull IV Chronic Diseasebull A Heart Diseasebull B Pulmonarybull 1 Cystic Fibrosisbull 2 Asthmabull C GI Disordersbull D Hepatic Diseasebull E Renalbull V Iatrogenicbull A Corticosteroids anabolic steroidsbull B ADHD meds

bull Causes of Delayed Pubertybull I Constitutional Delay in Growth and Maturationbull II Hypogonadotropic hypogonadismbull A Central nervous system disordersbull 1 Tumors bull a Craniopharyngiomasbull b Gliomasbull c Germinomasbull 2 Radiation Therapybull 3 Congenital Malformationsbull

Causes of Delayed Puberty

bull B Isolated Growth Hormone Deficiencybull 1 Kallmanns Syndromebull C Miscellaneous Disordersbull 1 Prader-Willi Syndromebull 2 Hypothyroidismbull 3 Malnutritionbull 4 Anorexia Nervosabull 5 Exercise amenorrheabull 6 Cushingsbull 7 Diabetesbull

Causes of Delayed Puberty

bull III Hypergonadotropic hypogonadism

bull A Turner Syndrome

bull B XX and XY gonadal dysgenesis

bull C Polycystic ovary Syndrome

bull D Noonans 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- Kallmanns 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 Klinefelters syndrome Other forms of primary testicular failureAnorchia or

cryptorchism- Females Turners syndromeOther forms of primary ovarian failure Pseudo-Turners

syndrome- Noonans 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 2512 years of age with idiopathic true precocious

13412-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 (-45 SD) and a weight of 286 kg (-3 SD) The patient had early stage 2 breast development There was no pubic hair Karyotype was 46XX Bone age was 10 years After administration of GnRH LH and FSH rose in a pubertal pattern Estradiol was 40 pgmL She has since spontaneously progressed through pubertal development

• TUMBUH KEMBANG REMAJA
• REMAJA
• Remaja awal (11-14 tahun)
• Remaja Tengah (15-17 tahun)
• Remaja Lanjut (Usia 18-21 tahun)
• FISIOLOGI PUBERTAS
• Pubertas
• Tanda Pubertas Perempuan
• Slide 9
• Tanda Pubertas Laki-laki
• Sexual Maturity Rating
• Pubertas Perempuan
• Pubertas Laki-laki
• Pertumbuhan fisik
• Slide 15
• Slide 16
• Lonjakan pertumbuhan
• Perkembangan psikososial
• MASALAH-MASALAH REMAJA
• Morbiditas
• Masalah lain
• Psychological Problems in Adolescence
• Slide 23
• Teen suicide (contrsquod)
• Cluster Suicides
• Warning signs of suicide
• Indikator remaja berisiko tinggi
• Slide 28
• Gejala psikofisiologis
• Terapi gejala psikofisiologi
• KLINIK REMAJA
• Sikap Dokter Dalam Menghadapi Pasien Remaja
• Pemberian pelayanan kesehatan
• Kerahasiaan
• What are The importan Aspects of an Adolescent History
• How to Talk to Teens about Puberty
• Wawancara
• Slide 38
• LAMPIRAN
• 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
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• CASE
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Causes of Short Stature
• Slide 65
• Slide 66
• Causes of Delayed Puberty
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73

Remaja awal (11-14 tahun)

bull Percepatan pertumbuhan fisik Perempuan biasanya lebih tinggi daripada teman laki-laki sebayanya

bull 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

bull Isu otonomi Pengaruh teman sebaya sangat kuat

bull

Remaja Lanjut (Usia 18-21 tahun)

bull 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

bull 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

bull Biasanya awal pubertas wanita 2 tahun lebih awal

Tanda Pubertas Perempuan

bull Tanda pertama thelarche (perkembangan payudara) dan pada 5 adrenarche (tumbuhnya rambut pubis)

bull Onset perkembangan payudara kadang unilateral biasanya seimbang dalam 6 bulan

bull Sebagian besar menarche terjadi dalam masa 6 bulan masa puncak kecepatan pertambahan tinggi badan

Tanda Pubertas Perempuan

bull Tanda progresi lainnya ndash Breast budingndash Pubic hair growthndash Peak high velocityndash Menarche

bull Pertumbuhan biasanya berhenti 2-3 tahun setelah menarche

bull

Tanda Pubertas Laki-laki

bull Tanda pertama pembesaran testis

bull Tanda lainnya ndash Tumbuhnya rambut pubis ndash Pembesaran penisndash Kecepatan puncak pertambahan tinggindash Pertumbuhan biasanya berhenti 2-3 tahun

setelah puncak kecepatan pertambahan tinggi

Sexual Maturity Rating

bull Dipublikasikan Tanner pada tahun 1962

bull Skala Tanner tingkat perkembangan genital secara klinis

bull Laki-laki pertumbuhan rambut genital dan pubis

bull Perempuan perubahan rambut pubis dan payudara

Pubertas Perempuan

bull Terlalu awal jika perkembangan payudara sebelum usia 8 tahun atau menarke kurang dari 10 tahun

bull Terlalu lambat jika payudara tidak berkembang pada usia 13 tahun atau belum menarke pada usia 16 tahun

bull

Pubertas Laki-laki

bull Terlalu awal jika pembesaran testis (gt25 cm) sebelum usia 9 tahun

bull 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

bull Biasanya 2-4 tahun

bull Perempuan 2 tahun lebih awal

bull Kecepatan tinggi puncak ndash W 115-12 tahunndash L 135-14 tahun

bull Pertambahan BB sampai 2 x

bull Pertambahan TB 15-20

Perkembangan psikososial

bull Mencari jati diri apa yang ingin dilakukan dan kekuatan-kelemahan

bull Periode progresif dan perpisahan dari keluarga

bull Fase-fase perkembangan psikososial--gt

3 fase remaja (lihat bagian depan)

MASALAH-MASALAH REMAJA

bull Morbiditas

bull Mortalitas

Morbiditas

bull Kehamilan yang tak diinginkan

bull Penyakit menular seksual

bull Penyalahgunaan zat

bull Merokok

bull Depresi

bull Psikofifiologis

bull Kekerasan fisik

bull Lari dari rumah

Masalah lain

bull Depresibull Bunuh diri remajabull Penyalahgunaan zatbull Gangguan makanbull Obesitas eksogenbull Kegagalan di sekolahbull Gangguan payudarabull Kelainan ginekologis bull PMS dan Penyakit radang pelvis

Psychological Problems in Adolescence

bull Depression 13 of teens have experienced some symptoms of depression

bull Rates are higher among girls than boys

bull Rates are higher among African-American and Native American teens

bull Additionally lack of popularity rejection death of a loved one contributes

Psychological Problems in Adolescence

bull Teen suicide rate has tripled in last 30 years

bull Annual rate now 122 per 100000 3rd most common cause of death for those age 15-24

bull Successful suicide rate is higher in boys (more lethal means) but girls attempt suicide more often

Teen suicide (contrsquod)

bull Risk factors ndash Depression Social inhibition

Perfectionism

ndash Anxiety Family conflicts romantic rejection

ndash History of drugalcohol abuse gaylesbian orientation

Cluster Suicides

bull 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

bull Schools increasing using crisis teams to counsel students after one student is successful in suicide

Warning signs of suicide

bull Direct or indirect talk of suicidebull School difficulties writing a willbull Giving stuff away arranging for pet

carebull Change in appetite general

depressionbull Changes in behavior preoccupation

with death in art music or literature

Indikator remaja berisiko tinggi

1 Penurunan kemampuan belajar

2 Absen sekolah yang berlebihan

3 Keluhan psikosomatik yang seringmenetap

4 Perubahan kebiasaan tidur atau makan

5 Kesulitan konsentrasi atau kebosanan yang menetap

6 Tanda dan gejala stres atau kecemasan

Indikator remaja berisiko tinggi

7 Menarik diri atau berpindah kelompok8 Perilaku menentang atau kekerasan yang

hebat dan atau perubahan kepribadian yang radikal

9 Konflik dengan orang tua10 Perilaku seksual yang berlebihan11 Konflik dengan hukum12 Memperlihatkan pikiran bunuh diri13 Penyalahgunaan obat dan alkohol14 Melarikan diri dari rumah

Gejala psikofisiologis

bull Reaksi konversi perasaan tidak menyenangkan dikomunikasikan dengan gejala fisik ldquoperolehan sekunderrdquo

bull Riwayat dan temuan fisik tidak konsisten dengan konsep anatomi dan fisiologis

bull Cenderung mempunyai OT yang overprotektif dan menjadi semakin tergantung pada OT

Terapi gejala psikofisiologi

bull Jelaskan hubungan antara penyebab fisik dari nyeri emosional atau penyebab emosional dari nyeri fisik

bull Memberi dorongan untuk mengerti bahwa gejala dapat menetap

bull Membantu pasien meneruskan aktivitas harian yang normal

bull Obat-obatan jarang membantubull Dokter suportif dan tidak menduga bahwa

nyeri tidak benar-benar terjadi

KLINIK REMAJA

Sikap Dokter Dalam Menghadapi Pasien Remaja

bull Dokter tampil jujur sederhana tidak perlu tampil ldquoprofesionalrdquo berlebihan

bull Remaja kurang PD dokter hati-hati

bull Sensitif terhadap tingkat perkembangan

Pemberian pelayanan kesehatan

bull 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

bull Beritahu remaja dan orang tuanya tentang kerahasiaan yang akan dijaga

bull Waktu adekuat

bull Yakinkan bahwa dokter tidak akan mencampuri kehidupan pribadi remaja tetapi merupakan hal penting untuk kesehatannya

What are The importan Aspects of an Adolescent History

bull HEADSSS untuk melacak informasi psikososial yang penting dari pasien remaja

bull H Homehealthbull E EducationEmploymentEatingbull A ActivitiesAspirationAffiliationbull D Drugsbull S Sexbull S SleepSuicidebull S Shoplifting

How to Talk to Teens about Puberty

1048708 Be open and honest

1048708 Treat the teen with respect

1048708 Talk directly to the teen

1048708 Begin conversation with least

threatening topics

1048708 Provide confidentiality

Wawancara

Wawancara terpimpinPenilaian tugas-tugas psikoperkembanganPemeriksaan sistemik meliputi 1 Nutrisi2 Tidur3 Perawatan diri pengetahuan ttg

pemeriksaan sendiri 4 Olah raga5 Hubungan keluarga dan sahabat6 Teman sebaya

Wawancara

7 Sekolah8 Minat pendidikan dan pekerjaan 9 Tembakau10 Penyalahgunaan zat11 Seksualitas12 Kesehatan mental

Usahakan pasien mendapat kesan tertarik dan seperti mempunyai ldquodokternyardquo sendiri

LAMPIRAN

PHYSIOLOGY OF PUBERTYPhysical 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 25 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 134 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 25 SD below the mean and is considered to have delayed puberty

- By this definition 06 of the healthy population are classified as having constitutional delay in growth and adolescence

CASE

bull 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

bull 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)

bull 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 15 to 35 year period

bull 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 124 to 128 years of age African-American girls are maturing earlier

bull 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 115 years

bull 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 135 and 17 years of age Growth of the penis reaches a SMR (Tanner) stage V between 125 and 165 years of age Nocturnal emissions (wet dreams) may first appear during SMR stage III

bull 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

bull 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

bull 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

bull 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

bull 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)

bull

bull 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

bull 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

bull 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 50ile of the patients actual height)

bull 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 (Klinefelters syndrome)

Causes of Short Staturebull I Constitutional Short Staturebull II Primordial Dwarfism (intrauterine growth retardation)bull III Endocrine Causesbull A Growth Hormone Deficiencybull 1 Congenitalbull 2 Acquiredbull a HypothalamicPituitary Tumorsbull b Head Traumabull c CNS infectionsbull d Psychosocial Dwarfismbull 3 Laron Dwarfismbull 4 Hypothyroidismbull 5 Syndromes of Short Staturebull a Turner Syndrome (gonadal dysgenesis)bull b Noonans Syndromebull c Prader-Willi Syndromebull

Causes of Short Stature

bull IV Chronic Diseasebull A Heart Diseasebull B Pulmonarybull 1 Cystic Fibrosisbull 2 Asthmabull C GI Disordersbull D Hepatic Diseasebull E Renalbull V Iatrogenicbull A Corticosteroids anabolic steroidsbull B ADHD meds

bull Causes of Delayed Pubertybull I Constitutional Delay in Growth and Maturationbull II Hypogonadotropic hypogonadismbull A Central nervous system disordersbull 1 Tumors bull a Craniopharyngiomasbull b Gliomasbull c Germinomasbull 2 Radiation Therapybull 3 Congenital Malformationsbull

Causes of Delayed Puberty

bull B Isolated Growth Hormone Deficiencybull 1 Kallmanns Syndromebull C Miscellaneous Disordersbull 1 Prader-Willi Syndromebull 2 Hypothyroidismbull 3 Malnutritionbull 4 Anorexia Nervosabull 5 Exercise amenorrheabull 6 Cushingsbull 7 Diabetesbull

Causes of Delayed Puberty

bull III Hypergonadotropic hypogonadism

bull A Turner Syndrome

bull B XX and XY gonadal dysgenesis

bull C Polycystic ovary Syndrome

bull D Noonans 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- Kallmanns 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 Klinefelters syndrome Other forms of primary testicular failureAnorchia or

cryptorchism- Females Turners syndromeOther forms of primary ovarian failure Pseudo-Turners

syndrome- Noonans 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 2512 years of age with idiopathic true precocious

13412-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 (-45 SD) and a weight of 286 kg (-3 SD) The patient had early stage 2 breast development There was no pubic hair Karyotype was 46XX Bone age was 10 years After administration of GnRH LH and FSH rose in a pubertal pattern Estradiol was 40 pgmL She has since spontaneously progressed through pubertal development

• TUMBUH KEMBANG REMAJA
• REMAJA
• Remaja awal (11-14 tahun)
• Remaja Tengah (15-17 tahun)
• Remaja Lanjut (Usia 18-21 tahun)
• FISIOLOGI PUBERTAS
• Pubertas
• Tanda Pubertas Perempuan
• Slide 9
• Tanda Pubertas Laki-laki
• Sexual Maturity Rating
• Pubertas Perempuan
• Pubertas Laki-laki
• Pertumbuhan fisik
• Slide 15
• Slide 16
• Lonjakan pertumbuhan
• Perkembangan psikososial
• MASALAH-MASALAH REMAJA
• Morbiditas
• Masalah lain
• Psychological Problems in Adolescence
• Slide 23
• Teen suicide (contrsquod)
• Cluster Suicides
• Warning signs of suicide
• Indikator remaja berisiko tinggi
• Slide 28
• Gejala psikofisiologis
• Terapi gejala psikofisiologi
• KLINIK REMAJA
• Sikap Dokter Dalam Menghadapi Pasien Remaja
• Pemberian pelayanan kesehatan
• Kerahasiaan
• What are The importan Aspects of an Adolescent History
• How to Talk to Teens about Puberty
• Wawancara
• Slide 38
• LAMPIRAN
• 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
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• CASE
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Causes of Short Stature
• Slide 65
• Slide 66
• Causes of Delayed Puberty
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73

Remaja Tengah (15-17 tahun)

Pubertas biasanya hampir tuntas sehingga perhatian remaja terfokus pada identitas pribadi dan aliansi dengan teman sebayanya

bull Isu otonomi Pengaruh teman sebaya sangat kuat

bull

Remaja Lanjut (Usia 18-21 tahun)

bull 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

bull 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

bull Biasanya awal pubertas wanita 2 tahun lebih awal

Tanda Pubertas Perempuan

bull Tanda pertama thelarche (perkembangan payudara) dan pada 5 adrenarche (tumbuhnya rambut pubis)

bull Onset perkembangan payudara kadang unilateral biasanya seimbang dalam 6 bulan

bull Sebagian besar menarche terjadi dalam masa 6 bulan masa puncak kecepatan pertambahan tinggi badan

Tanda Pubertas Perempuan

bull Tanda progresi lainnya ndash Breast budingndash Pubic hair growthndash Peak high velocityndash Menarche

bull Pertumbuhan biasanya berhenti 2-3 tahun setelah menarche

bull

Tanda Pubertas Laki-laki

bull Tanda pertama pembesaran testis

bull Tanda lainnya ndash Tumbuhnya rambut pubis ndash Pembesaran penisndash Kecepatan puncak pertambahan tinggindash Pertumbuhan biasanya berhenti 2-3 tahun

setelah puncak kecepatan pertambahan tinggi

Sexual Maturity Rating

bull Dipublikasikan Tanner pada tahun 1962

bull Skala Tanner tingkat perkembangan genital secara klinis

bull Laki-laki pertumbuhan rambut genital dan pubis

bull Perempuan perubahan rambut pubis dan payudara

Pubertas Perempuan

bull Terlalu awal jika perkembangan payudara sebelum usia 8 tahun atau menarke kurang dari 10 tahun

bull Terlalu lambat jika payudara tidak berkembang pada usia 13 tahun atau belum menarke pada usia 16 tahun

bull

Pubertas Laki-laki

bull Terlalu awal jika pembesaran testis (gt25 cm) sebelum usia 9 tahun

bull 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

bull Biasanya 2-4 tahun

bull Perempuan 2 tahun lebih awal

bull Kecepatan tinggi puncak ndash W 115-12 tahunndash L 135-14 tahun

bull Pertambahan BB sampai 2 x

bull Pertambahan TB 15-20

Perkembangan psikososial

bull Mencari jati diri apa yang ingin dilakukan dan kekuatan-kelemahan

bull Periode progresif dan perpisahan dari keluarga

bull Fase-fase perkembangan psikososial--gt

3 fase remaja (lihat bagian depan)

MASALAH-MASALAH REMAJA

bull Morbiditas

bull Mortalitas

Morbiditas

bull Kehamilan yang tak diinginkan

bull Penyakit menular seksual

bull Penyalahgunaan zat

bull Merokok

bull Depresi

bull Psikofifiologis

bull Kekerasan fisik

bull Lari dari rumah

Masalah lain

bull Depresibull Bunuh diri remajabull Penyalahgunaan zatbull Gangguan makanbull Obesitas eksogenbull Kegagalan di sekolahbull Gangguan payudarabull Kelainan ginekologis bull PMS dan Penyakit radang pelvis

Psychological Problems in Adolescence

bull Depression 13 of teens have experienced some symptoms of depression

bull Rates are higher among girls than boys

bull Rates are higher among African-American and Native American teens

bull Additionally lack of popularity rejection death of a loved one contributes

Psychological Problems in Adolescence

bull Teen suicide rate has tripled in last 30 years

bull Annual rate now 122 per 100000 3rd most common cause of death for those age 15-24

bull Successful suicide rate is higher in boys (more lethal means) but girls attempt suicide more often

Teen suicide (contrsquod)

bull Risk factors ndash Depression Social inhibition

Perfectionism

ndash Anxiety Family conflicts romantic rejection

ndash History of drugalcohol abuse gaylesbian orientation

Cluster Suicides

bull 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

bull Schools increasing using crisis teams to counsel students after one student is successful in suicide

Warning signs of suicide

bull Direct or indirect talk of suicidebull School difficulties writing a willbull Giving stuff away arranging for pet

carebull Change in appetite general

depressionbull Changes in behavior preoccupation

with death in art music or literature

Indikator remaja berisiko tinggi

1 Penurunan kemampuan belajar

2 Absen sekolah yang berlebihan

3 Keluhan psikosomatik yang seringmenetap

4 Perubahan kebiasaan tidur atau makan

5 Kesulitan konsentrasi atau kebosanan yang menetap

6 Tanda dan gejala stres atau kecemasan

Indikator remaja berisiko tinggi

7 Menarik diri atau berpindah kelompok8 Perilaku menentang atau kekerasan yang

hebat dan atau perubahan kepribadian yang radikal

9 Konflik dengan orang tua10 Perilaku seksual yang berlebihan11 Konflik dengan hukum12 Memperlihatkan pikiran bunuh diri13 Penyalahgunaan obat dan alkohol14 Melarikan diri dari rumah

Gejala psikofisiologis

bull Reaksi konversi perasaan tidak menyenangkan dikomunikasikan dengan gejala fisik ldquoperolehan sekunderrdquo

bull Riwayat dan temuan fisik tidak konsisten dengan konsep anatomi dan fisiologis

bull Cenderung mempunyai OT yang overprotektif dan menjadi semakin tergantung pada OT

Terapi gejala psikofisiologi

bull Jelaskan hubungan antara penyebab fisik dari nyeri emosional atau penyebab emosional dari nyeri fisik

bull Memberi dorongan untuk mengerti bahwa gejala dapat menetap

bull Membantu pasien meneruskan aktivitas harian yang normal

bull Obat-obatan jarang membantubull Dokter suportif dan tidak menduga bahwa

nyeri tidak benar-benar terjadi

KLINIK REMAJA

Sikap Dokter Dalam Menghadapi Pasien Remaja

bull Dokter tampil jujur sederhana tidak perlu tampil ldquoprofesionalrdquo berlebihan

bull Remaja kurang PD dokter hati-hati

bull Sensitif terhadap tingkat perkembangan

Pemberian pelayanan kesehatan

bull 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

bull Beritahu remaja dan orang tuanya tentang kerahasiaan yang akan dijaga

bull Waktu adekuat

bull Yakinkan bahwa dokter tidak akan mencampuri kehidupan pribadi remaja tetapi merupakan hal penting untuk kesehatannya

What are The importan Aspects of an Adolescent History

bull HEADSSS untuk melacak informasi psikososial yang penting dari pasien remaja

bull H Homehealthbull E EducationEmploymentEatingbull A ActivitiesAspirationAffiliationbull D Drugsbull S Sexbull S SleepSuicidebull S Shoplifting

How to Talk to Teens about Puberty

1048708 Be open and honest

1048708 Treat the teen with respect

1048708 Talk directly to the teen

1048708 Begin conversation with least

threatening topics

1048708 Provide confidentiality

Wawancara

Wawancara terpimpinPenilaian tugas-tugas psikoperkembanganPemeriksaan sistemik meliputi 1 Nutrisi2 Tidur3 Perawatan diri pengetahuan ttg

pemeriksaan sendiri 4 Olah raga5 Hubungan keluarga dan sahabat6 Teman sebaya

Wawancara

7 Sekolah8 Minat pendidikan dan pekerjaan 9 Tembakau10 Penyalahgunaan zat11 Seksualitas12 Kesehatan mental

Usahakan pasien mendapat kesan tertarik dan seperti mempunyai ldquodokternyardquo sendiri

LAMPIRAN

PHYSIOLOGY OF PUBERTYPhysical 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 25 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 134 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 25 SD below the mean and is considered to have delayed puberty

- By this definition 06 of the healthy population are classified as having constitutional delay in growth and adolescence

CASE

bull 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

bull 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)

bull 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 15 to 35 year period

bull 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 124 to 128 years of age African-American girls are maturing earlier

bull 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 115 years

bull 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 135 and 17 years of age Growth of the penis reaches a SMR (Tanner) stage V between 125 and 165 years of age Nocturnal emissions (wet dreams) may first appear during SMR stage III

bull 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

bull 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

bull 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

bull 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

bull 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)

bull

bull 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

bull 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

bull 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 50ile of the patients actual height)

bull 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 (Klinefelters syndrome)

Causes of Short Staturebull I Constitutional Short Staturebull II Primordial Dwarfism (intrauterine growth retardation)bull III Endocrine Causesbull A Growth Hormone Deficiencybull 1 Congenitalbull 2 Acquiredbull a HypothalamicPituitary Tumorsbull b Head Traumabull c CNS infectionsbull d Psychosocial Dwarfismbull 3 Laron Dwarfismbull 4 Hypothyroidismbull 5 Syndromes of Short Staturebull a Turner Syndrome (gonadal dysgenesis)bull b Noonans Syndromebull c Prader-Willi Syndromebull

Causes of Short Stature

bull IV Chronic Diseasebull A Heart Diseasebull B Pulmonarybull 1 Cystic Fibrosisbull 2 Asthmabull C GI Disordersbull D Hepatic Diseasebull E Renalbull V Iatrogenicbull A Corticosteroids anabolic steroidsbull B ADHD meds

bull Causes of Delayed Pubertybull I Constitutional Delay in Growth and Maturationbull II Hypogonadotropic hypogonadismbull A Central nervous system disordersbull 1 Tumors bull a Craniopharyngiomasbull b Gliomasbull c Germinomasbull 2 Radiation Therapybull 3 Congenital Malformationsbull

Causes of Delayed Puberty

bull B Isolated Growth Hormone Deficiencybull 1 Kallmanns Syndromebull C Miscellaneous Disordersbull 1 Prader-Willi Syndromebull 2 Hypothyroidismbull 3 Malnutritionbull 4 Anorexia Nervosabull 5 Exercise amenorrheabull 6 Cushingsbull 7 Diabetesbull

Causes of Delayed Puberty

bull III Hypergonadotropic hypogonadism

bull A Turner Syndrome

bull B XX and XY gonadal dysgenesis

bull C Polycystic ovary Syndrome

bull D Noonans 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- Kallmanns 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 Klinefelters syndrome Other forms of primary testicular failureAnorchia or

cryptorchism- Females Turners syndromeOther forms of primary ovarian failure Pseudo-Turners

syndrome- Noonans 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 2512 years of age with idiopathic true precocious

13412-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 (-45 SD) and a weight of 286 kg (-3 SD) The patient had early stage 2 breast development There was no pubic hair Karyotype was 46XX Bone age was 10 years After administration of GnRH LH and FSH rose in a pubertal pattern Estradiol was 40 pgmL She has since spontaneously progressed through pubertal development

• TUMBUH KEMBANG REMAJA
• REMAJA
• Remaja awal (11-14 tahun)
• Remaja Tengah (15-17 tahun)
• Remaja Lanjut (Usia 18-21 tahun)
• FISIOLOGI PUBERTAS
• Pubertas
• Tanda Pubertas Perempuan
• Slide 9
• Tanda Pubertas Laki-laki
• Sexual Maturity Rating
• Pubertas Perempuan
• Pubertas Laki-laki
• Pertumbuhan fisik
• Slide 15
• Slide 16
• Lonjakan pertumbuhan
• Perkembangan psikososial
• MASALAH-MASALAH REMAJA
• Morbiditas
• Masalah lain
• Psychological Problems in Adolescence
• Slide 23
• Teen suicide (contrsquod)
• Cluster Suicides
• Warning signs of suicide
• Indikator remaja berisiko tinggi
• Slide 28
• Gejala psikofisiologis
• Terapi gejala psikofisiologi
• KLINIK REMAJA
• Sikap Dokter Dalam Menghadapi Pasien Remaja
• Pemberian pelayanan kesehatan
• Kerahasiaan
• What are The importan Aspects of an Adolescent History
• How to Talk to Teens about Puberty
• Wawancara
• Slide 38
• LAMPIRAN
• 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
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• CASE
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Causes of Short Stature
• Slide 65
• Slide 66
• Causes of Delayed Puberty
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73

Remaja Lanjut (Usia 18-21 tahun)

bull 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

bull 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

bull Biasanya awal pubertas wanita 2 tahun lebih awal

Tanda Pubertas Perempuan

bull Tanda pertama thelarche (perkembangan payudara) dan pada 5 adrenarche (tumbuhnya rambut pubis)

bull Onset perkembangan payudara kadang unilateral biasanya seimbang dalam 6 bulan

bull Sebagian besar menarche terjadi dalam masa 6 bulan masa puncak kecepatan pertambahan tinggi badan

Tanda Pubertas Perempuan

bull Tanda progresi lainnya ndash Breast budingndash Pubic hair growthndash Peak high velocityndash Menarche

bull Pertumbuhan biasanya berhenti 2-3 tahun setelah menarche

bull

Tanda Pubertas Laki-laki

bull Tanda pertama pembesaran testis

bull Tanda lainnya ndash Tumbuhnya rambut pubis ndash Pembesaran penisndash Kecepatan puncak pertambahan tinggindash Pertumbuhan biasanya berhenti 2-3 tahun

setelah puncak kecepatan pertambahan tinggi

Sexual Maturity Rating

bull Dipublikasikan Tanner pada tahun 1962

bull Skala Tanner tingkat perkembangan genital secara klinis

bull Laki-laki pertumbuhan rambut genital dan pubis

bull Perempuan perubahan rambut pubis dan payudara

Pubertas Perempuan

bull Terlalu awal jika perkembangan payudara sebelum usia 8 tahun atau menarke kurang dari 10 tahun

bull Terlalu lambat jika payudara tidak berkembang pada usia 13 tahun atau belum menarke pada usia 16 tahun

bull

Pubertas Laki-laki

bull Terlalu awal jika pembesaran testis (gt25 cm) sebelum usia 9 tahun

bull 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

bull Biasanya 2-4 tahun

bull Perempuan 2 tahun lebih awal

bull Kecepatan tinggi puncak ndash W 115-12 tahunndash L 135-14 tahun

bull Pertambahan BB sampai 2 x

bull Pertambahan TB 15-20

Perkembangan psikososial

bull Mencari jati diri apa yang ingin dilakukan dan kekuatan-kelemahan

bull Periode progresif dan perpisahan dari keluarga

bull Fase-fase perkembangan psikososial--gt

3 fase remaja (lihat bagian depan)

MASALAH-MASALAH REMAJA

bull Morbiditas

bull Mortalitas

Morbiditas

bull Kehamilan yang tak diinginkan

bull Penyakit menular seksual

bull Penyalahgunaan zat

bull Merokok

bull Depresi

bull Psikofifiologis

bull Kekerasan fisik

bull Lari dari rumah

Masalah lain

bull Depresibull Bunuh diri remajabull Penyalahgunaan zatbull Gangguan makanbull Obesitas eksogenbull Kegagalan di sekolahbull Gangguan payudarabull Kelainan ginekologis bull PMS dan Penyakit radang pelvis

Psychological Problems in Adolescence

bull Depression 13 of teens have experienced some symptoms of depression

bull Rates are higher among girls than boys

bull Rates are higher among African-American and Native American teens

bull Additionally lack of popularity rejection death of a loved one contributes

Psychological Problems in Adolescence

bull Teen suicide rate has tripled in last 30 years

bull Annual rate now 122 per 100000 3rd most common cause of death for those age 15-24

bull Successful suicide rate is higher in boys (more lethal means) but girls attempt suicide more often

Teen suicide (contrsquod)

bull Risk factors ndash Depression Social inhibition

Perfectionism

ndash Anxiety Family conflicts romantic rejection

ndash History of drugalcohol abuse gaylesbian orientation

Cluster Suicides

bull 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

bull Schools increasing using crisis teams to counsel students after one student is successful in suicide

Warning signs of suicide

bull Direct or indirect talk of suicidebull School difficulties writing a willbull Giving stuff away arranging for pet

carebull Change in appetite general

depressionbull Changes in behavior preoccupation

with death in art music or literature

Indikator remaja berisiko tinggi

1 Penurunan kemampuan belajar

2 Absen sekolah yang berlebihan

3 Keluhan psikosomatik yang seringmenetap

4 Perubahan kebiasaan tidur atau makan

5 Kesulitan konsentrasi atau kebosanan yang menetap

6 Tanda dan gejala stres atau kecemasan

Indikator remaja berisiko tinggi

7 Menarik diri atau berpindah kelompok8 Perilaku menentang atau kekerasan yang

hebat dan atau perubahan kepribadian yang radikal

9 Konflik dengan orang tua10 Perilaku seksual yang berlebihan11 Konflik dengan hukum12 Memperlihatkan pikiran bunuh diri13 Penyalahgunaan obat dan alkohol14 Melarikan diri dari rumah

Gejala psikofisiologis

bull Reaksi konversi perasaan tidak menyenangkan dikomunikasikan dengan gejala fisik ldquoperolehan sekunderrdquo

bull Riwayat dan temuan fisik tidak konsisten dengan konsep anatomi dan fisiologis

bull Cenderung mempunyai OT yang overprotektif dan menjadi semakin tergantung pada OT

Terapi gejala psikofisiologi

bull Jelaskan hubungan antara penyebab fisik dari nyeri emosional atau penyebab emosional dari nyeri fisik

bull Memberi dorongan untuk mengerti bahwa gejala dapat menetap

bull Membantu pasien meneruskan aktivitas harian yang normal

bull Obat-obatan jarang membantubull Dokter suportif dan tidak menduga bahwa

nyeri tidak benar-benar terjadi

KLINIK REMAJA

Sikap Dokter Dalam Menghadapi Pasien Remaja

bull Dokter tampil jujur sederhana tidak perlu tampil ldquoprofesionalrdquo berlebihan

bull Remaja kurang PD dokter hati-hati

bull Sensitif terhadap tingkat perkembangan

Pemberian pelayanan kesehatan

bull 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

bull Beritahu remaja dan orang tuanya tentang kerahasiaan yang akan dijaga

bull Waktu adekuat

bull Yakinkan bahwa dokter tidak akan mencampuri kehidupan pribadi remaja tetapi merupakan hal penting untuk kesehatannya

What are The importan Aspects of an Adolescent History

bull HEADSSS untuk melacak informasi psikososial yang penting dari pasien remaja

bull H Homehealthbull E EducationEmploymentEatingbull A ActivitiesAspirationAffiliationbull D Drugsbull S Sexbull S SleepSuicidebull S Shoplifting

How to Talk to Teens about Puberty

1048708 Be open and honest

1048708 Treat the teen with respect

1048708 Talk directly to the teen

1048708 Begin conversation with least

threatening topics

1048708 Provide confidentiality

Wawancara

Wawancara terpimpinPenilaian tugas-tugas psikoperkembanganPemeriksaan sistemik meliputi 1 Nutrisi2 Tidur3 Perawatan diri pengetahuan ttg

pemeriksaan sendiri 4 Olah raga5 Hubungan keluarga dan sahabat6 Teman sebaya

Wawancara

7 Sekolah8 Minat pendidikan dan pekerjaan 9 Tembakau10 Penyalahgunaan zat11 Seksualitas12 Kesehatan mental

Usahakan pasien mendapat kesan tertarik dan seperti mempunyai ldquodokternyardquo sendiri

LAMPIRAN

PHYSIOLOGY OF PUBERTYPhysical 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 25 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 134 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 25 SD below the mean and is considered to have delayed puberty

- By this definition 06 of the healthy population are classified as having constitutional delay in growth and adolescence

CASE

bull 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

bull 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)

bull 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 15 to 35 year period

bull 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 124 to 128 years of age African-American girls are maturing earlier

bull 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 115 years

bull 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 135 and 17 years of age Growth of the penis reaches a SMR (Tanner) stage V between 125 and 165 years of age Nocturnal emissions (wet dreams) may first appear during SMR stage III

bull 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

bull 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

bull 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

bull 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

bull 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)

bull

bull 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

bull 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

bull 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 50ile of the patients actual height)

bull 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 (Klinefelters syndrome)

Causes of Short Staturebull I Constitutional Short Staturebull II Primordial Dwarfism (intrauterine growth retardation)bull III Endocrine Causesbull A Growth Hormone Deficiencybull 1 Congenitalbull 2 Acquiredbull a HypothalamicPituitary Tumorsbull b Head Traumabull c CNS infectionsbull d Psychosocial Dwarfismbull 3 Laron Dwarfismbull 4 Hypothyroidismbull 5 Syndromes of Short Staturebull a Turner Syndrome (gonadal dysgenesis)bull b Noonans Syndromebull c Prader-Willi Syndromebull

Causes of Short Stature

bull IV Chronic Diseasebull A Heart Diseasebull B Pulmonarybull 1 Cystic Fibrosisbull 2 Asthmabull C GI Disordersbull D Hepatic Diseasebull E Renalbull V Iatrogenicbull A Corticosteroids anabolic steroidsbull B ADHD meds

bull Causes of Delayed Pubertybull I Constitutional Delay in Growth and Maturationbull II Hypogonadotropic hypogonadismbull A Central nervous system disordersbull 1 Tumors bull a Craniopharyngiomasbull b Gliomasbull c Germinomasbull 2 Radiation Therapybull 3 Congenital Malformationsbull

Causes of Delayed Puberty

bull B Isolated Growth Hormone Deficiencybull 1 Kallmanns Syndromebull C Miscellaneous Disordersbull 1 Prader-Willi Syndromebull 2 Hypothyroidismbull 3 Malnutritionbull 4 Anorexia Nervosabull 5 Exercise amenorrheabull 6 Cushingsbull 7 Diabetesbull

Causes of Delayed Puberty

bull III Hypergonadotropic hypogonadism

bull A Turner Syndrome

bull B XX and XY gonadal dysgenesis

bull C Polycystic ovary Syndrome

bull D Noonans 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- Kallmanns 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 Klinefelters syndrome Other forms of primary testicular failureAnorchia or

cryptorchism- Females Turners syndromeOther forms of primary ovarian failure Pseudo-Turners

syndrome- Noonans 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 2512 years of age with idiopathic true precocious

13412-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 (-45 SD) and a weight of 286 kg (-3 SD) The patient had early stage 2 breast development There was no pubic hair Karyotype was 46XX Bone age was 10 years After administration of GnRH LH and FSH rose in a pubertal pattern Estradiol was 40 pgmL She has since spontaneously progressed through pubertal development

• TUMBUH KEMBANG REMAJA
• REMAJA
• Remaja awal (11-14 tahun)
• Remaja Tengah (15-17 tahun)
• Remaja Lanjut (Usia 18-21 tahun)
• FISIOLOGI PUBERTAS
• Pubertas
• Tanda Pubertas Perempuan
• Slide 9
• Tanda Pubertas Laki-laki
• Sexual Maturity Rating
• Pubertas Perempuan
• Pubertas Laki-laki
• Pertumbuhan fisik
• Slide 15
• Slide 16
• Lonjakan pertumbuhan
• Perkembangan psikososial
• MASALAH-MASALAH REMAJA
• Morbiditas
• Masalah lain
• Psychological Problems in Adolescence
• Slide 23
• Teen suicide (contrsquod)
• Cluster Suicides
• Warning signs of suicide
• Indikator remaja berisiko tinggi
• Slide 28
• Gejala psikofisiologis
• Terapi gejala psikofisiologi
• KLINIK REMAJA
• Sikap Dokter Dalam Menghadapi Pasien Remaja
• Pemberian pelayanan kesehatan
• Kerahasiaan
• What are The importan Aspects of an Adolescent History
• How to Talk to Teens about Puberty
• Wawancara
• Slide 38
• LAMPIRAN
• 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
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• CASE
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Causes of Short Stature
• Slide 65
• Slide 66
• Causes of Delayed Puberty
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73

FISIOLOGI PUBERTAS

Pubertas

bull 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

bull Biasanya awal pubertas wanita 2 tahun lebih awal

Tanda Pubertas Perempuan

bull Tanda pertama thelarche (perkembangan payudara) dan pada 5 adrenarche (tumbuhnya rambut pubis)

bull Onset perkembangan payudara kadang unilateral biasanya seimbang dalam 6 bulan

bull Sebagian besar menarche terjadi dalam masa 6 bulan masa puncak kecepatan pertambahan tinggi badan

Tanda Pubertas Perempuan

bull Tanda progresi lainnya ndash Breast budingndash Pubic hair growthndash Peak high velocityndash Menarche

bull Pertumbuhan biasanya berhenti 2-3 tahun setelah menarche

bull

Tanda Pubertas Laki-laki

bull Tanda pertama pembesaran testis

bull Tanda lainnya ndash Tumbuhnya rambut pubis ndash Pembesaran penisndash Kecepatan puncak pertambahan tinggindash Pertumbuhan biasanya berhenti 2-3 tahun

setelah puncak kecepatan pertambahan tinggi

Sexual Maturity Rating

bull Dipublikasikan Tanner pada tahun 1962

bull Skala Tanner tingkat perkembangan genital secara klinis

bull Laki-laki pertumbuhan rambut genital dan pubis

bull Perempuan perubahan rambut pubis dan payudara

Pubertas Perempuan

bull Terlalu awal jika perkembangan payudara sebelum usia 8 tahun atau menarke kurang dari 10 tahun

bull Terlalu lambat jika payudara tidak berkembang pada usia 13 tahun atau belum menarke pada usia 16 tahun

bull

Pubertas Laki-laki

bull Terlalu awal jika pembesaran testis (gt25 cm) sebelum usia 9 tahun

bull 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

bull Biasanya 2-4 tahun

bull Perempuan 2 tahun lebih awal

bull Kecepatan tinggi puncak ndash W 115-12 tahunndash L 135-14 tahun

bull Pertambahan BB sampai 2 x

bull Pertambahan TB 15-20

Perkembangan psikososial

bull Mencari jati diri apa yang ingin dilakukan dan kekuatan-kelemahan

bull Periode progresif dan perpisahan dari keluarga

bull Fase-fase perkembangan psikososial--gt

3 fase remaja (lihat bagian depan)

MASALAH-MASALAH REMAJA

bull Morbiditas

bull Mortalitas

Morbiditas

bull Kehamilan yang tak diinginkan

bull Penyakit menular seksual

bull Penyalahgunaan zat

bull Merokok

bull Depresi

bull Psikofifiologis

bull Kekerasan fisik

bull Lari dari rumah

Masalah lain

bull Depresibull Bunuh diri remajabull Penyalahgunaan zatbull Gangguan makanbull Obesitas eksogenbull Kegagalan di sekolahbull Gangguan payudarabull Kelainan ginekologis bull PMS dan Penyakit radang pelvis

Psychological Problems in Adolescence

bull Depression 13 of teens have experienced some symptoms of depression

bull Rates are higher among girls than boys

bull Rates are higher among African-American and Native American teens

bull Additionally lack of popularity rejection death of a loved one contributes

Psychological Problems in Adolescence

bull Teen suicide rate has tripled in last 30 years

bull Annual rate now 122 per 100000 3rd most common cause of death for those age 15-24

bull Successful suicide rate is higher in boys (more lethal means) but girls attempt suicide more often

Teen suicide (contrsquod)

bull Risk factors ndash Depression Social inhibition

Perfectionism

ndash Anxiety Family conflicts romantic rejection

ndash History of drugalcohol abuse gaylesbian orientation

Cluster Suicides

bull 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

bull Schools increasing using crisis teams to counsel students after one student is successful in suicide

Warning signs of suicide

bull Direct or indirect talk of suicidebull School difficulties writing a willbull Giving stuff away arranging for pet

carebull Change in appetite general

depressionbull Changes in behavior preoccupation

with death in art music or literature

Indikator remaja berisiko tinggi

1 Penurunan kemampuan belajar

2 Absen sekolah yang berlebihan

3 Keluhan psikosomatik yang seringmenetap

4 Perubahan kebiasaan tidur atau makan

5 Kesulitan konsentrasi atau kebosanan yang menetap

6 Tanda dan gejala stres atau kecemasan

Indikator remaja berisiko tinggi

7 Menarik diri atau berpindah kelompok8 Perilaku menentang atau kekerasan yang

hebat dan atau perubahan kepribadian yang radikal

9 Konflik dengan orang tua10 Perilaku seksual yang berlebihan11 Konflik dengan hukum12 Memperlihatkan pikiran bunuh diri13 Penyalahgunaan obat dan alkohol14 Melarikan diri dari rumah

Gejala psikofisiologis

bull Reaksi konversi perasaan tidak menyenangkan dikomunikasikan dengan gejala fisik ldquoperolehan sekunderrdquo

bull Riwayat dan temuan fisik tidak konsisten dengan konsep anatomi dan fisiologis

bull Cenderung mempunyai OT yang overprotektif dan menjadi semakin tergantung pada OT

Terapi gejala psikofisiologi

bull Jelaskan hubungan antara penyebab fisik dari nyeri emosional atau penyebab emosional dari nyeri fisik

bull Memberi dorongan untuk mengerti bahwa gejala dapat menetap

bull Membantu pasien meneruskan aktivitas harian yang normal

bull Obat-obatan jarang membantubull Dokter suportif dan tidak menduga bahwa

nyeri tidak benar-benar terjadi

KLINIK REMAJA

Sikap Dokter Dalam Menghadapi Pasien Remaja

bull Dokter tampil jujur sederhana tidak perlu tampil ldquoprofesionalrdquo berlebihan

bull Remaja kurang PD dokter hati-hati

bull Sensitif terhadap tingkat perkembangan

Pemberian pelayanan kesehatan

bull 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

bull Beritahu remaja dan orang tuanya tentang kerahasiaan yang akan dijaga

bull Waktu adekuat

bull Yakinkan bahwa dokter tidak akan mencampuri kehidupan pribadi remaja tetapi merupakan hal penting untuk kesehatannya

What are The importan Aspects of an Adolescent History

bull HEADSSS untuk melacak informasi psikososial yang penting dari pasien remaja

bull H Homehealthbull E EducationEmploymentEatingbull A ActivitiesAspirationAffiliationbull D Drugsbull S Sexbull S SleepSuicidebull S Shoplifting

How to Talk to Teens about Puberty

1048708 Be open and honest

1048708 Treat the teen with respect

1048708 Talk directly to the teen

1048708 Begin conversation with least

threatening topics

1048708 Provide confidentiality

Wawancara

Wawancara terpimpinPenilaian tugas-tugas psikoperkembanganPemeriksaan sistemik meliputi 1 Nutrisi2 Tidur3 Perawatan diri pengetahuan ttg

pemeriksaan sendiri 4 Olah raga5 Hubungan keluarga dan sahabat6 Teman sebaya

Wawancara

7 Sekolah8 Minat pendidikan dan pekerjaan 9 Tembakau10 Penyalahgunaan zat11 Seksualitas12 Kesehatan mental

Usahakan pasien mendapat kesan tertarik dan seperti mempunyai ldquodokternyardquo sendiri

LAMPIRAN

PHYSIOLOGY OF PUBERTYPhysical 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 25 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 134 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 25 SD below the mean and is considered to have delayed puberty

- By this definition 06 of the healthy population are classified as having constitutional delay in growth and adolescence

CASE

bull 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

bull 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)

bull 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 15 to 35 year period

bull 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 124 to 128 years of age African-American girls are maturing earlier

bull 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 115 years

bull 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 135 and 17 years of age Growth of the penis reaches a SMR (Tanner) stage V between 125 and 165 years of age Nocturnal emissions (wet dreams) may first appear during SMR stage III

bull 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

bull 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

bull 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

bull 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

bull 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)

bull

bull 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

bull 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

bull 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 50ile of the patients actual height)

bull 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 (Klinefelters syndrome)

Causes of Short Staturebull I Constitutional Short Staturebull II Primordial Dwarfism (intrauterine growth retardation)bull III Endocrine Causesbull A Growth Hormone Deficiencybull 1 Congenitalbull 2 Acquiredbull a HypothalamicPituitary Tumorsbull b Head Traumabull c CNS infectionsbull d Psychosocial Dwarfismbull 3 Laron Dwarfismbull 4 Hypothyroidismbull 5 Syndromes of Short Staturebull a Turner Syndrome (gonadal dysgenesis)bull b Noonans Syndromebull c Prader-Willi Syndromebull

Causes of Short Stature

bull IV Chronic Diseasebull A Heart Diseasebull B Pulmonarybull 1 Cystic Fibrosisbull 2 Asthmabull C GI Disordersbull D Hepatic Diseasebull E Renalbull V Iatrogenicbull A Corticosteroids anabolic steroidsbull B ADHD meds

bull Causes of Delayed Pubertybull I Constitutional Delay in Growth and Maturationbull II Hypogonadotropic hypogonadismbull A Central nervous system disordersbull 1 Tumors bull a Craniopharyngiomasbull b Gliomasbull c Germinomasbull 2 Radiation Therapybull 3 Congenital Malformationsbull

Causes of Delayed Puberty

bull B Isolated Growth Hormone Deficiencybull 1 Kallmanns Syndromebull C Miscellaneous Disordersbull 1 Prader-Willi Syndromebull 2 Hypothyroidismbull 3 Malnutritionbull 4 Anorexia Nervosabull 5 Exercise amenorrheabull 6 Cushingsbull 7 Diabetesbull

Causes of Delayed Puberty

bull III Hypergonadotropic hypogonadism

bull A Turner Syndrome

bull B XX and XY gonadal dysgenesis

bull C Polycystic ovary Syndrome

bull D Noonans 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- Kallmanns 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 Klinefelters syndrome Other forms of primary testicular failureAnorchia or

cryptorchism- Females Turners syndromeOther forms of primary ovarian failure Pseudo-Turners

syndrome- Noonans 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 2512 years of age with idiopathic true precocious

13412-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 (-45 SD) and a weight of 286 kg (-3 SD) The patient had early stage 2 breast development There was no pubic hair Karyotype was 46XX Bone age was 10 years After administration of GnRH LH and FSH rose in a pubertal pattern Estradiol was 40 pgmL She has since spontaneously progressed through pubertal development

• TUMBUH KEMBANG REMAJA
• REMAJA
• Remaja awal (11-14 tahun)
• Remaja Tengah (15-17 tahun)
• Remaja Lanjut (Usia 18-21 tahun)
• FISIOLOGI PUBERTAS
• Pubertas
• Tanda Pubertas Perempuan
• Slide 9
• Tanda Pubertas Laki-laki
• Sexual Maturity Rating
• Pubertas Perempuan
• Pubertas Laki-laki
• Pertumbuhan fisik
• Slide 15
• Slide 16
• Lonjakan pertumbuhan
• Perkembangan psikososial
• MASALAH-MASALAH REMAJA
• Morbiditas
• Masalah lain
• Psychological Problems in Adolescence
• Slide 23
• Teen suicide (contrsquod)
• Cluster Suicides
• Warning signs of suicide
• Indikator remaja berisiko tinggi
• Slide 28
• Gejala psikofisiologis
• Terapi gejala psikofisiologi
• KLINIK REMAJA
• Sikap Dokter Dalam Menghadapi Pasien Remaja
• Pemberian pelayanan kesehatan
• Kerahasiaan
• What are The importan Aspects of an Adolescent History
• How to Talk to Teens about Puberty
• Wawancara
• Slide 38
• LAMPIRAN
• 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
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• CASE
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Causes of Short Stature
• Slide 65
• Slide 66
• Causes of Delayed Puberty
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73

Pubertas

bull 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

bull Biasanya awal pubertas wanita 2 tahun lebih awal

Tanda Pubertas Perempuan

bull Tanda pertama thelarche (perkembangan payudara) dan pada 5 adrenarche (tumbuhnya rambut pubis)

bull Onset perkembangan payudara kadang unilateral biasanya seimbang dalam 6 bulan

bull Sebagian besar menarche terjadi dalam masa 6 bulan masa puncak kecepatan pertambahan tinggi badan

Tanda Pubertas Perempuan

bull Tanda progresi lainnya ndash Breast budingndash Pubic hair growthndash Peak high velocityndash Menarche

bull Pertumbuhan biasanya berhenti 2-3 tahun setelah menarche

bull

Tanda Pubertas Laki-laki

bull Tanda pertama pembesaran testis

bull Tanda lainnya ndash Tumbuhnya rambut pubis ndash Pembesaran penisndash Kecepatan puncak pertambahan tinggindash Pertumbuhan biasanya berhenti 2-3 tahun

setelah puncak kecepatan pertambahan tinggi

Sexual Maturity Rating

bull Dipublikasikan Tanner pada tahun 1962

bull Skala Tanner tingkat perkembangan genital secara klinis

bull Laki-laki pertumbuhan rambut genital dan pubis

bull Perempuan perubahan rambut pubis dan payudara

Pubertas Perempuan

bull Terlalu awal jika perkembangan payudara sebelum usia 8 tahun atau menarke kurang dari 10 tahun

bull Terlalu lambat jika payudara tidak berkembang pada usia 13 tahun atau belum menarke pada usia 16 tahun

bull

Pubertas Laki-laki

bull Terlalu awal jika pembesaran testis (gt25 cm) sebelum usia 9 tahun

bull 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

bull Biasanya 2-4 tahun

bull Perempuan 2 tahun lebih awal

bull Kecepatan tinggi puncak ndash W 115-12 tahunndash L 135-14 tahun

bull Pertambahan BB sampai 2 x

bull Pertambahan TB 15-20

Perkembangan psikososial

bull Mencari jati diri apa yang ingin dilakukan dan kekuatan-kelemahan

bull Periode progresif dan perpisahan dari keluarga

bull Fase-fase perkembangan psikososial--gt

3 fase remaja (lihat bagian depan)

MASALAH-MASALAH REMAJA

bull Morbiditas

bull Mortalitas

Morbiditas

bull Kehamilan yang tak diinginkan

bull Penyakit menular seksual

bull Penyalahgunaan zat

bull Merokok

bull Depresi

bull Psikofifiologis

bull Kekerasan fisik

bull Lari dari rumah

Masalah lain

bull Depresibull Bunuh diri remajabull Penyalahgunaan zatbull Gangguan makanbull Obesitas eksogenbull Kegagalan di sekolahbull Gangguan payudarabull Kelainan ginekologis bull PMS dan Penyakit radang pelvis

Psychological Problems in Adolescence

bull Depression 13 of teens have experienced some symptoms of depression

bull Rates are higher among girls than boys

bull Rates are higher among African-American and Native American teens

bull Additionally lack of popularity rejection death of a loved one contributes

Psychological Problems in Adolescence

bull Teen suicide rate has tripled in last 30 years

bull Annual rate now 122 per 100000 3rd most common cause of death for those age 15-24

bull Successful suicide rate is higher in boys (more lethal means) but girls attempt suicide more often

Teen suicide (contrsquod)

bull Risk factors ndash Depression Social inhibition

Perfectionism

ndash Anxiety Family conflicts romantic rejection

ndash History of drugalcohol abuse gaylesbian orientation

Cluster Suicides

bull 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

bull Schools increasing using crisis teams to counsel students after one student is successful in suicide

Warning signs of suicide

bull Direct or indirect talk of suicidebull School difficulties writing a willbull Giving stuff away arranging for pet

carebull Change in appetite general

depressionbull Changes in behavior preoccupation

with death in art music or literature

Indikator remaja berisiko tinggi

1 Penurunan kemampuan belajar

2 Absen sekolah yang berlebihan

3 Keluhan psikosomatik yang seringmenetap

4 Perubahan kebiasaan tidur atau makan

5 Kesulitan konsentrasi atau kebosanan yang menetap

6 Tanda dan gejala stres atau kecemasan

Indikator remaja berisiko tinggi

7 Menarik diri atau berpindah kelompok8 Perilaku menentang atau kekerasan yang

hebat dan atau perubahan kepribadian yang radikal

9 Konflik dengan orang tua10 Perilaku seksual yang berlebihan11 Konflik dengan hukum12 Memperlihatkan pikiran bunuh diri13 Penyalahgunaan obat dan alkohol14 Melarikan diri dari rumah

Gejala psikofisiologis

bull Reaksi konversi perasaan tidak menyenangkan dikomunikasikan dengan gejala fisik ldquoperolehan sekunderrdquo

bull Riwayat dan temuan fisik tidak konsisten dengan konsep anatomi dan fisiologis

bull Cenderung mempunyai OT yang overprotektif dan menjadi semakin tergantung pada OT

Terapi gejala psikofisiologi

bull Jelaskan hubungan antara penyebab fisik dari nyeri emosional atau penyebab emosional dari nyeri fisik

bull Memberi dorongan untuk mengerti bahwa gejala dapat menetap

bull Membantu pasien meneruskan aktivitas harian yang normal

bull Obat-obatan jarang membantubull Dokter suportif dan tidak menduga bahwa

nyeri tidak benar-benar terjadi

KLINIK REMAJA

Sikap Dokter Dalam Menghadapi Pasien Remaja

bull Dokter tampil jujur sederhana tidak perlu tampil ldquoprofesionalrdquo berlebihan

bull Remaja kurang PD dokter hati-hati

bull Sensitif terhadap tingkat perkembangan

Pemberian pelayanan kesehatan

bull 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

bull Beritahu remaja dan orang tuanya tentang kerahasiaan yang akan dijaga

bull Waktu adekuat

bull Yakinkan bahwa dokter tidak akan mencampuri kehidupan pribadi remaja tetapi merupakan hal penting untuk kesehatannya

What are The importan Aspects of an Adolescent History

bull HEADSSS untuk melacak informasi psikososial yang penting dari pasien remaja

bull H Homehealthbull E EducationEmploymentEatingbull A ActivitiesAspirationAffiliationbull D Drugsbull S Sexbull S SleepSuicidebull S Shoplifting

How to Talk to Teens about Puberty

1048708 Be open and honest

1048708 Treat the teen with respect

1048708 Talk directly to the teen

1048708 Begin conversation with least

threatening topics

1048708 Provide confidentiality

Wawancara

Wawancara terpimpinPenilaian tugas-tugas psikoperkembanganPemeriksaan sistemik meliputi 1 Nutrisi2 Tidur3 Perawatan diri pengetahuan ttg

pemeriksaan sendiri 4 Olah raga5 Hubungan keluarga dan sahabat6 Teman sebaya

Wawancara

7 Sekolah8 Minat pendidikan dan pekerjaan 9 Tembakau10 Penyalahgunaan zat11 Seksualitas12 Kesehatan mental

Usahakan pasien mendapat kesan tertarik dan seperti mempunyai ldquodokternyardquo sendiri

LAMPIRAN

PHYSIOLOGY OF PUBERTYPhysical 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 25 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 134 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 25 SD below the mean and is considered to have delayed puberty

- By this definition 06 of the healthy population are classified as having constitutional delay in growth and adolescence

CASE

bull 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

bull 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)

bull 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 15 to 35 year period

bull 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 124 to 128 years of age African-American girls are maturing earlier

bull 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 115 years

bull 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 135 and 17 years of age Growth of the penis reaches a SMR (Tanner) stage V between 125 and 165 years of age Nocturnal emissions (wet dreams) may first appear during SMR stage III

bull 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

bull 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

bull 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

bull 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

bull 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)

bull

bull 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

bull 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

bull 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 50ile of the patients actual height)

bull 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 (Klinefelters syndrome)

Causes of Short Staturebull I Constitutional Short Staturebull II Primordial Dwarfism (intrauterine growth retardation)bull III Endocrine Causesbull A Growth Hormone Deficiencybull 1 Congenitalbull 2 Acquiredbull a HypothalamicPituitary Tumorsbull b Head Traumabull c CNS infectionsbull d Psychosocial Dwarfismbull 3 Laron Dwarfismbull 4 Hypothyroidismbull 5 Syndromes of Short Staturebull a Turner Syndrome (gonadal dysgenesis)bull b Noonans Syndromebull c Prader-Willi Syndromebull

Causes of Short Stature

bull IV Chronic Diseasebull A Heart Diseasebull B Pulmonarybull 1 Cystic Fibrosisbull 2 Asthmabull C GI Disordersbull D Hepatic Diseasebull E Renalbull V Iatrogenicbull A Corticosteroids anabolic steroidsbull B ADHD meds

bull Causes of Delayed Pubertybull I Constitutional Delay in Growth and Maturationbull II Hypogonadotropic hypogonadismbull A Central nervous system disordersbull 1 Tumors bull a Craniopharyngiomasbull b Gliomasbull c Germinomasbull 2 Radiation Therapybull 3 Congenital Malformationsbull

Causes of Delayed Puberty

bull B Isolated Growth Hormone Deficiencybull 1 Kallmanns Syndromebull C Miscellaneous Disordersbull 1 Prader-Willi Syndromebull 2 Hypothyroidismbull 3 Malnutritionbull 4 Anorexia Nervosabull 5 Exercise amenorrheabull 6 Cushingsbull 7 Diabetesbull

Causes of Delayed Puberty

bull III Hypergonadotropic hypogonadism

bull A Turner Syndrome

bull B XX and XY gonadal dysgenesis

bull C Polycystic ovary Syndrome

bull D Noonans 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- Kallmanns 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 Klinefelters syndrome Other forms of primary testicular failureAnorchia or

cryptorchism- Females Turners syndromeOther forms of primary ovarian failure Pseudo-Turners

syndrome- Noonans 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 2512 years of age with idiopathic true precocious

13412-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 (-45 SD) and a weight of 286 kg (-3 SD) The patient had early stage 2 breast development There was no pubic hair Karyotype was 46XX Bone age was 10 years After administration of GnRH LH and FSH rose in a pubertal pattern Estradiol was 40 pgmL She has since spontaneously progressed through pubertal development

• TUMBUH KEMBANG REMAJA
• REMAJA
• Remaja awal (11-14 tahun)
• Remaja Tengah (15-17 tahun)
• Remaja Lanjut (Usia 18-21 tahun)
• FISIOLOGI PUBERTAS
• Pubertas
• Tanda Pubertas Perempuan
• Slide 9
• Tanda Pubertas Laki-laki
• Sexual Maturity Rating
• Pubertas Perempuan
• Pubertas Laki-laki
• Pertumbuhan fisik
• Slide 15
• Slide 16
• Lonjakan pertumbuhan
• Perkembangan psikososial
• MASALAH-MASALAH REMAJA
• Morbiditas
• Masalah lain
• Psychological Problems in Adolescence
• Slide 23
• Teen suicide (contrsquod)
• Cluster Suicides
• Warning signs of suicide
• Indikator remaja berisiko tinggi
• Slide 28
• Gejala psikofisiologis
• Terapi gejala psikofisiologi
• KLINIK REMAJA
• Sikap Dokter Dalam Menghadapi Pasien Remaja
• Pemberian pelayanan kesehatan
• Kerahasiaan
• What are The importan Aspects of an Adolescent History
• How to Talk to Teens about Puberty
• Wawancara
• Slide 38
• LAMPIRAN
• 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
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• CASE
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Causes of Short Stature
• Slide 65
• Slide 66
• Causes of Delayed Puberty
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73

Tanda Pubertas Perempuan

bull Tanda pertama thelarche (perkembangan payudara) dan pada 5 adrenarche (tumbuhnya rambut pubis)

bull Onset perkembangan payudara kadang unilateral biasanya seimbang dalam 6 bulan

bull Sebagian besar menarche terjadi dalam masa 6 bulan masa puncak kecepatan pertambahan tinggi badan

Tanda Pubertas Perempuan

bull Tanda progresi lainnya ndash Breast budingndash Pubic hair growthndash Peak high velocityndash Menarche

bull Pertumbuhan biasanya berhenti 2-3 tahun setelah menarche

bull

Tanda Pubertas Laki-laki

bull Tanda pertama pembesaran testis

bull Tanda lainnya ndash Tumbuhnya rambut pubis ndash Pembesaran penisndash Kecepatan puncak pertambahan tinggindash Pertumbuhan biasanya berhenti 2-3 tahun

setelah puncak kecepatan pertambahan tinggi

Sexual Maturity Rating

bull Dipublikasikan Tanner pada tahun 1962

bull Skala Tanner tingkat perkembangan genital secara klinis

bull Laki-laki pertumbuhan rambut genital dan pubis

bull Perempuan perubahan rambut pubis dan payudara

Pubertas Perempuan

bull Terlalu awal jika perkembangan payudara sebelum usia 8 tahun atau menarke kurang dari 10 tahun

bull Terlalu lambat jika payudara tidak berkembang pada usia 13 tahun atau belum menarke pada usia 16 tahun

bull

Pubertas Laki-laki

bull Terlalu awal jika pembesaran testis (gt25 cm) sebelum usia 9 tahun

bull 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

bull Biasanya 2-4 tahun

bull Perempuan 2 tahun lebih awal

bull Kecepatan tinggi puncak ndash W 115-12 tahunndash L 135-14 tahun

bull Pertambahan BB sampai 2 x

bull Pertambahan TB 15-20

Perkembangan psikososial

bull Mencari jati diri apa yang ingin dilakukan dan kekuatan-kelemahan

bull Periode progresif dan perpisahan dari keluarga

bull Fase-fase perkembangan psikososial--gt

3 fase remaja (lihat bagian depan)

MASALAH-MASALAH REMAJA

bull Morbiditas

bull Mortalitas

Morbiditas

bull Kehamilan yang tak diinginkan

bull Penyakit menular seksual

bull Penyalahgunaan zat

bull Merokok

bull Depresi

bull Psikofifiologis

bull Kekerasan fisik

bull Lari dari rumah

Masalah lain

bull Depresibull Bunuh diri remajabull Penyalahgunaan zatbull Gangguan makanbull Obesitas eksogenbull Kegagalan di sekolahbull Gangguan payudarabull Kelainan ginekologis bull PMS dan Penyakit radang pelvis

Psychological Problems in Adolescence

bull Depression 13 of teens have experienced some symptoms of depression

bull Rates are higher among girls than boys

bull Rates are higher among African-American and Native American teens

bull Additionally lack of popularity rejection death of a loved one contributes

Psychological Problems in Adolescence

bull Teen suicide rate has tripled in last 30 years

bull Annual rate now 122 per 100000 3rd most common cause of death for those age 15-24

bull Successful suicide rate is higher in boys (more lethal means) but girls attempt suicide more often

Teen suicide (contrsquod)

bull Risk factors ndash Depression Social inhibition

Perfectionism

ndash Anxiety Family conflicts romantic rejection

ndash History of drugalcohol abuse gaylesbian orientation

Cluster Suicides

bull 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

bull Schools increasing using crisis teams to counsel students after one student is successful in suicide

Warning signs of suicide

bull Direct or indirect talk of suicidebull School difficulties writing a willbull Giving stuff away arranging for pet

carebull Change in appetite general

depressionbull Changes in behavior preoccupation

with death in art music or literature

Indikator remaja berisiko tinggi

1 Penurunan kemampuan belajar

2 Absen sekolah yang berlebihan

3 Keluhan psikosomatik yang seringmenetap

4 Perubahan kebiasaan tidur atau makan

5 Kesulitan konsentrasi atau kebosanan yang menetap

6 Tanda dan gejala stres atau kecemasan

Indikator remaja berisiko tinggi

7 Menarik diri atau berpindah kelompok8 Perilaku menentang atau kekerasan yang

hebat dan atau perubahan kepribadian yang radikal

9 Konflik dengan orang tua10 Perilaku seksual yang berlebihan11 Konflik dengan hukum12 Memperlihatkan pikiran bunuh diri13 Penyalahgunaan obat dan alkohol14 Melarikan diri dari rumah

Gejala psikofisiologis

bull Reaksi konversi perasaan tidak menyenangkan dikomunikasikan dengan gejala fisik ldquoperolehan sekunderrdquo

bull Riwayat dan temuan fisik tidak konsisten dengan konsep anatomi dan fisiologis

bull Cenderung mempunyai OT yang overprotektif dan menjadi semakin tergantung pada OT

Terapi gejala psikofisiologi

bull Jelaskan hubungan antara penyebab fisik dari nyeri emosional atau penyebab emosional dari nyeri fisik

bull Memberi dorongan untuk mengerti bahwa gejala dapat menetap

bull Membantu pasien meneruskan aktivitas harian yang normal

bull Obat-obatan jarang membantubull Dokter suportif dan tidak menduga bahwa

nyeri tidak benar-benar terjadi

KLINIK REMAJA

Sikap Dokter Dalam Menghadapi Pasien Remaja

bull Dokter tampil jujur sederhana tidak perlu tampil ldquoprofesionalrdquo berlebihan

bull Remaja kurang PD dokter hati-hati

bull Sensitif terhadap tingkat perkembangan

Pemberian pelayanan kesehatan

bull 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

bull Beritahu remaja dan orang tuanya tentang kerahasiaan yang akan dijaga

bull Waktu adekuat

bull Yakinkan bahwa dokter tidak akan mencampuri kehidupan pribadi remaja tetapi merupakan hal penting untuk kesehatannya

What are The importan Aspects of an Adolescent History

bull HEADSSS untuk melacak informasi psikososial yang penting dari pasien remaja

bull H Homehealthbull E EducationEmploymentEatingbull A ActivitiesAspirationAffiliationbull D Drugsbull S Sexbull S SleepSuicidebull S Shoplifting

How to Talk to Teens about Puberty

1048708 Be open and honest

1048708 Treat the teen with respect

1048708 Talk directly to the teen

1048708 Begin conversation with least

threatening topics

1048708 Provide confidentiality

Wawancara

Wawancara terpimpinPenilaian tugas-tugas psikoperkembanganPemeriksaan sistemik meliputi 1 Nutrisi2 Tidur3 Perawatan diri pengetahuan ttg

pemeriksaan sendiri 4 Olah raga5 Hubungan keluarga dan sahabat6 Teman sebaya

Wawancara

7 Sekolah8 Minat pendidikan dan pekerjaan 9 Tembakau10 Penyalahgunaan zat11 Seksualitas12 Kesehatan mental

Usahakan pasien mendapat kesan tertarik dan seperti mempunyai ldquodokternyardquo sendiri

LAMPIRAN

PHYSIOLOGY OF PUBERTYPhysical 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 25 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 134 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 25 SD below the mean and is considered to have delayed puberty

- By this definition 06 of the healthy population are classified as having constitutional delay in growth and adolescence

CASE

bull 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

bull 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)

bull 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 15 to 35 year period

bull 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 124 to 128 years of age African-American girls are maturing earlier

bull 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 115 years

bull 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 135 and 17 years of age Growth of the penis reaches a SMR (Tanner) stage V between 125 and 165 years of age Nocturnal emissions (wet dreams) may first appear during SMR stage III

bull 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

bull 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

bull 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

bull 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

bull 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)

bull

bull 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

bull 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

bull 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 50ile of the patients actual height)

bull 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 (Klinefelters syndrome)

Causes of Short Staturebull I Constitutional Short Staturebull II Primordial Dwarfism (intrauterine growth retardation)bull III Endocrine Causesbull A Growth Hormone Deficiencybull 1 Congenitalbull 2 Acquiredbull a HypothalamicPituitary Tumorsbull b Head Traumabull c CNS infectionsbull d Psychosocial Dwarfismbull 3 Laron Dwarfismbull 4 Hypothyroidismbull 5 Syndromes of Short Staturebull a Turner Syndrome (gonadal dysgenesis)bull b Noonans Syndromebull c Prader-Willi Syndromebull

Causes of Short Stature

bull IV Chronic Diseasebull A Heart Diseasebull B Pulmonarybull 1 Cystic Fibrosisbull 2 Asthmabull C GI Disordersbull D Hepatic Diseasebull E Renalbull V Iatrogenicbull A Corticosteroids anabolic steroidsbull B ADHD meds

bull Causes of Delayed Pubertybull I Constitutional Delay in Growth and Maturationbull II Hypogonadotropic hypogonadismbull A Central nervous system disordersbull 1 Tumors bull a Craniopharyngiomasbull b Gliomasbull c Germinomasbull 2 Radiation Therapybull 3 Congenital Malformationsbull

Causes of Delayed Puberty

bull B Isolated Growth Hormone Deficiencybull 1 Kallmanns Syndromebull C Miscellaneous Disordersbull 1 Prader-Willi Syndromebull 2 Hypothyroidismbull 3 Malnutritionbull 4 Anorexia Nervosabull 5 Exercise amenorrheabull 6 Cushingsbull 7 Diabetesbull

Causes of Delayed Puberty

bull III Hypergonadotropic hypogonadism

bull A Turner Syndrome

bull B XX and XY gonadal dysgenesis

bull C Polycystic ovary Syndrome

bull D Noonans 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- Kallmanns 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 Klinefelters syndrome Other forms of primary testicular failureAnorchia or

cryptorchism- Females Turners syndromeOther forms of primary ovarian failure Pseudo-Turners

syndrome- Noonans 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 2512 years of age with idiopathic true precocious

13412-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 (-45 SD) and a weight of 286 kg (-3 SD) The patient had early stage 2 breast development There was no pubic hair Karyotype was 46XX Bone age was 10 years After administration of GnRH LH and FSH rose in a pubertal pattern Estradiol was 40 pgmL She has since spontaneously progressed through pubertal development

• TUMBUH KEMBANG REMAJA
• REMAJA
• Remaja awal (11-14 tahun)
• Remaja Tengah (15-17 tahun)
• Remaja Lanjut (Usia 18-21 tahun)
• FISIOLOGI PUBERTAS
• Pubertas
• Tanda Pubertas Perempuan
• Slide 9
• Tanda Pubertas Laki-laki
• Sexual Maturity Rating
• Pubertas Perempuan
• Pubertas Laki-laki
• Pertumbuhan fisik
• Slide 15
• Slide 16
• Lonjakan pertumbuhan
• Perkembangan psikososial
• MASALAH-MASALAH REMAJA
• Morbiditas
• Masalah lain
• Psychological Problems in Adolescence
• Slide 23
• Teen suicide (contrsquod)
• Cluster Suicides
• Warning signs of suicide
• Indikator remaja berisiko tinggi
• Slide 28
• Gejala psikofisiologis
• Terapi gejala psikofisiologi
• KLINIK REMAJA
• Sikap Dokter Dalam Menghadapi Pasien Remaja
• Pemberian pelayanan kesehatan
• Kerahasiaan
• What are The importan Aspects of an Adolescent History
• How to Talk to Teens about Puberty
• Wawancara
• Slide 38
• LAMPIRAN
• 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
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• CASE
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Causes of Short Stature
• Slide 65
• Slide 66
• Causes of Delayed Puberty
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73

Tanda Pubertas Perempuan

bull Tanda progresi lainnya ndash Breast budingndash Pubic hair growthndash Peak high velocityndash Menarche

bull Pertumbuhan biasanya berhenti 2-3 tahun setelah menarche

bull

Tanda Pubertas Laki-laki

bull Tanda pertama pembesaran testis

bull Tanda lainnya ndash Tumbuhnya rambut pubis ndash Pembesaran penisndash Kecepatan puncak pertambahan tinggindash Pertumbuhan biasanya berhenti 2-3 tahun

setelah puncak kecepatan pertambahan tinggi

Sexual Maturity Rating

bull Dipublikasikan Tanner pada tahun 1962

bull Skala Tanner tingkat perkembangan genital secara klinis

bull Laki-laki pertumbuhan rambut genital dan pubis

bull Perempuan perubahan rambut pubis dan payudara

Pubertas Perempuan

bull Terlalu awal jika perkembangan payudara sebelum usia 8 tahun atau menarke kurang dari 10 tahun

bull Terlalu lambat jika payudara tidak berkembang pada usia 13 tahun atau belum menarke pada usia 16 tahun

bull

Pubertas Laki-laki

bull Terlalu awal jika pembesaran testis (gt25 cm) sebelum usia 9 tahun

bull 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

bull Biasanya 2-4 tahun

bull Perempuan 2 tahun lebih awal

bull Kecepatan tinggi puncak ndash W 115-12 tahunndash L 135-14 tahun

bull Pertambahan BB sampai 2 x

bull Pertambahan TB 15-20

Perkembangan psikososial

bull Mencari jati diri apa yang ingin dilakukan dan kekuatan-kelemahan

bull Periode progresif dan perpisahan dari keluarga

bull Fase-fase perkembangan psikososial--gt

3 fase remaja (lihat bagian depan)

MASALAH-MASALAH REMAJA

bull Morbiditas

bull Mortalitas

Morbiditas

bull Kehamilan yang tak diinginkan

bull Penyakit menular seksual

bull Penyalahgunaan zat

bull Merokok

bull Depresi

bull Psikofifiologis

bull Kekerasan fisik

bull Lari dari rumah

Masalah lain

bull Depresibull Bunuh diri remajabull Penyalahgunaan zatbull Gangguan makanbull Obesitas eksogenbull Kegagalan di sekolahbull Gangguan payudarabull Kelainan ginekologis bull PMS dan Penyakit radang pelvis

Psychological Problems in Adolescence

bull Depression 13 of teens have experienced some symptoms of depression

bull Rates are higher among girls than boys

bull Rates are higher among African-American and Native American teens

bull Additionally lack of popularity rejection death of a loved one contributes

Psychological Problems in Adolescence

bull Teen suicide rate has tripled in last 30 years

bull Annual rate now 122 per 100000 3rd most common cause of death for those age 15-24

bull Successful suicide rate is higher in boys (more lethal means) but girls attempt suicide more often

Teen suicide (contrsquod)

bull Risk factors ndash Depression Social inhibition

Perfectionism

ndash Anxiety Family conflicts romantic rejection

ndash History of drugalcohol abuse gaylesbian orientation

Cluster Suicides

bull 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

bull Schools increasing using crisis teams to counsel students after one student is successful in suicide

Warning signs of suicide

bull Direct or indirect talk of suicidebull School difficulties writing a willbull Giving stuff away arranging for pet

carebull Change in appetite general

depressionbull Changes in behavior preoccupation

with death in art music or literature

Indikator remaja berisiko tinggi

1 Penurunan kemampuan belajar

2 Absen sekolah yang berlebihan

3 Keluhan psikosomatik yang seringmenetap

4 Perubahan kebiasaan tidur atau makan

5 Kesulitan konsentrasi atau kebosanan yang menetap

6 Tanda dan gejala stres atau kecemasan

Indikator remaja berisiko tinggi

7 Menarik diri atau berpindah kelompok8 Perilaku menentang atau kekerasan yang

hebat dan atau perubahan kepribadian yang radikal

9 Konflik dengan orang tua10 Perilaku seksual yang berlebihan11 Konflik dengan hukum12 Memperlihatkan pikiran bunuh diri13 Penyalahgunaan obat dan alkohol14 Melarikan diri dari rumah

Gejala psikofisiologis

bull Reaksi konversi perasaan tidak menyenangkan dikomunikasikan dengan gejala fisik ldquoperolehan sekunderrdquo

bull Riwayat dan temuan fisik tidak konsisten dengan konsep anatomi dan fisiologis

bull Cenderung mempunyai OT yang overprotektif dan menjadi semakin tergantung pada OT

Terapi gejala psikofisiologi

bull Jelaskan hubungan antara penyebab fisik dari nyeri emosional atau penyebab emosional dari nyeri fisik

bull Memberi dorongan untuk mengerti bahwa gejala dapat menetap

bull Membantu pasien meneruskan aktivitas harian yang normal

bull Obat-obatan jarang membantubull Dokter suportif dan tidak menduga bahwa

nyeri tidak benar-benar terjadi

KLINIK REMAJA

Sikap Dokter Dalam Menghadapi Pasien Remaja

bull Dokter tampil jujur sederhana tidak perlu tampil ldquoprofesionalrdquo berlebihan

bull Remaja kurang PD dokter hati-hati

bull Sensitif terhadap tingkat perkembangan

Pemberian pelayanan kesehatan

bull 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

bull Beritahu remaja dan orang tuanya tentang kerahasiaan yang akan dijaga

bull Waktu adekuat

bull Yakinkan bahwa dokter tidak akan mencampuri kehidupan pribadi remaja tetapi merupakan hal penting untuk kesehatannya

What are The importan Aspects of an Adolescent History

bull HEADSSS untuk melacak informasi psikososial yang penting dari pasien remaja

bull H Homehealthbull E EducationEmploymentEatingbull A ActivitiesAspirationAffiliationbull D Drugsbull S Sexbull S SleepSuicidebull S Shoplifting

How to Talk to Teens about Puberty

1048708 Be open and honest

1048708 Treat the teen with respect

1048708 Talk directly to the teen

1048708 Begin conversation with least

threatening topics

1048708 Provide confidentiality

Wawancara

Wawancara terpimpinPenilaian tugas-tugas psikoperkembanganPemeriksaan sistemik meliputi 1 Nutrisi2 Tidur3 Perawatan diri pengetahuan ttg

pemeriksaan sendiri 4 Olah raga5 Hubungan keluarga dan sahabat6 Teman sebaya

Wawancara

7 Sekolah8 Minat pendidikan dan pekerjaan 9 Tembakau10 Penyalahgunaan zat11 Seksualitas12 Kesehatan mental

Usahakan pasien mendapat kesan tertarik dan seperti mempunyai ldquodokternyardquo sendiri

LAMPIRAN

PHYSIOLOGY OF PUBERTYPhysical 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 25 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 134 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 25 SD below the mean and is considered to have delayed puberty

- By this definition 06 of the healthy population are classified as having constitutional delay in growth and adolescence

CASE

bull 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

bull 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)

bull 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 15 to 35 year period

bull 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 124 to 128 years of age African-American girls are maturing earlier

bull 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 115 years

bull 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 135 and 17 years of age Growth of the penis reaches a SMR (Tanner) stage V between 125 and 165 years of age Nocturnal emissions (wet dreams) may first appear during SMR stage III

bull 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

bull 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

bull 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

bull 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

bull 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)

bull

bull 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

bull 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

bull 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 50ile of the patients actual height)

bull 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 (Klinefelters syndrome)

Causes of Short Staturebull I Constitutional Short Staturebull II Primordial Dwarfism (intrauterine growth retardation)bull III Endocrine Causesbull A Growth Hormone Deficiencybull 1 Congenitalbull 2 Acquiredbull a HypothalamicPituitary Tumorsbull b Head Traumabull c CNS infectionsbull d Psychosocial Dwarfismbull 3 Laron Dwarfismbull 4 Hypothyroidismbull 5 Syndromes of Short Staturebull a Turner Syndrome (gonadal dysgenesis)bull b Noonans Syndromebull c Prader-Willi Syndromebull

Causes of Short Stature

bull IV Chronic Diseasebull A Heart Diseasebull B Pulmonarybull 1 Cystic Fibrosisbull 2 Asthmabull C GI Disordersbull D Hepatic Diseasebull E Renalbull V Iatrogenicbull A Corticosteroids anabolic steroidsbull B ADHD meds

bull Causes of Delayed Pubertybull I Constitutional Delay in Growth and Maturationbull II Hypogonadotropic hypogonadismbull A Central nervous system disordersbull 1 Tumors bull a Craniopharyngiomasbull b Gliomasbull c Germinomasbull 2 Radiation Therapybull 3 Congenital Malformationsbull

Causes of Delayed Puberty

bull B Isolated Growth Hormone Deficiencybull 1 Kallmanns Syndromebull C Miscellaneous Disordersbull 1 Prader-Willi Syndromebull 2 Hypothyroidismbull 3 Malnutritionbull 4 Anorexia Nervosabull 5 Exercise amenorrheabull 6 Cushingsbull 7 Diabetesbull

Causes of Delayed Puberty

bull III Hypergonadotropic hypogonadism

bull A Turner Syndrome

bull B XX and XY gonadal dysgenesis

bull C Polycystic ovary Syndrome

bull D Noonans 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- Kallmanns 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 Klinefelters syndrome Other forms of primary testicular failureAnorchia or

cryptorchism- Females Turners syndromeOther forms of primary ovarian failure Pseudo-Turners

syndrome- Noonans 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 2512 years of age with idiopathic true precocious

13412-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 (-45 SD) and a weight of 286 kg (-3 SD) The patient had early stage 2 breast development There was no pubic hair Karyotype was 46XX Bone age was 10 years After administration of GnRH LH and FSH rose in a pubertal pattern Estradiol was 40 pgmL She has since spontaneously progressed through pubertal development

• TUMBUH KEMBANG REMAJA
• REMAJA
• Remaja awal (11-14 tahun)
• Remaja Tengah (15-17 tahun)
• Remaja Lanjut (Usia 18-21 tahun)
• FISIOLOGI PUBERTAS
• Pubertas
• Tanda Pubertas Perempuan
• Slide 9
• Tanda Pubertas Laki-laki
• Sexual Maturity Rating
• Pubertas Perempuan
• Pubertas Laki-laki
• Pertumbuhan fisik
• Slide 15
• Slide 16
• Lonjakan pertumbuhan
• Perkembangan psikososial
• MASALAH-MASALAH REMAJA
• Morbiditas
• Masalah lain
• Psychological Problems in Adolescence
• Slide 23
• Teen suicide (contrsquod)
• Cluster Suicides
• Warning signs of suicide
• Indikator remaja berisiko tinggi
• Slide 28
• Gejala psikofisiologis
• Terapi gejala psikofisiologi
• KLINIK REMAJA
• Sikap Dokter Dalam Menghadapi Pasien Remaja
• Pemberian pelayanan kesehatan
• Kerahasiaan
• What are The importan Aspects of an Adolescent History
• How to Talk to Teens about Puberty
• Wawancara
• Slide 38
• LAMPIRAN
• 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
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• CASE
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Causes of Short Stature
• Slide 65
• Slide 66
• Causes of Delayed Puberty
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73

Tanda Pubertas Laki-laki

bull Tanda pertama pembesaran testis

bull Tanda lainnya ndash Tumbuhnya rambut pubis ndash Pembesaran penisndash Kecepatan puncak pertambahan tinggindash Pertumbuhan biasanya berhenti 2-3 tahun

setelah puncak kecepatan pertambahan tinggi

Sexual Maturity Rating

bull Dipublikasikan Tanner pada tahun 1962

bull Skala Tanner tingkat perkembangan genital secara klinis

bull Laki-laki pertumbuhan rambut genital dan pubis

bull Perempuan perubahan rambut pubis dan payudara

Pubertas Perempuan

bull Terlalu awal jika perkembangan payudara sebelum usia 8 tahun atau menarke kurang dari 10 tahun

bull Terlalu lambat jika payudara tidak berkembang pada usia 13 tahun atau belum menarke pada usia 16 tahun

bull

Pubertas Laki-laki

bull Terlalu awal jika pembesaran testis (gt25 cm) sebelum usia 9 tahun

bull 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

bull Biasanya 2-4 tahun

bull Perempuan 2 tahun lebih awal

bull Kecepatan tinggi puncak ndash W 115-12 tahunndash L 135-14 tahun

bull Pertambahan BB sampai 2 x

bull Pertambahan TB 15-20

Perkembangan psikososial

bull Mencari jati diri apa yang ingin dilakukan dan kekuatan-kelemahan

bull Periode progresif dan perpisahan dari keluarga

bull Fase-fase perkembangan psikososial--gt

3 fase remaja (lihat bagian depan)

MASALAH-MASALAH REMAJA

bull Morbiditas

bull Mortalitas

Morbiditas

bull Kehamilan yang tak diinginkan

bull Penyakit menular seksual

bull Penyalahgunaan zat

bull Merokok

bull Depresi

bull Psikofifiologis

bull Kekerasan fisik

bull Lari dari rumah

Masalah lain

bull Depresibull Bunuh diri remajabull Penyalahgunaan zatbull Gangguan makanbull Obesitas eksogenbull Kegagalan di sekolahbull Gangguan payudarabull Kelainan ginekologis bull PMS dan Penyakit radang pelvis

Psychological Problems in Adolescence

bull Depression 13 of teens have experienced some symptoms of depression

bull Rates are higher among girls than boys

bull Rates are higher among African-American and Native American teens

bull Additionally lack of popularity rejection death of a loved one contributes

Psychological Problems in Adolescence

bull Teen suicide rate has tripled in last 30 years

bull Annual rate now 122 per 100000 3rd most common cause of death for those age 15-24

bull Successful suicide rate is higher in boys (more lethal means) but girls attempt suicide more often

Teen suicide (contrsquod)

bull Risk factors ndash Depression Social inhibition

Perfectionism

ndash Anxiety Family conflicts romantic rejection

ndash History of drugalcohol abuse gaylesbian orientation

Cluster Suicides

bull 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

bull Schools increasing using crisis teams to counsel students after one student is successful in suicide

Warning signs of suicide

bull Direct or indirect talk of suicidebull School difficulties writing a willbull Giving stuff away arranging for pet

carebull Change in appetite general

depressionbull Changes in behavior preoccupation

with death in art music or literature

Indikator remaja berisiko tinggi

1 Penurunan kemampuan belajar

2 Absen sekolah yang berlebihan

3 Keluhan psikosomatik yang seringmenetap

4 Perubahan kebiasaan tidur atau makan

5 Kesulitan konsentrasi atau kebosanan yang menetap

6 Tanda dan gejala stres atau kecemasan

Indikator remaja berisiko tinggi

7 Menarik diri atau berpindah kelompok8 Perilaku menentang atau kekerasan yang

hebat dan atau perubahan kepribadian yang radikal

9 Konflik dengan orang tua10 Perilaku seksual yang berlebihan11 Konflik dengan hukum12 Memperlihatkan pikiran bunuh diri13 Penyalahgunaan obat dan alkohol14 Melarikan diri dari rumah

Gejala psikofisiologis

bull Reaksi konversi perasaan tidak menyenangkan dikomunikasikan dengan gejala fisik ldquoperolehan sekunderrdquo

bull Riwayat dan temuan fisik tidak konsisten dengan konsep anatomi dan fisiologis

bull Cenderung mempunyai OT yang overprotektif dan menjadi semakin tergantung pada OT

Terapi gejala psikofisiologi

bull Jelaskan hubungan antara penyebab fisik dari nyeri emosional atau penyebab emosional dari nyeri fisik

bull Memberi dorongan untuk mengerti bahwa gejala dapat menetap

bull Membantu pasien meneruskan aktivitas harian yang normal

bull Obat-obatan jarang membantubull Dokter suportif dan tidak menduga bahwa

nyeri tidak benar-benar terjadi

KLINIK REMAJA

Sikap Dokter Dalam Menghadapi Pasien Remaja

bull Dokter tampil jujur sederhana tidak perlu tampil ldquoprofesionalrdquo berlebihan

bull Remaja kurang PD dokter hati-hati

bull Sensitif terhadap tingkat perkembangan

Pemberian pelayanan kesehatan

bull 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

bull Beritahu remaja dan orang tuanya tentang kerahasiaan yang akan dijaga

bull Waktu adekuat

bull Yakinkan bahwa dokter tidak akan mencampuri kehidupan pribadi remaja tetapi merupakan hal penting untuk kesehatannya

What are The importan Aspects of an Adolescent History

bull HEADSSS untuk melacak informasi psikososial yang penting dari pasien remaja

bull H Homehealthbull E EducationEmploymentEatingbull A ActivitiesAspirationAffiliationbull D Drugsbull S Sexbull S SleepSuicidebull S Shoplifting

How to Talk to Teens about Puberty

1048708 Be open and honest

1048708 Treat the teen with respect

1048708 Talk directly to the teen

1048708 Begin conversation with least

threatening topics

1048708 Provide confidentiality

Wawancara

Wawancara terpimpinPenilaian tugas-tugas psikoperkembanganPemeriksaan sistemik meliputi 1 Nutrisi2 Tidur3 Perawatan diri pengetahuan ttg

pemeriksaan sendiri 4 Olah raga5 Hubungan keluarga dan sahabat6 Teman sebaya

Wawancara

7 Sekolah8 Minat pendidikan dan pekerjaan 9 Tembakau10 Penyalahgunaan zat11 Seksualitas12 Kesehatan mental

Usahakan pasien mendapat kesan tertarik dan seperti mempunyai ldquodokternyardquo sendiri

LAMPIRAN

PHYSIOLOGY OF PUBERTYPhysical 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 25 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 134 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 25 SD below the mean and is considered to have delayed puberty

- By this definition 06 of the healthy population are classified as having constitutional delay in growth and adolescence

CASE

bull 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

bull 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)

bull 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 15 to 35 year period

bull 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 124 to 128 years of age African-American girls are maturing earlier

bull 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 115 years

bull 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 135 and 17 years of age Growth of the penis reaches a SMR (Tanner) stage V between 125 and 165 years of age Nocturnal emissions (wet dreams) may first appear during SMR stage III

bull 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

bull 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

bull 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

bull 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

bull 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)

bull

bull 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

bull 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

bull 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 50ile of the patients actual height)

bull 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 (Klinefelters syndrome)

Causes of Short Staturebull I Constitutional Short Staturebull II Primordial Dwarfism (intrauterine growth retardation)bull III Endocrine Causesbull A Growth Hormone Deficiencybull 1 Congenitalbull 2 Acquiredbull a HypothalamicPituitary Tumorsbull b Head Traumabull c CNS infectionsbull d Psychosocial Dwarfismbull 3 Laron Dwarfismbull 4 Hypothyroidismbull 5 Syndromes of Short Staturebull a Turner Syndrome (gonadal dysgenesis)bull b Noonans Syndromebull c Prader-Willi Syndromebull

Causes of Short Stature

bull IV Chronic Diseasebull A Heart Diseasebull B Pulmonarybull 1 Cystic Fibrosisbull 2 Asthmabull C GI Disordersbull D Hepatic Diseasebull E Renalbull V Iatrogenicbull A Corticosteroids anabolic steroidsbull B ADHD meds

bull Causes of Delayed Pubertybull I Constitutional Delay in Growth and Maturationbull II Hypogonadotropic hypogonadismbull A Central nervous system disordersbull 1 Tumors bull a Craniopharyngiomasbull b Gliomasbull c Germinomasbull 2 Radiation Therapybull 3 Congenital Malformationsbull

Causes of Delayed Puberty

bull B Isolated Growth Hormone Deficiencybull 1 Kallmanns Syndromebull C Miscellaneous Disordersbull 1 Prader-Willi Syndromebull 2 Hypothyroidismbull 3 Malnutritionbull 4 Anorexia Nervosabull 5 Exercise amenorrheabull 6 Cushingsbull 7 Diabetesbull

Causes of Delayed Puberty

bull III Hypergonadotropic hypogonadism

bull A Turner Syndrome

bull B XX and XY gonadal dysgenesis

bull C Polycystic ovary Syndrome

bull D Noonans 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- Kallmanns 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 Klinefelters syndrome Other forms of primary testicular failureAnorchia or

cryptorchism- Females Turners syndromeOther forms of primary ovarian failure Pseudo-Turners

syndrome- Noonans 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 2512 years of age with idiopathic true precocious

13412-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 (-45 SD) and a weight of 286 kg (-3 SD) The patient had early stage 2 breast development There was no pubic hair Karyotype was 46XX Bone age was 10 years After administration of GnRH LH and FSH rose in a pubertal pattern Estradiol was 40 pgmL She has since spontaneously progressed through pubertal development

• TUMBUH KEMBANG REMAJA
• REMAJA
• Remaja awal (11-14 tahun)
• Remaja Tengah (15-17 tahun)
• Remaja Lanjut (Usia 18-21 tahun)
• FISIOLOGI PUBERTAS
• Pubertas
• Tanda Pubertas Perempuan
• Slide 9
• Tanda Pubertas Laki-laki
• Sexual Maturity Rating
• Pubertas Perempuan
• Pubertas Laki-laki
• Pertumbuhan fisik
• Slide 15
• Slide 16
• Lonjakan pertumbuhan
• Perkembangan psikososial
• MASALAH-MASALAH REMAJA
• Morbiditas
• Masalah lain
• Psychological Problems in Adolescence
• Slide 23
• Teen suicide (contrsquod)
• Cluster Suicides
• Warning signs of suicide
• Indikator remaja berisiko tinggi
• Slide 28
• Gejala psikofisiologis
• Terapi gejala psikofisiologi
• KLINIK REMAJA
• Sikap Dokter Dalam Menghadapi Pasien Remaja
• Pemberian pelayanan kesehatan
• Kerahasiaan
• What are The importan Aspects of an Adolescent History
• How to Talk to Teens about Puberty
• Wawancara
• Slide 38
• LAMPIRAN
• 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
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• CASE
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Causes of Short Stature
• Slide 65
• Slide 66
• Causes of Delayed Puberty
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73

Sexual Maturity Rating

bull Dipublikasikan Tanner pada tahun 1962

bull Skala Tanner tingkat perkembangan genital secara klinis

bull Laki-laki pertumbuhan rambut genital dan pubis

bull Perempuan perubahan rambut pubis dan payudara

Pubertas Perempuan

bull Terlalu awal jika perkembangan payudara sebelum usia 8 tahun atau menarke kurang dari 10 tahun

bull Terlalu lambat jika payudara tidak berkembang pada usia 13 tahun atau belum menarke pada usia 16 tahun

bull

Pubertas Laki-laki

bull Terlalu awal jika pembesaran testis (gt25 cm) sebelum usia 9 tahun

bull 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

bull Biasanya 2-4 tahun

bull Perempuan 2 tahun lebih awal

bull Kecepatan tinggi puncak ndash W 115-12 tahunndash L 135-14 tahun

bull Pertambahan BB sampai 2 x

bull Pertambahan TB 15-20

Perkembangan psikososial

bull Mencari jati diri apa yang ingin dilakukan dan kekuatan-kelemahan

bull Periode progresif dan perpisahan dari keluarga

bull Fase-fase perkembangan psikososial--gt

3 fase remaja (lihat bagian depan)

MASALAH-MASALAH REMAJA

bull Morbiditas

bull Mortalitas

Morbiditas

bull Kehamilan yang tak diinginkan

bull Penyakit menular seksual

bull Penyalahgunaan zat

bull Merokok

bull Depresi

bull Psikofifiologis

bull Kekerasan fisik

bull Lari dari rumah

Masalah lain

bull Depresibull Bunuh diri remajabull Penyalahgunaan zatbull Gangguan makanbull Obesitas eksogenbull Kegagalan di sekolahbull Gangguan payudarabull Kelainan ginekologis bull PMS dan Penyakit radang pelvis

Psychological Problems in Adolescence

bull Depression 13 of teens have experienced some symptoms of depression

bull Rates are higher among girls than boys

bull Rates are higher among African-American and Native American teens

bull Additionally lack of popularity rejection death of a loved one contributes

Psychological Problems in Adolescence

bull Teen suicide rate has tripled in last 30 years

bull Annual rate now 122 per 100000 3rd most common cause of death for those age 15-24

bull Successful suicide rate is higher in boys (more lethal means) but girls attempt suicide more often

Teen suicide (contrsquod)

bull Risk factors ndash Depression Social inhibition

Perfectionism

ndash Anxiety Family conflicts romantic rejection

ndash History of drugalcohol abuse gaylesbian orientation

Cluster Suicides

bull 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

bull Schools increasing using crisis teams to counsel students after one student is successful in suicide

Warning signs of suicide

bull Direct or indirect talk of suicidebull School difficulties writing a willbull Giving stuff away arranging for pet

carebull Change in appetite general

depressionbull Changes in behavior preoccupation

with death in art music or literature

Indikator remaja berisiko tinggi

1 Penurunan kemampuan belajar

2 Absen sekolah yang berlebihan

3 Keluhan psikosomatik yang seringmenetap

4 Perubahan kebiasaan tidur atau makan

5 Kesulitan konsentrasi atau kebosanan yang menetap

6 Tanda dan gejala stres atau kecemasan

Indikator remaja berisiko tinggi

7 Menarik diri atau berpindah kelompok8 Perilaku menentang atau kekerasan yang

hebat dan atau perubahan kepribadian yang radikal

9 Konflik dengan orang tua10 Perilaku seksual yang berlebihan11 Konflik dengan hukum12 Memperlihatkan pikiran bunuh diri13 Penyalahgunaan obat dan alkohol14 Melarikan diri dari rumah

Gejala psikofisiologis

bull Reaksi konversi perasaan tidak menyenangkan dikomunikasikan dengan gejala fisik ldquoperolehan sekunderrdquo

bull Riwayat dan temuan fisik tidak konsisten dengan konsep anatomi dan fisiologis

bull Cenderung mempunyai OT yang overprotektif dan menjadi semakin tergantung pada OT

Terapi gejala psikofisiologi

bull Jelaskan hubungan antara penyebab fisik dari nyeri emosional atau penyebab emosional dari nyeri fisik

bull Memberi dorongan untuk mengerti bahwa gejala dapat menetap

bull Membantu pasien meneruskan aktivitas harian yang normal

bull Obat-obatan jarang membantubull Dokter suportif dan tidak menduga bahwa

nyeri tidak benar-benar terjadi

KLINIK REMAJA

Sikap Dokter Dalam Menghadapi Pasien Remaja

bull Dokter tampil jujur sederhana tidak perlu tampil ldquoprofesionalrdquo berlebihan

bull Remaja kurang PD dokter hati-hati

bull Sensitif terhadap tingkat perkembangan

Pemberian pelayanan kesehatan

bull 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

bull Beritahu remaja dan orang tuanya tentang kerahasiaan yang akan dijaga

bull Waktu adekuat

bull Yakinkan bahwa dokter tidak akan mencampuri kehidupan pribadi remaja tetapi merupakan hal penting untuk kesehatannya

What are The importan Aspects of an Adolescent History

bull HEADSSS untuk melacak informasi psikososial yang penting dari pasien remaja

bull H Homehealthbull E EducationEmploymentEatingbull A ActivitiesAspirationAffiliationbull D Drugsbull S Sexbull S SleepSuicidebull S Shoplifting

How to Talk to Teens about Puberty

1048708 Be open and honest

1048708 Treat the teen with respect

1048708 Talk directly to the teen

1048708 Begin conversation with least

threatening topics

1048708 Provide confidentiality

Wawancara

Wawancara terpimpinPenilaian tugas-tugas psikoperkembanganPemeriksaan sistemik meliputi 1 Nutrisi2 Tidur3 Perawatan diri pengetahuan ttg

pemeriksaan sendiri 4 Olah raga5 Hubungan keluarga dan sahabat6 Teman sebaya

Wawancara

7 Sekolah8 Minat pendidikan dan pekerjaan 9 Tembakau10 Penyalahgunaan zat11 Seksualitas12 Kesehatan mental

Usahakan pasien mendapat kesan tertarik dan seperti mempunyai ldquodokternyardquo sendiri

LAMPIRAN

PHYSIOLOGY OF PUBERTYPhysical 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 25 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 134 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 25 SD below the mean and is considered to have delayed puberty

- By this definition 06 of the healthy population are classified as having constitutional delay in growth and adolescence

CASE

bull 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

bull 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)

bull 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 15 to 35 year period

bull 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 124 to 128 years of age African-American girls are maturing earlier

bull 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 115 years

bull 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 135 and 17 years of age Growth of the penis reaches a SMR (Tanner) stage V between 125 and 165 years of age Nocturnal emissions (wet dreams) may first appear during SMR stage III

bull 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

bull 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

bull 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

bull 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

bull 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)

bull

bull 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

bull 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

bull 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 50ile of the patients actual height)

bull 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 (Klinefelters syndrome)

Causes of Short Staturebull I Constitutional Short Staturebull II Primordial Dwarfism (intrauterine growth retardation)bull III Endocrine Causesbull A Growth Hormone Deficiencybull 1 Congenitalbull 2 Acquiredbull a HypothalamicPituitary Tumorsbull b Head Traumabull c CNS infectionsbull d Psychosocial Dwarfismbull 3 Laron Dwarfismbull 4 Hypothyroidismbull 5 Syndromes of Short Staturebull a Turner Syndrome (gonadal dysgenesis)bull b Noonans Syndromebull c Prader-Willi Syndromebull

Causes of Short Stature

bull IV Chronic Diseasebull A Heart Diseasebull B Pulmonarybull 1 Cystic Fibrosisbull 2 Asthmabull C GI Disordersbull D Hepatic Diseasebull E Renalbull V Iatrogenicbull A Corticosteroids anabolic steroidsbull B ADHD meds

bull Causes of Delayed Pubertybull I Constitutional Delay in Growth and Maturationbull II Hypogonadotropic hypogonadismbull A Central nervous system disordersbull 1 Tumors bull a Craniopharyngiomasbull b Gliomasbull c Germinomasbull 2 Radiation Therapybull 3 Congenital Malformationsbull

Causes of Delayed Puberty

bull B Isolated Growth Hormone Deficiencybull 1 Kallmanns Syndromebull C Miscellaneous Disordersbull 1 Prader-Willi Syndromebull 2 Hypothyroidismbull 3 Malnutritionbull 4 Anorexia Nervosabull 5 Exercise amenorrheabull 6 Cushingsbull 7 Diabetesbull

Causes of Delayed Puberty

bull III Hypergonadotropic hypogonadism

bull A Turner Syndrome

bull B XX and XY gonadal dysgenesis

bull C Polycystic ovary Syndrome

bull D Noonans 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- Kallmanns 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 Klinefelters syndrome Other forms of primary testicular failureAnorchia or

cryptorchism- Females Turners syndromeOther forms of primary ovarian failure Pseudo-Turners

syndrome- Noonans 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 2512 years of age with idiopathic true precocious

13412-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 (-45 SD) and a weight of 286 kg (-3 SD) The patient had early stage 2 breast development There was no pubic hair Karyotype was 46XX Bone age was 10 years After administration of GnRH LH and FSH rose in a pubertal pattern Estradiol was 40 pgmL She has since spontaneously progressed through pubertal development

• TUMBUH KEMBANG REMAJA
• REMAJA
• Remaja awal (11-14 tahun)
• Remaja Tengah (15-17 tahun)
• Remaja Lanjut (Usia 18-21 tahun)
• FISIOLOGI PUBERTAS
• Pubertas
• Tanda Pubertas Perempuan
• Slide 9
• Tanda Pubertas Laki-laki
• Sexual Maturity Rating
• Pubertas Perempuan
• Pubertas Laki-laki
• Pertumbuhan fisik
• Slide 15
• Slide 16
• Lonjakan pertumbuhan
• Perkembangan psikososial
• MASALAH-MASALAH REMAJA
• Morbiditas
• Masalah lain
• Psychological Problems in Adolescence
• Slide 23
• Teen suicide (contrsquod)
• Cluster Suicides
• Warning signs of suicide
• Indikator remaja berisiko tinggi
• Slide 28
• Gejala psikofisiologis
• Terapi gejala psikofisiologi
• KLINIK REMAJA
• Sikap Dokter Dalam Menghadapi Pasien Remaja
• Pemberian pelayanan kesehatan
• Kerahasiaan
• What are The importan Aspects of an Adolescent History
• How to Talk to Teens about Puberty
• Wawancara
• Slide 38
• LAMPIRAN
• 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
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• CASE
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Causes of Short Stature
• Slide 65
• Slide 66
• Causes of Delayed Puberty
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73

Pubertas Perempuan

bull Terlalu awal jika perkembangan payudara sebelum usia 8 tahun atau menarke kurang dari 10 tahun

bull Terlalu lambat jika payudara tidak berkembang pada usia 13 tahun atau belum menarke pada usia 16 tahun

bull

Pubertas Laki-laki

bull Terlalu awal jika pembesaran testis (gt25 cm) sebelum usia 9 tahun

bull 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

bull Biasanya 2-4 tahun

bull Perempuan 2 tahun lebih awal

bull Kecepatan tinggi puncak ndash W 115-12 tahunndash L 135-14 tahun

bull Pertambahan BB sampai 2 x

bull Pertambahan TB 15-20

Perkembangan psikososial

bull Mencari jati diri apa yang ingin dilakukan dan kekuatan-kelemahan

bull Periode progresif dan perpisahan dari keluarga

bull Fase-fase perkembangan psikososial--gt

3 fase remaja (lihat bagian depan)

MASALAH-MASALAH REMAJA

bull Morbiditas

bull Mortalitas

Morbiditas

bull Kehamilan yang tak diinginkan

bull Penyakit menular seksual

bull Penyalahgunaan zat

bull Merokok

bull Depresi

bull Psikofifiologis

bull Kekerasan fisik

bull Lari dari rumah

Masalah lain

bull Depresibull Bunuh diri remajabull Penyalahgunaan zatbull Gangguan makanbull Obesitas eksogenbull Kegagalan di sekolahbull Gangguan payudarabull Kelainan ginekologis bull PMS dan Penyakit radang pelvis

Psychological Problems in Adolescence

bull Depression 13 of teens have experienced some symptoms of depression

bull Rates are higher among girls than boys

bull Rates are higher among African-American and Native American teens

bull Additionally lack of popularity rejection death of a loved one contributes

Psychological Problems in Adolescence

bull Teen suicide rate has tripled in last 30 years

bull Annual rate now 122 per 100000 3rd most common cause of death for those age 15-24

bull Successful suicide rate is higher in boys (more lethal means) but girls attempt suicide more often

Teen suicide (contrsquod)

bull Risk factors ndash Depression Social inhibition

Perfectionism

ndash Anxiety Family conflicts romantic rejection

ndash History of drugalcohol abuse gaylesbian orientation

Cluster Suicides

bull 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

bull Schools increasing using crisis teams to counsel students after one student is successful in suicide

Warning signs of suicide

bull Direct or indirect talk of suicidebull School difficulties writing a willbull Giving stuff away arranging for pet

carebull Change in appetite general

depressionbull Changes in behavior preoccupation

with death in art music or literature

Indikator remaja berisiko tinggi

1 Penurunan kemampuan belajar

2 Absen sekolah yang berlebihan

3 Keluhan psikosomatik yang seringmenetap

4 Perubahan kebiasaan tidur atau makan

5 Kesulitan konsentrasi atau kebosanan yang menetap

6 Tanda dan gejala stres atau kecemasan

Indikator remaja berisiko tinggi

7 Menarik diri atau berpindah kelompok8 Perilaku menentang atau kekerasan yang

hebat dan atau perubahan kepribadian yang radikal

9 Konflik dengan orang tua10 Perilaku seksual yang berlebihan11 Konflik dengan hukum12 Memperlihatkan pikiran bunuh diri13 Penyalahgunaan obat dan alkohol14 Melarikan diri dari rumah

Gejala psikofisiologis

bull Reaksi konversi perasaan tidak menyenangkan dikomunikasikan dengan gejala fisik ldquoperolehan sekunderrdquo

bull Riwayat dan temuan fisik tidak konsisten dengan konsep anatomi dan fisiologis

bull Cenderung mempunyai OT yang overprotektif dan menjadi semakin tergantung pada OT

Terapi gejala psikofisiologi

bull Jelaskan hubungan antara penyebab fisik dari nyeri emosional atau penyebab emosional dari nyeri fisik

bull Memberi dorongan untuk mengerti bahwa gejala dapat menetap

bull Membantu pasien meneruskan aktivitas harian yang normal

bull Obat-obatan jarang membantubull Dokter suportif dan tidak menduga bahwa

nyeri tidak benar-benar terjadi

KLINIK REMAJA

Sikap Dokter Dalam Menghadapi Pasien Remaja

bull Dokter tampil jujur sederhana tidak perlu tampil ldquoprofesionalrdquo berlebihan

bull Remaja kurang PD dokter hati-hati

bull Sensitif terhadap tingkat perkembangan

Pemberian pelayanan kesehatan

bull 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

bull Beritahu remaja dan orang tuanya tentang kerahasiaan yang akan dijaga

bull Waktu adekuat

bull Yakinkan bahwa dokter tidak akan mencampuri kehidupan pribadi remaja tetapi merupakan hal penting untuk kesehatannya

What are The importan Aspects of an Adolescent History

bull HEADSSS untuk melacak informasi psikososial yang penting dari pasien remaja

bull H Homehealthbull E EducationEmploymentEatingbull A ActivitiesAspirationAffiliationbull D Drugsbull S Sexbull S SleepSuicidebull S Shoplifting

How to Talk to Teens about Puberty

1048708 Be open and honest

1048708 Treat the teen with respect

1048708 Talk directly to the teen

1048708 Begin conversation with least

threatening topics

1048708 Provide confidentiality

Wawancara

Wawancara terpimpinPenilaian tugas-tugas psikoperkembanganPemeriksaan sistemik meliputi 1 Nutrisi2 Tidur3 Perawatan diri pengetahuan ttg

pemeriksaan sendiri 4 Olah raga5 Hubungan keluarga dan sahabat6 Teman sebaya

Wawancara

7 Sekolah8 Minat pendidikan dan pekerjaan 9 Tembakau10 Penyalahgunaan zat11 Seksualitas12 Kesehatan mental

Usahakan pasien mendapat kesan tertarik dan seperti mempunyai ldquodokternyardquo sendiri

LAMPIRAN

PHYSIOLOGY OF PUBERTYPhysical 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 25 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 134 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 25 SD below the mean and is considered to have delayed puberty

- By this definition 06 of the healthy population are classified as having constitutional delay in growth and adolescence

CASE

bull 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

bull 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)

bull 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 15 to 35 year period

bull 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 124 to 128 years of age African-American girls are maturing earlier

bull 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 115 years

bull 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 135 and 17 years of age Growth of the penis reaches a SMR (Tanner) stage V between 125 and 165 years of age Nocturnal emissions (wet dreams) may first appear during SMR stage III

bull 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

bull 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

bull 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

bull 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

bull 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)

bull

bull 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

bull 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

bull 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 50ile of the patients actual height)

bull 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 (Klinefelters syndrome)

Causes of Short Staturebull I Constitutional Short Staturebull II Primordial Dwarfism (intrauterine growth retardation)bull III Endocrine Causesbull A Growth Hormone Deficiencybull 1 Congenitalbull 2 Acquiredbull a HypothalamicPituitary Tumorsbull b Head Traumabull c CNS infectionsbull d Psychosocial Dwarfismbull 3 Laron Dwarfismbull 4 Hypothyroidismbull 5 Syndromes of Short Staturebull a Turner Syndrome (gonadal dysgenesis)bull b Noonans Syndromebull c Prader-Willi Syndromebull

Causes of Short Stature

bull IV Chronic Diseasebull A Heart Diseasebull B Pulmonarybull 1 Cystic Fibrosisbull 2 Asthmabull C GI Disordersbull D Hepatic Diseasebull E Renalbull V Iatrogenicbull A Corticosteroids anabolic steroidsbull B ADHD meds

bull Causes of Delayed Pubertybull I Constitutional Delay in Growth and Maturationbull II Hypogonadotropic hypogonadismbull A Central nervous system disordersbull 1 Tumors bull a Craniopharyngiomasbull b Gliomasbull c Germinomasbull 2 Radiation Therapybull 3 Congenital Malformationsbull

Causes of Delayed Puberty

bull B Isolated Growth Hormone Deficiencybull 1 Kallmanns Syndromebull C Miscellaneous Disordersbull 1 Prader-Willi Syndromebull 2 Hypothyroidismbull 3 Malnutritionbull 4 Anorexia Nervosabull 5 Exercise amenorrheabull 6 Cushingsbull 7 Diabetesbull

Causes of Delayed Puberty

bull III Hypergonadotropic hypogonadism

bull A Turner Syndrome

bull B XX and XY gonadal dysgenesis

bull C Polycystic ovary Syndrome

bull D Noonans 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- Kallmanns 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 Klinefelters syndrome Other forms of primary testicular failureAnorchia or

cryptorchism- Females Turners syndromeOther forms of primary ovarian failure Pseudo-Turners

syndrome- Noonans 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 2512 years of age with idiopathic true precocious

13412-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 (-45 SD) and a weight of 286 kg (-3 SD) The patient had early stage 2 breast development There was no pubic hair Karyotype was 46XX Bone age was 10 years After administration of GnRH LH and FSH rose in a pubertal pattern Estradiol was 40 pgmL She has since spontaneously progressed through pubertal development

• TUMBUH KEMBANG REMAJA
• REMAJA
• Remaja awal (11-14 tahun)
• Remaja Tengah (15-17 tahun)
• Remaja Lanjut (Usia 18-21 tahun)
• FISIOLOGI PUBERTAS
• Pubertas
• Tanda Pubertas Perempuan
• Slide 9
• Tanda Pubertas Laki-laki
• Sexual Maturity Rating
• Pubertas Perempuan
• Pubertas Laki-laki
• Pertumbuhan fisik
• Slide 15
• Slide 16
• Lonjakan pertumbuhan
• Perkembangan psikososial
• MASALAH-MASALAH REMAJA
• Morbiditas
• Masalah lain
• Psychological Problems in Adolescence
• Slide 23
• Teen suicide (contrsquod)
• Cluster Suicides
• Warning signs of suicide
• Indikator remaja berisiko tinggi
• Slide 28
• Gejala psikofisiologis
• Terapi gejala psikofisiologi
• KLINIK REMAJA
• Sikap Dokter Dalam Menghadapi Pasien Remaja
• Pemberian pelayanan kesehatan
• Kerahasiaan
• What are The importan Aspects of an Adolescent History
• How to Talk to Teens about Puberty
• Wawancara
• Slide 38
• LAMPIRAN
• 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
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• CASE
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Causes of Short Stature
• Slide 65
• Slide 66
• Causes of Delayed Puberty
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73

Pubertas Laki-laki

bull Terlalu awal jika pembesaran testis (gt25 cm) sebelum usia 9 tahun

bull 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

bull Biasanya 2-4 tahun

bull Perempuan 2 tahun lebih awal

bull Kecepatan tinggi puncak ndash W 115-12 tahunndash L 135-14 tahun

bull Pertambahan BB sampai 2 x

bull Pertambahan TB 15-20

Perkembangan psikososial

bull Mencari jati diri apa yang ingin dilakukan dan kekuatan-kelemahan

bull Periode progresif dan perpisahan dari keluarga

bull Fase-fase perkembangan psikososial--gt

3 fase remaja (lihat bagian depan)

MASALAH-MASALAH REMAJA

bull Morbiditas

bull Mortalitas

Morbiditas

bull Kehamilan yang tak diinginkan

bull Penyakit menular seksual

bull Penyalahgunaan zat

bull Merokok

bull Depresi

bull Psikofifiologis

bull Kekerasan fisik

bull Lari dari rumah

Masalah lain

bull Depresibull Bunuh diri remajabull Penyalahgunaan zatbull Gangguan makanbull Obesitas eksogenbull Kegagalan di sekolahbull Gangguan payudarabull Kelainan ginekologis bull PMS dan Penyakit radang pelvis

Psychological Problems in Adolescence

bull Depression 13 of teens have experienced some symptoms of depression

bull Rates are higher among girls than boys

bull Rates are higher among African-American and Native American teens

bull Additionally lack of popularity rejection death of a loved one contributes

Psychological Problems in Adolescence

bull Teen suicide rate has tripled in last 30 years

bull Annual rate now 122 per 100000 3rd most common cause of death for those age 15-24

bull Successful suicide rate is higher in boys (more lethal means) but girls attempt suicide more often

Teen suicide (contrsquod)

bull Risk factors ndash Depression Social inhibition

Perfectionism

ndash Anxiety Family conflicts romantic rejection

ndash History of drugalcohol abuse gaylesbian orientation

Cluster Suicides

bull 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

bull Schools increasing using crisis teams to counsel students after one student is successful in suicide

Warning signs of suicide

bull Direct or indirect talk of suicidebull School difficulties writing a willbull Giving stuff away arranging for pet

carebull Change in appetite general

depressionbull Changes in behavior preoccupation

with death in art music or literature

Indikator remaja berisiko tinggi

1 Penurunan kemampuan belajar

2 Absen sekolah yang berlebihan

3 Keluhan psikosomatik yang seringmenetap

4 Perubahan kebiasaan tidur atau makan

5 Kesulitan konsentrasi atau kebosanan yang menetap

6 Tanda dan gejala stres atau kecemasan

Indikator remaja berisiko tinggi

7 Menarik diri atau berpindah kelompok8 Perilaku menentang atau kekerasan yang

hebat dan atau perubahan kepribadian yang radikal

9 Konflik dengan orang tua10 Perilaku seksual yang berlebihan11 Konflik dengan hukum12 Memperlihatkan pikiran bunuh diri13 Penyalahgunaan obat dan alkohol14 Melarikan diri dari rumah

Gejala psikofisiologis

bull Reaksi konversi perasaan tidak menyenangkan dikomunikasikan dengan gejala fisik ldquoperolehan sekunderrdquo

bull Riwayat dan temuan fisik tidak konsisten dengan konsep anatomi dan fisiologis

bull Cenderung mempunyai OT yang overprotektif dan menjadi semakin tergantung pada OT

Terapi gejala psikofisiologi

bull Jelaskan hubungan antara penyebab fisik dari nyeri emosional atau penyebab emosional dari nyeri fisik

bull Memberi dorongan untuk mengerti bahwa gejala dapat menetap

bull Membantu pasien meneruskan aktivitas harian yang normal

bull Obat-obatan jarang membantubull Dokter suportif dan tidak menduga bahwa

nyeri tidak benar-benar terjadi

KLINIK REMAJA

Sikap Dokter Dalam Menghadapi Pasien Remaja

bull Dokter tampil jujur sederhana tidak perlu tampil ldquoprofesionalrdquo berlebihan

bull Remaja kurang PD dokter hati-hati

bull Sensitif terhadap tingkat perkembangan

Pemberian pelayanan kesehatan

bull 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

bull Beritahu remaja dan orang tuanya tentang kerahasiaan yang akan dijaga

bull Waktu adekuat

bull Yakinkan bahwa dokter tidak akan mencampuri kehidupan pribadi remaja tetapi merupakan hal penting untuk kesehatannya

What are The importan Aspects of an Adolescent History

bull HEADSSS untuk melacak informasi psikososial yang penting dari pasien remaja

bull H Homehealthbull E EducationEmploymentEatingbull A ActivitiesAspirationAffiliationbull D Drugsbull S Sexbull S SleepSuicidebull S Shoplifting

How to Talk to Teens about Puberty

1048708 Be open and honest

1048708 Treat the teen with respect

1048708 Talk directly to the teen

1048708 Begin conversation with least

threatening topics

1048708 Provide confidentiality

Wawancara

Wawancara terpimpinPenilaian tugas-tugas psikoperkembanganPemeriksaan sistemik meliputi 1 Nutrisi2 Tidur3 Perawatan diri pengetahuan ttg

pemeriksaan sendiri 4 Olah raga5 Hubungan keluarga dan sahabat6 Teman sebaya

Wawancara

7 Sekolah8 Minat pendidikan dan pekerjaan 9 Tembakau10 Penyalahgunaan zat11 Seksualitas12 Kesehatan mental

Usahakan pasien mendapat kesan tertarik dan seperti mempunyai ldquodokternyardquo sendiri

LAMPIRAN

PHYSIOLOGY OF PUBERTYPhysical 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 25 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 134 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 25 SD below the mean and is considered to have delayed puberty

- By this definition 06 of the healthy population are classified as having constitutional delay in growth and adolescence

CASE

bull 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

bull 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)

bull 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 15 to 35 year period

bull 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 124 to 128 years of age African-American girls are maturing earlier

bull 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 115 years

bull 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 135 and 17 years of age Growth of the penis reaches a SMR (Tanner) stage V between 125 and 165 years of age Nocturnal emissions (wet dreams) may first appear during SMR stage III

bull 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

bull 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

bull 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

bull 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

bull 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)

bull

bull 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

bull 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

bull 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 50ile of the patients actual height)

bull 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 (Klinefelters syndrome)

Causes of Short Staturebull I Constitutional Short Staturebull II Primordial Dwarfism (intrauterine growth retardation)bull III Endocrine Causesbull A Growth Hormone Deficiencybull 1 Congenitalbull 2 Acquiredbull a HypothalamicPituitary Tumorsbull b Head Traumabull c CNS infectionsbull d Psychosocial Dwarfismbull 3 Laron Dwarfismbull 4 Hypothyroidismbull 5 Syndromes of Short Staturebull a Turner Syndrome (gonadal dysgenesis)bull b Noonans Syndromebull c Prader-Willi Syndromebull

Causes of Short Stature

bull IV Chronic Diseasebull A Heart Diseasebull B Pulmonarybull 1 Cystic Fibrosisbull 2 Asthmabull C GI Disordersbull D Hepatic Diseasebull E Renalbull V Iatrogenicbull A Corticosteroids anabolic steroidsbull B ADHD meds

bull Causes of Delayed Pubertybull I Constitutional Delay in Growth and Maturationbull II Hypogonadotropic hypogonadismbull A Central nervous system disordersbull 1 Tumors bull a Craniopharyngiomasbull b Gliomasbull c Germinomasbull 2 Radiation Therapybull 3 Congenital Malformationsbull

Causes of Delayed Puberty

bull B Isolated Growth Hormone Deficiencybull 1 Kallmanns Syndromebull C Miscellaneous Disordersbull 1 Prader-Willi Syndromebull 2 Hypothyroidismbull 3 Malnutritionbull 4 Anorexia Nervosabull 5 Exercise amenorrheabull 6 Cushingsbull 7 Diabetesbull

Causes of Delayed Puberty

bull III Hypergonadotropic hypogonadism

bull A Turner Syndrome

bull B XX and XY gonadal dysgenesis

bull C Polycystic ovary Syndrome

bull D Noonans 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- Kallmanns 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 Klinefelters syndrome Other forms of primary testicular failureAnorchia or

cryptorchism- Females Turners syndromeOther forms of primary ovarian failure Pseudo-Turners

syndrome- Noonans 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 2512 years of age with idiopathic true precocious

13412-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 (-45 SD) and a weight of 286 kg (-3 SD) The patient had early stage 2 breast development There was no pubic hair Karyotype was 46XX Bone age was 10 years After administration of GnRH LH and FSH rose in a pubertal pattern Estradiol was 40 pgmL She has since spontaneously progressed through pubertal development

• TUMBUH KEMBANG REMAJA
• REMAJA
• Remaja awal (11-14 tahun)
• Remaja Tengah (15-17 tahun)
• Remaja Lanjut (Usia 18-21 tahun)
• FISIOLOGI PUBERTAS
• Pubertas
• Tanda Pubertas Perempuan
• Slide 9
• Tanda Pubertas Laki-laki
• Sexual Maturity Rating
• Pubertas Perempuan
• Pubertas Laki-laki
• Pertumbuhan fisik
• Slide 15
• Slide 16
• Lonjakan pertumbuhan
• Perkembangan psikososial
• MASALAH-MASALAH REMAJA
• Morbiditas
• Masalah lain
• Psychological Problems in Adolescence
• Slide 23
• Teen suicide (contrsquod)
• Cluster Suicides
• Warning signs of suicide
• Indikator remaja berisiko tinggi
• Slide 28
• Gejala psikofisiologis
• Terapi gejala psikofisiologi
• KLINIK REMAJA
• Sikap Dokter Dalam Menghadapi Pasien Remaja
• Pemberian pelayanan kesehatan
• Kerahasiaan
• What are The importan Aspects of an Adolescent History
• How to Talk to Teens about Puberty
• Wawancara
• Slide 38
• LAMPIRAN
• 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
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• CASE
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Causes of Short Stature
• Slide 65
• Slide 66
• Causes of Delayed Puberty
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73

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

bull Biasanya 2-4 tahun

bull Perempuan 2 tahun lebih awal

bull Kecepatan tinggi puncak ndash W 115-12 tahunndash L 135-14 tahun

bull Pertambahan BB sampai 2 x

bull Pertambahan TB 15-20

Perkembangan psikososial

bull Mencari jati diri apa yang ingin dilakukan dan kekuatan-kelemahan

bull Periode progresif dan perpisahan dari keluarga

bull Fase-fase perkembangan psikososial--gt

3 fase remaja (lihat bagian depan)

MASALAH-MASALAH REMAJA

bull Morbiditas

bull Mortalitas

Morbiditas

bull Kehamilan yang tak diinginkan

bull Penyakit menular seksual

bull Penyalahgunaan zat

bull Merokok

bull Depresi

bull Psikofifiologis

bull Kekerasan fisik

bull Lari dari rumah

Masalah lain

bull Depresibull Bunuh diri remajabull Penyalahgunaan zatbull Gangguan makanbull Obesitas eksogenbull Kegagalan di sekolahbull Gangguan payudarabull Kelainan ginekologis bull PMS dan Penyakit radang pelvis

Psychological Problems in Adolescence

bull Depression 13 of teens have experienced some symptoms of depression

bull Rates are higher among girls than boys

bull Rates are higher among African-American and Native American teens

bull Additionally lack of popularity rejection death of a loved one contributes

Psychological Problems in Adolescence

bull Teen suicide rate has tripled in last 30 years

bull Annual rate now 122 per 100000 3rd most common cause of death for those age 15-24

bull Successful suicide rate is higher in boys (more lethal means) but girls attempt suicide more often

Teen suicide (contrsquod)

bull Risk factors ndash Depression Social inhibition

Perfectionism

ndash Anxiety Family conflicts romantic rejection

ndash History of drugalcohol abuse gaylesbian orientation

Cluster Suicides

bull 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

bull Schools increasing using crisis teams to counsel students after one student is successful in suicide

Warning signs of suicide

bull Direct or indirect talk of suicidebull School difficulties writing a willbull Giving stuff away arranging for pet

carebull Change in appetite general

depressionbull Changes in behavior preoccupation

with death in art music or literature

Indikator remaja berisiko tinggi

1 Penurunan kemampuan belajar

2 Absen sekolah yang berlebihan

3 Keluhan psikosomatik yang seringmenetap

4 Perubahan kebiasaan tidur atau makan

5 Kesulitan konsentrasi atau kebosanan yang menetap

6 Tanda dan gejala stres atau kecemasan

Indikator remaja berisiko tinggi

7 Menarik diri atau berpindah kelompok8 Perilaku menentang atau kekerasan yang

hebat dan atau perubahan kepribadian yang radikal

9 Konflik dengan orang tua10 Perilaku seksual yang berlebihan11 Konflik dengan hukum12 Memperlihatkan pikiran bunuh diri13 Penyalahgunaan obat dan alkohol14 Melarikan diri dari rumah

Gejala psikofisiologis

bull Reaksi konversi perasaan tidak menyenangkan dikomunikasikan dengan gejala fisik ldquoperolehan sekunderrdquo

bull Riwayat dan temuan fisik tidak konsisten dengan konsep anatomi dan fisiologis

bull Cenderung mempunyai OT yang overprotektif dan menjadi semakin tergantung pada OT

Terapi gejala psikofisiologi

bull Jelaskan hubungan antara penyebab fisik dari nyeri emosional atau penyebab emosional dari nyeri fisik

bull Memberi dorongan untuk mengerti bahwa gejala dapat menetap

bull Membantu pasien meneruskan aktivitas harian yang normal

bull Obat-obatan jarang membantubull Dokter suportif dan tidak menduga bahwa

nyeri tidak benar-benar terjadi

KLINIK REMAJA

Sikap Dokter Dalam Menghadapi Pasien Remaja

bull Dokter tampil jujur sederhana tidak perlu tampil ldquoprofesionalrdquo berlebihan

bull Remaja kurang PD dokter hati-hati

bull Sensitif terhadap tingkat perkembangan

Pemberian pelayanan kesehatan

bull 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

bull Beritahu remaja dan orang tuanya tentang kerahasiaan yang akan dijaga

bull Waktu adekuat

bull Yakinkan bahwa dokter tidak akan mencampuri kehidupan pribadi remaja tetapi merupakan hal penting untuk kesehatannya

What are The importan Aspects of an Adolescent History

bull HEADSSS untuk melacak informasi psikososial yang penting dari pasien remaja

bull H Homehealthbull E EducationEmploymentEatingbull A ActivitiesAspirationAffiliationbull D Drugsbull S Sexbull S SleepSuicidebull S Shoplifting

How to Talk to Teens about Puberty

1048708 Be open and honest

1048708 Treat the teen with respect

1048708 Talk directly to the teen

1048708 Begin conversation with least

threatening topics

1048708 Provide confidentiality

Wawancara

Wawancara terpimpinPenilaian tugas-tugas psikoperkembanganPemeriksaan sistemik meliputi 1 Nutrisi2 Tidur3 Perawatan diri pengetahuan ttg

pemeriksaan sendiri 4 Olah raga5 Hubungan keluarga dan sahabat6 Teman sebaya

Wawancara

7 Sekolah8 Minat pendidikan dan pekerjaan 9 Tembakau10 Penyalahgunaan zat11 Seksualitas12 Kesehatan mental

Usahakan pasien mendapat kesan tertarik dan seperti mempunyai ldquodokternyardquo sendiri

LAMPIRAN

PHYSIOLOGY OF PUBERTYPhysical 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 25 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 134 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 25 SD below the mean and is considered to have delayed puberty

- By this definition 06 of the healthy population are classified as having constitutional delay in growth and adolescence

CASE

bull 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

bull 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)

bull 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 15 to 35 year period

bull 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 124 to 128 years of age African-American girls are maturing earlier

bull 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 115 years

bull 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 135 and 17 years of age Growth of the penis reaches a SMR (Tanner) stage V between 125 and 165 years of age Nocturnal emissions (wet dreams) may first appear during SMR stage III

bull 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

bull 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

bull 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

bull 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

bull 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)

bull

bull 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

bull 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

bull 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 50ile of the patients actual height)

bull 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 (Klinefelters syndrome)

Causes of Short Staturebull I Constitutional Short Staturebull II Primordial Dwarfism (intrauterine growth retardation)bull III Endocrine Causesbull A Growth Hormone Deficiencybull 1 Congenitalbull 2 Acquiredbull a HypothalamicPituitary Tumorsbull b Head Traumabull c CNS infectionsbull d Psychosocial Dwarfismbull 3 Laron Dwarfismbull 4 Hypothyroidismbull 5 Syndromes of Short Staturebull a Turner Syndrome (gonadal dysgenesis)bull b Noonans Syndromebull c Prader-Willi Syndromebull

Causes of Short Stature

bull IV Chronic Diseasebull A Heart Diseasebull B Pulmonarybull 1 Cystic Fibrosisbull 2 Asthmabull C GI Disordersbull D Hepatic Diseasebull E Renalbull V Iatrogenicbull A Corticosteroids anabolic steroidsbull B ADHD meds

bull Causes of Delayed Pubertybull I Constitutional Delay in Growth and Maturationbull II Hypogonadotropic hypogonadismbull A Central nervous system disordersbull 1 Tumors bull a Craniopharyngiomasbull b Gliomasbull c Germinomasbull 2 Radiation Therapybull 3 Congenital Malformationsbull

Causes of Delayed Puberty

bull B Isolated Growth Hormone Deficiencybull 1 Kallmanns Syndromebull C Miscellaneous Disordersbull 1 Prader-Willi Syndromebull 2 Hypothyroidismbull 3 Malnutritionbull 4 Anorexia Nervosabull 5 Exercise amenorrheabull 6 Cushingsbull 7 Diabetesbull

Causes of Delayed Puberty

bull III Hypergonadotropic hypogonadism

bull A Turner Syndrome

bull B XX and XY gonadal dysgenesis

bull C Polycystic ovary Syndrome

bull D Noonans 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- Kallmanns 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 Klinefelters syndrome Other forms of primary testicular failureAnorchia or

cryptorchism- Females Turners syndromeOther forms of primary ovarian failure Pseudo-Turners

syndrome- Noonans 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 2512 years of age with idiopathic true precocious

13412-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 (-45 SD) and a weight of 286 kg (-3 SD) The patient had early stage 2 breast development There was no pubic hair Karyotype was 46XX Bone age was 10 years After administration of GnRH LH and FSH rose in a pubertal pattern Estradiol was 40 pgmL She has since spontaneously progressed through pubertal development

• TUMBUH KEMBANG REMAJA
• REMAJA
• Remaja awal (11-14 tahun)
• Remaja Tengah (15-17 tahun)
• Remaja Lanjut (Usia 18-21 tahun)
• FISIOLOGI PUBERTAS
• Pubertas
• Tanda Pubertas Perempuan
• Slide 9
• Tanda Pubertas Laki-laki
• Sexual Maturity Rating
• Pubertas Perempuan
• Pubertas Laki-laki
• Pertumbuhan fisik
• Slide 15
• Slide 16
• Lonjakan pertumbuhan
• Perkembangan psikososial
• MASALAH-MASALAH REMAJA
• Morbiditas
• Masalah lain
• Psychological Problems in Adolescence
• Slide 23
• Teen suicide (contrsquod)
• Cluster Suicides
• Warning signs of suicide
• Indikator remaja berisiko tinggi
• Slide 28
• Gejala psikofisiologis
• Terapi gejala psikofisiologi
• KLINIK REMAJA
• Sikap Dokter Dalam Menghadapi Pasien Remaja
• Pemberian pelayanan kesehatan
• Kerahasiaan
• What are The importan Aspects of an Adolescent History
• How to Talk to Teens about Puberty
• Wawancara
• Slide 38
• LAMPIRAN
• 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
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• CASE
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Causes of Short Stature
• Slide 65
• Slide 66
• Causes of Delayed Puberty
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73

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

bull Biasanya 2-4 tahun

bull Perempuan 2 tahun lebih awal

bull Kecepatan tinggi puncak ndash W 115-12 tahunndash L 135-14 tahun

bull Pertambahan BB sampai 2 x

bull Pertambahan TB 15-20

Perkembangan psikososial

bull Mencari jati diri apa yang ingin dilakukan dan kekuatan-kelemahan

bull Periode progresif dan perpisahan dari keluarga

bull Fase-fase perkembangan psikososial--gt

3 fase remaja (lihat bagian depan)

MASALAH-MASALAH REMAJA

bull Morbiditas

bull Mortalitas

Morbiditas

bull Kehamilan yang tak diinginkan

bull Penyakit menular seksual

bull Penyalahgunaan zat

bull Merokok

bull Depresi

bull Psikofifiologis

bull Kekerasan fisik

bull Lari dari rumah

Masalah lain

bull Depresibull Bunuh diri remajabull Penyalahgunaan zatbull Gangguan makanbull Obesitas eksogenbull Kegagalan di sekolahbull Gangguan payudarabull Kelainan ginekologis bull PMS dan Penyakit radang pelvis

Psychological Problems in Adolescence

bull Depression 13 of teens have experienced some symptoms of depression

bull Rates are higher among girls than boys

bull Rates are higher among African-American and Native American teens

bull Additionally lack of popularity rejection death of a loved one contributes

Psychological Problems in Adolescence

bull Teen suicide rate has tripled in last 30 years

bull Annual rate now 122 per 100000 3rd most common cause of death for those age 15-24

bull Successful suicide rate is higher in boys (more lethal means) but girls attempt suicide more often

Teen suicide (contrsquod)

bull Risk factors ndash Depression Social inhibition

Perfectionism

ndash Anxiety Family conflicts romantic rejection

ndash History of drugalcohol abuse gaylesbian orientation

Cluster Suicides

bull 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

bull Schools increasing using crisis teams to counsel students after one student is successful in suicide

Warning signs of suicide

bull Direct or indirect talk of suicidebull School difficulties writing a willbull Giving stuff away arranging for pet

carebull Change in appetite general

depressionbull Changes in behavior preoccupation

with death in art music or literature

Indikator remaja berisiko tinggi

1 Penurunan kemampuan belajar

2 Absen sekolah yang berlebihan

3 Keluhan psikosomatik yang seringmenetap

4 Perubahan kebiasaan tidur atau makan

5 Kesulitan konsentrasi atau kebosanan yang menetap

6 Tanda dan gejala stres atau kecemasan

Indikator remaja berisiko tinggi

7 Menarik diri atau berpindah kelompok8 Perilaku menentang atau kekerasan yang

hebat dan atau perubahan kepribadian yang radikal

9 Konflik dengan orang tua10 Perilaku seksual yang berlebihan11 Konflik dengan hukum12 Memperlihatkan pikiran bunuh diri13 Penyalahgunaan obat dan alkohol14 Melarikan diri dari rumah

Gejala psikofisiologis

bull Reaksi konversi perasaan tidak menyenangkan dikomunikasikan dengan gejala fisik ldquoperolehan sekunderrdquo

bull Riwayat dan temuan fisik tidak konsisten dengan konsep anatomi dan fisiologis

bull Cenderung mempunyai OT yang overprotektif dan menjadi semakin tergantung pada OT

Terapi gejala psikofisiologi

bull Jelaskan hubungan antara penyebab fisik dari nyeri emosional atau penyebab emosional dari nyeri fisik

bull Memberi dorongan untuk mengerti bahwa gejala dapat menetap

bull Membantu pasien meneruskan aktivitas harian yang normal

bull Obat-obatan jarang membantubull Dokter suportif dan tidak menduga bahwa

nyeri tidak benar-benar terjadi

KLINIK REMAJA

Sikap Dokter Dalam Menghadapi Pasien Remaja

bull Dokter tampil jujur sederhana tidak perlu tampil ldquoprofesionalrdquo berlebihan

bull Remaja kurang PD dokter hati-hati

bull Sensitif terhadap tingkat perkembangan

Pemberian pelayanan kesehatan

bull 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

bull Beritahu remaja dan orang tuanya tentang kerahasiaan yang akan dijaga

bull Waktu adekuat

bull Yakinkan bahwa dokter tidak akan mencampuri kehidupan pribadi remaja tetapi merupakan hal penting untuk kesehatannya

What are The importan Aspects of an Adolescent History

bull HEADSSS untuk melacak informasi psikososial yang penting dari pasien remaja

bull H Homehealthbull E EducationEmploymentEatingbull A ActivitiesAspirationAffiliationbull D Drugsbull S Sexbull S SleepSuicidebull S Shoplifting

How to Talk to Teens about Puberty

1048708 Be open and honest

1048708 Treat the teen with respect

1048708 Talk directly to the teen

1048708 Begin conversation with least

threatening topics

1048708 Provide confidentiality

Wawancara

Wawancara terpimpinPenilaian tugas-tugas psikoperkembanganPemeriksaan sistemik meliputi 1 Nutrisi2 Tidur3 Perawatan diri pengetahuan ttg

pemeriksaan sendiri 4 Olah raga5 Hubungan keluarga dan sahabat6 Teman sebaya

Wawancara

7 Sekolah8 Minat pendidikan dan pekerjaan 9 Tembakau10 Penyalahgunaan zat11 Seksualitas12 Kesehatan mental

Usahakan pasien mendapat kesan tertarik dan seperti mempunyai ldquodokternyardquo sendiri

LAMPIRAN

PHYSIOLOGY OF PUBERTYPhysical 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 25 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 134 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 25 SD below the mean and is considered to have delayed puberty

- By this definition 06 of the healthy population are classified as having constitutional delay in growth and adolescence

CASE

bull 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

bull 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)

bull 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 15 to 35 year period

bull 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 124 to 128 years of age African-American girls are maturing earlier

bull 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 115 years

bull 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 135 and 17 years of age Growth of the penis reaches a SMR (Tanner) stage V between 125 and 165 years of age Nocturnal emissions (wet dreams) may first appear during SMR stage III

bull 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

bull 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

bull 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

bull 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

bull 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)

bull

bull 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

bull 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

bull 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 50ile of the patients actual height)

bull 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 (Klinefelters syndrome)

Causes of Short Staturebull I Constitutional Short Staturebull II Primordial Dwarfism (intrauterine growth retardation)bull III Endocrine Causesbull A Growth Hormone Deficiencybull 1 Congenitalbull 2 Acquiredbull a HypothalamicPituitary Tumorsbull b Head Traumabull c CNS infectionsbull d Psychosocial Dwarfismbull 3 Laron Dwarfismbull 4 Hypothyroidismbull 5 Syndromes of Short Staturebull a Turner Syndrome (gonadal dysgenesis)bull b Noonans Syndromebull c Prader-Willi Syndromebull

Causes of Short Stature

bull IV Chronic Diseasebull A Heart Diseasebull B Pulmonarybull 1 Cystic Fibrosisbull 2 Asthmabull C GI Disordersbull D Hepatic Diseasebull E Renalbull V Iatrogenicbull A Corticosteroids anabolic steroidsbull B ADHD meds

bull Causes of Delayed Pubertybull I Constitutional Delay in Growth and Maturationbull II Hypogonadotropic hypogonadismbull A Central nervous system disordersbull 1 Tumors bull a Craniopharyngiomasbull b Gliomasbull c Germinomasbull 2 Radiation Therapybull 3 Congenital Malformationsbull

Causes of Delayed Puberty

bull B Isolated Growth Hormone Deficiencybull 1 Kallmanns Syndromebull C Miscellaneous Disordersbull 1 Prader-Willi Syndromebull 2 Hypothyroidismbull 3 Malnutritionbull 4 Anorexia Nervosabull 5 Exercise amenorrheabull 6 Cushingsbull 7 Diabetesbull

Causes of Delayed Puberty

bull III Hypergonadotropic hypogonadism

bull A Turner Syndrome

bull B XX and XY gonadal dysgenesis

bull C Polycystic ovary Syndrome

bull D Noonans 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- Kallmanns 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 Klinefelters syndrome Other forms of primary testicular failureAnorchia or

cryptorchism- Females Turners syndromeOther forms of primary ovarian failure Pseudo-Turners

syndrome- Noonans 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 2512 years of age with idiopathic true precocious

13412-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 (-45 SD) and a weight of 286 kg (-3 SD) The patient had early stage 2 breast development There was no pubic hair Karyotype was 46XX Bone age was 10 years After administration of GnRH LH and FSH rose in a pubertal pattern Estradiol was 40 pgmL She has since spontaneously progressed through pubertal development

• TUMBUH KEMBANG REMAJA
• REMAJA
• Remaja awal (11-14 tahun)
• Remaja Tengah (15-17 tahun)
• Remaja Lanjut (Usia 18-21 tahun)
• FISIOLOGI PUBERTAS
• Pubertas
• Tanda Pubertas Perempuan
• Slide 9
• Tanda Pubertas Laki-laki
• Sexual Maturity Rating
• Pubertas Perempuan
• Pubertas Laki-laki
• Pertumbuhan fisik
• Slide 15
• Slide 16
• Lonjakan pertumbuhan
• Perkembangan psikososial
• MASALAH-MASALAH REMAJA
• Morbiditas
• Masalah lain
• Psychological Problems in Adolescence
• Slide 23
• Teen suicide (contrsquod)
• Cluster Suicides
• Warning signs of suicide
• Indikator remaja berisiko tinggi
• Slide 28
• Gejala psikofisiologis
• Terapi gejala psikofisiologi
• KLINIK REMAJA
• Sikap Dokter Dalam Menghadapi Pasien Remaja
• Pemberian pelayanan kesehatan
• Kerahasiaan
• What are The importan Aspects of an Adolescent History
• How to Talk to Teens about Puberty
• Wawancara
• Slide 38
• LAMPIRAN
• 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
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• CASE
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Causes of Short Stature
• Slide 65
• Slide 66
• Causes of Delayed Puberty
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73

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

bull Biasanya 2-4 tahun

bull Perempuan 2 tahun lebih awal

bull Kecepatan tinggi puncak ndash W 115-12 tahunndash L 135-14 tahun

bull Pertambahan BB sampai 2 x

bull Pertambahan TB 15-20

Perkembangan psikososial

bull Mencari jati diri apa yang ingin dilakukan dan kekuatan-kelemahan

bull Periode progresif dan perpisahan dari keluarga

bull Fase-fase perkembangan psikososial--gt

3 fase remaja (lihat bagian depan)

MASALAH-MASALAH REMAJA

bull Morbiditas

bull Mortalitas

Morbiditas

bull Kehamilan yang tak diinginkan

bull Penyakit menular seksual

bull Penyalahgunaan zat

bull Merokok

bull Depresi

bull Psikofifiologis

bull Kekerasan fisik

bull Lari dari rumah

Masalah lain

bull Depresibull Bunuh diri remajabull Penyalahgunaan zatbull Gangguan makanbull Obesitas eksogenbull Kegagalan di sekolahbull Gangguan payudarabull Kelainan ginekologis bull PMS dan Penyakit radang pelvis

Psychological Problems in Adolescence

bull Depression 13 of teens have experienced some symptoms of depression

bull Rates are higher among girls than boys

bull Rates are higher among African-American and Native American teens

bull Additionally lack of popularity rejection death of a loved one contributes

Psychological Problems in Adolescence

bull Teen suicide rate has tripled in last 30 years

bull Annual rate now 122 per 100000 3rd most common cause of death for those age 15-24

bull Successful suicide rate is higher in boys (more lethal means) but girls attempt suicide more often

Teen suicide (contrsquod)

bull Risk factors ndash Depression Social inhibition

Perfectionism

ndash Anxiety Family conflicts romantic rejection

ndash History of drugalcohol abuse gaylesbian orientation

Cluster Suicides

bull 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

bull Schools increasing using crisis teams to counsel students after one student is successful in suicide

Warning signs of suicide

bull Direct or indirect talk of suicidebull School difficulties writing a willbull Giving stuff away arranging for pet

carebull Change in appetite general

depressionbull Changes in behavior preoccupation

with death in art music or literature

Indikator remaja berisiko tinggi

1 Penurunan kemampuan belajar

2 Absen sekolah yang berlebihan

3 Keluhan psikosomatik yang seringmenetap

4 Perubahan kebiasaan tidur atau makan

5 Kesulitan konsentrasi atau kebosanan yang menetap

6 Tanda dan gejala stres atau kecemasan

Indikator remaja berisiko tinggi

7 Menarik diri atau berpindah kelompok8 Perilaku menentang atau kekerasan yang

hebat dan atau perubahan kepribadian yang radikal

9 Konflik dengan orang tua10 Perilaku seksual yang berlebihan11 Konflik dengan hukum12 Memperlihatkan pikiran bunuh diri13 Penyalahgunaan obat dan alkohol14 Melarikan diri dari rumah

Gejala psikofisiologis

bull Reaksi konversi perasaan tidak menyenangkan dikomunikasikan dengan gejala fisik ldquoperolehan sekunderrdquo

bull Riwayat dan temuan fisik tidak konsisten dengan konsep anatomi dan fisiologis

bull Cenderung mempunyai OT yang overprotektif dan menjadi semakin tergantung pada OT

Terapi gejala psikofisiologi

bull Jelaskan hubungan antara penyebab fisik dari nyeri emosional atau penyebab emosional dari nyeri fisik

bull Memberi dorongan untuk mengerti bahwa gejala dapat menetap

bull Membantu pasien meneruskan aktivitas harian yang normal

bull Obat-obatan jarang membantubull Dokter suportif dan tidak menduga bahwa

nyeri tidak benar-benar terjadi

KLINIK REMAJA

Sikap Dokter Dalam Menghadapi Pasien Remaja

bull Dokter tampil jujur sederhana tidak perlu tampil ldquoprofesionalrdquo berlebihan

bull Remaja kurang PD dokter hati-hati

bull Sensitif terhadap tingkat perkembangan

Pemberian pelayanan kesehatan

bull 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

bull Beritahu remaja dan orang tuanya tentang kerahasiaan yang akan dijaga

bull Waktu adekuat

bull Yakinkan bahwa dokter tidak akan mencampuri kehidupan pribadi remaja tetapi merupakan hal penting untuk kesehatannya

What are The importan Aspects of an Adolescent History

bull HEADSSS untuk melacak informasi psikososial yang penting dari pasien remaja

bull H Homehealthbull E EducationEmploymentEatingbull A ActivitiesAspirationAffiliationbull D Drugsbull S Sexbull S SleepSuicidebull S Shoplifting

How to Talk to Teens about Puberty

1048708 Be open and honest

1048708 Treat the teen with respect

1048708 Talk directly to the teen

1048708 Begin conversation with least

threatening topics

1048708 Provide confidentiality

Wawancara

Wawancara terpimpinPenilaian tugas-tugas psikoperkembanganPemeriksaan sistemik meliputi 1 Nutrisi2 Tidur3 Perawatan diri pengetahuan ttg

pemeriksaan sendiri 4 Olah raga5 Hubungan keluarga dan sahabat6 Teman sebaya

Wawancara

7 Sekolah8 Minat pendidikan dan pekerjaan 9 Tembakau10 Penyalahgunaan zat11 Seksualitas12 Kesehatan mental

Usahakan pasien mendapat kesan tertarik dan seperti mempunyai ldquodokternyardquo sendiri

LAMPIRAN

PHYSIOLOGY OF PUBERTYPhysical 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 25 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 134 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 25 SD below the mean and is considered to have delayed puberty

- By this definition 06 of the healthy population are classified as having constitutional delay in growth and adolescence

CASE

bull 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

bull 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)

bull 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 15 to 35 year period

bull 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 124 to 128 years of age African-American girls are maturing earlier

bull 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 115 years

bull 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 135 and 17 years of age Growth of the penis reaches a SMR (Tanner) stage V between 125 and 165 years of age Nocturnal emissions (wet dreams) may first appear during SMR stage III

bull 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

bull 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

bull 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

bull 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

bull 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)

bull

bull 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

bull 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

bull 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 50ile of the patients actual height)

bull 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 (Klinefelters syndrome)

Causes of Short Staturebull I Constitutional Short Staturebull II Primordial Dwarfism (intrauterine growth retardation)bull III Endocrine Causesbull A Growth Hormone Deficiencybull 1 Congenitalbull 2 Acquiredbull a HypothalamicPituitary Tumorsbull b Head Traumabull c CNS infectionsbull d Psychosocial Dwarfismbull 3 Laron Dwarfismbull 4 Hypothyroidismbull 5 Syndromes of Short Staturebull a Turner Syndrome (gonadal dysgenesis)bull b Noonans Syndromebull c Prader-Willi Syndromebull

Causes of Short Stature

bull IV Chronic Diseasebull A Heart Diseasebull B Pulmonarybull 1 Cystic Fibrosisbull 2 Asthmabull C GI Disordersbull D Hepatic Diseasebull E Renalbull V Iatrogenicbull A Corticosteroids anabolic steroidsbull B ADHD meds

bull Causes of Delayed Pubertybull I Constitutional Delay in Growth and Maturationbull II Hypogonadotropic hypogonadismbull A Central nervous system disordersbull 1 Tumors bull a Craniopharyngiomasbull b Gliomasbull c Germinomasbull 2 Radiation Therapybull 3 Congenital Malformationsbull

Causes of Delayed Puberty

bull B Isolated Growth Hormone Deficiencybull 1 Kallmanns Syndromebull C Miscellaneous Disordersbull 1 Prader-Willi Syndromebull 2 Hypothyroidismbull 3 Malnutritionbull 4 Anorexia Nervosabull 5 Exercise amenorrheabull 6 Cushingsbull 7 Diabetesbull

Causes of Delayed Puberty

bull III Hypergonadotropic hypogonadism

bull A Turner Syndrome

bull B XX and XY gonadal dysgenesis

bull C Polycystic ovary Syndrome

bull D Noonans 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- Kallmanns 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 Klinefelters syndrome Other forms of primary testicular failureAnorchia or

cryptorchism- Females Turners syndromeOther forms of primary ovarian failure Pseudo-Turners

syndrome- Noonans 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 2512 years of age with idiopathic true precocious

13412-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 (-45 SD) and a weight of 286 kg (-3 SD) The patient had early stage 2 breast development There was no pubic hair Karyotype was 46XX Bone age was 10 years After administration of GnRH LH and FSH rose in a pubertal pattern Estradiol was 40 pgmL She has since spontaneously progressed through pubertal development

• TUMBUH KEMBANG REMAJA
• REMAJA
• Remaja awal (11-14 tahun)
• Remaja Tengah (15-17 tahun)
• Remaja Lanjut (Usia 18-21 tahun)
• FISIOLOGI PUBERTAS
• Pubertas
• Tanda Pubertas Perempuan
• Slide 9
• Tanda Pubertas Laki-laki
• Sexual Maturity Rating
• Pubertas Perempuan
• Pubertas Laki-laki
• Pertumbuhan fisik
• Slide 15
• Slide 16
• Lonjakan pertumbuhan
• Perkembangan psikososial
• MASALAH-MASALAH REMAJA
• Morbiditas
• Masalah lain
• Psychological Problems in Adolescence
• Slide 23
• Teen suicide (contrsquod)
• Cluster Suicides
• Warning signs of suicide
• Indikator remaja berisiko tinggi
• Slide 28
• Gejala psikofisiologis
• Terapi gejala psikofisiologi
• KLINIK REMAJA
• Sikap Dokter Dalam Menghadapi Pasien Remaja
• Pemberian pelayanan kesehatan
• Kerahasiaan
• What are The importan Aspects of an Adolescent History
• How to Talk to Teens about Puberty
• Wawancara
• Slide 38
• LAMPIRAN
• 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
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• CASE
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Causes of Short Stature
• Slide 65
• Slide 66
• Causes of Delayed Puberty
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73

Lonjakan pertumbuhan

bull Biasanya 2-4 tahun

bull Perempuan 2 tahun lebih awal

bull Kecepatan tinggi puncak ndash W 115-12 tahunndash L 135-14 tahun

bull Pertambahan BB sampai 2 x

bull Pertambahan TB 15-20

Perkembangan psikososial

bull Mencari jati diri apa yang ingin dilakukan dan kekuatan-kelemahan

bull Periode progresif dan perpisahan dari keluarga

bull Fase-fase perkembangan psikososial--gt

3 fase remaja (lihat bagian depan)

MASALAH-MASALAH REMAJA

bull Morbiditas

bull Mortalitas

Morbiditas

bull Kehamilan yang tak diinginkan

bull Penyakit menular seksual

bull Penyalahgunaan zat

bull Merokok

bull Depresi

bull Psikofifiologis

bull Kekerasan fisik

bull Lari dari rumah

Masalah lain

bull Depresibull Bunuh diri remajabull Penyalahgunaan zatbull Gangguan makanbull Obesitas eksogenbull Kegagalan di sekolahbull Gangguan payudarabull Kelainan ginekologis bull PMS dan Penyakit radang pelvis

Psychological Problems in Adolescence

bull Depression 13 of teens have experienced some symptoms of depression

bull Rates are higher among girls than boys

bull Rates are higher among African-American and Native American teens

bull Additionally lack of popularity rejection death of a loved one contributes

Psychological Problems in Adolescence

bull Teen suicide rate has tripled in last 30 years

bull Annual rate now 122 per 100000 3rd most common cause of death for those age 15-24

bull Successful suicide rate is higher in boys (more lethal means) but girls attempt suicide more often

Teen suicide (contrsquod)

bull Risk factors ndash Depression Social inhibition

Perfectionism

ndash Anxiety Family conflicts romantic rejection

ndash History of drugalcohol abuse gaylesbian orientation

Cluster Suicides

bull 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

bull Schools increasing using crisis teams to counsel students after one student is successful in suicide

Warning signs of suicide

bull Direct or indirect talk of suicidebull School difficulties writing a willbull Giving stuff away arranging for pet

carebull Change in appetite general

depressionbull Changes in behavior preoccupation

with death in art music or literature

Indikator remaja berisiko tinggi

1 Penurunan kemampuan belajar

2 Absen sekolah yang berlebihan

3 Keluhan psikosomatik yang seringmenetap

4 Perubahan kebiasaan tidur atau makan

5 Kesulitan konsentrasi atau kebosanan yang menetap

6 Tanda dan gejala stres atau kecemasan

Indikator remaja berisiko tinggi

7 Menarik diri atau berpindah kelompok8 Perilaku menentang atau kekerasan yang

hebat dan atau perubahan kepribadian yang radikal

9 Konflik dengan orang tua10 Perilaku seksual yang berlebihan11 Konflik dengan hukum12 Memperlihatkan pikiran bunuh diri13 Penyalahgunaan obat dan alkohol14 Melarikan diri dari rumah

Gejala psikofisiologis

bull Reaksi konversi perasaan tidak menyenangkan dikomunikasikan dengan gejala fisik ldquoperolehan sekunderrdquo

bull Riwayat dan temuan fisik tidak konsisten dengan konsep anatomi dan fisiologis

bull Cenderung mempunyai OT yang overprotektif dan menjadi semakin tergantung pada OT

Terapi gejala psikofisiologi

bull Jelaskan hubungan antara penyebab fisik dari nyeri emosional atau penyebab emosional dari nyeri fisik

bull Memberi dorongan untuk mengerti bahwa gejala dapat menetap

bull Membantu pasien meneruskan aktivitas harian yang normal

bull Obat-obatan jarang membantubull Dokter suportif dan tidak menduga bahwa

nyeri tidak benar-benar terjadi

KLINIK REMAJA

Sikap Dokter Dalam Menghadapi Pasien Remaja

bull Dokter tampil jujur sederhana tidak perlu tampil ldquoprofesionalrdquo berlebihan

bull Remaja kurang PD dokter hati-hati

bull Sensitif terhadap tingkat perkembangan

Pemberian pelayanan kesehatan

bull 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

bull Beritahu remaja dan orang tuanya tentang kerahasiaan yang akan dijaga

bull Waktu adekuat

bull Yakinkan bahwa dokter tidak akan mencampuri kehidupan pribadi remaja tetapi merupakan hal penting untuk kesehatannya

What are The importan Aspects of an Adolescent History

bull HEADSSS untuk melacak informasi psikososial yang penting dari pasien remaja

bull H Homehealthbull E EducationEmploymentEatingbull A ActivitiesAspirationAffiliationbull D Drugsbull S Sexbull S SleepSuicidebull S Shoplifting

How to Talk to Teens about Puberty

1048708 Be open and honest

1048708 Treat the teen with respect

1048708 Talk directly to the teen

1048708 Begin conversation with least

threatening topics

1048708 Provide confidentiality

Wawancara

Wawancara terpimpinPenilaian tugas-tugas psikoperkembanganPemeriksaan sistemik meliputi 1 Nutrisi2 Tidur3 Perawatan diri pengetahuan ttg

pemeriksaan sendiri 4 Olah raga5 Hubungan keluarga dan sahabat6 Teman sebaya

Wawancara

7 Sekolah8 Minat pendidikan dan pekerjaan 9 Tembakau10 Penyalahgunaan zat11 Seksualitas12 Kesehatan mental

Usahakan pasien mendapat kesan tertarik dan seperti mempunyai ldquodokternyardquo sendiri

LAMPIRAN

PHYSIOLOGY OF PUBERTYPhysical 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 25 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 134 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 25 SD below the mean and is considered to have delayed puberty

- By this definition 06 of the healthy population are classified as having constitutional delay in growth and adolescence

CASE

bull 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

bull 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)

bull 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 15 to 35 year period

bull 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 124 to 128 years of age African-American girls are maturing earlier

bull 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 115 years

bull 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 135 and 17 years of age Growth of the penis reaches a SMR (Tanner) stage V between 125 and 165 years of age Nocturnal emissions (wet dreams) may first appear during SMR stage III

bull 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

bull 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

bull 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

bull 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

bull 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)

bull

bull 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

bull 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

bull 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 50ile of the patients actual height)

bull 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 (Klinefelters syndrome)

Causes of Short Staturebull I Constitutional Short Staturebull II Primordial Dwarfism (intrauterine growth retardation)bull III Endocrine Causesbull A Growth Hormone Deficiencybull 1 Congenitalbull 2 Acquiredbull a HypothalamicPituitary Tumorsbull b Head Traumabull c CNS infectionsbull d Psychosocial Dwarfismbull 3 Laron Dwarfismbull 4 Hypothyroidismbull 5 Syndromes of Short Staturebull a Turner Syndrome (gonadal dysgenesis)bull b Noonans Syndromebull c Prader-Willi Syndromebull

Causes of Short Stature

bull IV Chronic Diseasebull A Heart Diseasebull B Pulmonarybull 1 Cystic Fibrosisbull 2 Asthmabull C GI Disordersbull D Hepatic Diseasebull E Renalbull V Iatrogenicbull A Corticosteroids anabolic steroidsbull B ADHD meds

bull Causes of Delayed Pubertybull I Constitutional Delay in Growth and Maturationbull II Hypogonadotropic hypogonadismbull A Central nervous system disordersbull 1 Tumors bull a Craniopharyngiomasbull b Gliomasbull c Germinomasbull 2 Radiation Therapybull 3 Congenital Malformationsbull

Causes of Delayed Puberty

bull B Isolated Growth Hormone Deficiencybull 1 Kallmanns Syndromebull C Miscellaneous Disordersbull 1 Prader-Willi Syndromebull 2 Hypothyroidismbull 3 Malnutritionbull 4 Anorexia Nervosabull 5 Exercise amenorrheabull 6 Cushingsbull 7 Diabetesbull

Causes of Delayed Puberty

bull III Hypergonadotropic hypogonadism

bull A Turner Syndrome

bull B XX and XY gonadal dysgenesis

bull C Polycystic ovary Syndrome

bull D Noonans 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- Kallmanns 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 Klinefelters syndrome Other forms of primary testicular failureAnorchia or

cryptorchism- Females Turners syndromeOther forms of primary ovarian failure Pseudo-Turners

syndrome- Noonans 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 2512 years of age with idiopathic true precocious

13412-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 (-45 SD) and a weight of 286 kg (-3 SD) The patient had early stage 2 breast development There was no pubic hair Karyotype was 46XX Bone age was 10 years After administration of GnRH LH and FSH rose in a pubertal pattern Estradiol was 40 pgmL She has since spontaneously progressed through pubertal development

• TUMBUH KEMBANG REMAJA
• REMAJA
• Remaja awal (11-14 tahun)
• Remaja Tengah (15-17 tahun)
• Remaja Lanjut (Usia 18-21 tahun)
• FISIOLOGI PUBERTAS
• Pubertas
• Tanda Pubertas Perempuan
• Slide 9
• Tanda Pubertas Laki-laki
• Sexual Maturity Rating
• Pubertas Perempuan
• Pubertas Laki-laki
• Pertumbuhan fisik
• Slide 15
• Slide 16
• Lonjakan pertumbuhan
• Perkembangan psikososial
• MASALAH-MASALAH REMAJA
• Morbiditas
• Masalah lain
• Psychological Problems in Adolescence
• Slide 23
• Teen suicide (contrsquod)
• Cluster Suicides
• Warning signs of suicide
• Indikator remaja berisiko tinggi
• Slide 28
• Gejala psikofisiologis
• Terapi gejala psikofisiologi
• KLINIK REMAJA
• Sikap Dokter Dalam Menghadapi Pasien Remaja
• Pemberian pelayanan kesehatan
• Kerahasiaan
• What are The importan Aspects of an Adolescent History
• How to Talk to Teens about Puberty
• Wawancara
• Slide 38
• LAMPIRAN
• 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
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• CASE
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Causes of Short Stature
• Slide 65
• Slide 66
• Causes of Delayed Puberty
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73

Perkembangan psikososial

bull Mencari jati diri apa yang ingin dilakukan dan kekuatan-kelemahan

bull Periode progresif dan perpisahan dari keluarga

bull Fase-fase perkembangan psikososial--gt

3 fase remaja (lihat bagian depan)

MASALAH-MASALAH REMAJA

bull Morbiditas

bull Mortalitas

Morbiditas

bull Kehamilan yang tak diinginkan

bull Penyakit menular seksual

bull Penyalahgunaan zat

bull Merokok

bull Depresi

bull Psikofifiologis

bull Kekerasan fisik

bull Lari dari rumah

Masalah lain

bull Depresibull Bunuh diri remajabull Penyalahgunaan zatbull Gangguan makanbull Obesitas eksogenbull Kegagalan di sekolahbull Gangguan payudarabull Kelainan ginekologis bull PMS dan Penyakit radang pelvis

Psychological Problems in Adolescence

bull Depression 13 of teens have experienced some symptoms of depression

bull Rates are higher among girls than boys

bull Rates are higher among African-American and Native American teens

bull Additionally lack of popularity rejection death of a loved one contributes

Psychological Problems in Adolescence

bull Teen suicide rate has tripled in last 30 years

bull Annual rate now 122 per 100000 3rd most common cause of death for those age 15-24

bull Successful suicide rate is higher in boys (more lethal means) but girls attempt suicide more often

Teen suicide (contrsquod)

bull Risk factors ndash Depression Social inhibition

Perfectionism

ndash Anxiety Family conflicts romantic rejection

ndash History of drugalcohol abuse gaylesbian orientation

Cluster Suicides

bull 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

bull Schools increasing using crisis teams to counsel students after one student is successful in suicide

Warning signs of suicide

bull Direct or indirect talk of suicidebull School difficulties writing a willbull Giving stuff away arranging for pet

carebull Change in appetite general

depressionbull Changes in behavior preoccupation

with death in art music or literature

Indikator remaja berisiko tinggi

1 Penurunan kemampuan belajar

2 Absen sekolah yang berlebihan

3 Keluhan psikosomatik yang seringmenetap

4 Perubahan kebiasaan tidur atau makan

5 Kesulitan konsentrasi atau kebosanan yang menetap

6 Tanda dan gejala stres atau kecemasan

Indikator remaja berisiko tinggi

7 Menarik diri atau berpindah kelompok8 Perilaku menentang atau kekerasan yang

hebat dan atau perubahan kepribadian yang radikal

9 Konflik dengan orang tua10 Perilaku seksual yang berlebihan11 Konflik dengan hukum12 Memperlihatkan pikiran bunuh diri13 Penyalahgunaan obat dan alkohol14 Melarikan diri dari rumah

Gejala psikofisiologis

bull Reaksi konversi perasaan tidak menyenangkan dikomunikasikan dengan gejala fisik ldquoperolehan sekunderrdquo

bull Riwayat dan temuan fisik tidak konsisten dengan konsep anatomi dan fisiologis

bull Cenderung mempunyai OT yang overprotektif dan menjadi semakin tergantung pada OT

Terapi gejala psikofisiologi

bull Jelaskan hubungan antara penyebab fisik dari nyeri emosional atau penyebab emosional dari nyeri fisik

bull Memberi dorongan untuk mengerti bahwa gejala dapat menetap

bull Membantu pasien meneruskan aktivitas harian yang normal

bull Obat-obatan jarang membantubull Dokter suportif dan tidak menduga bahwa

nyeri tidak benar-benar terjadi

KLINIK REMAJA

Sikap Dokter Dalam Menghadapi Pasien Remaja

bull Dokter tampil jujur sederhana tidak perlu tampil ldquoprofesionalrdquo berlebihan

bull Remaja kurang PD dokter hati-hati

bull Sensitif terhadap tingkat perkembangan

Pemberian pelayanan kesehatan

bull 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

bull Beritahu remaja dan orang tuanya tentang kerahasiaan yang akan dijaga

bull Waktu adekuat

bull Yakinkan bahwa dokter tidak akan mencampuri kehidupan pribadi remaja tetapi merupakan hal penting untuk kesehatannya

What are The importan Aspects of an Adolescent History

bull HEADSSS untuk melacak informasi psikososial yang penting dari pasien remaja

bull H Homehealthbull E EducationEmploymentEatingbull A ActivitiesAspirationAffiliationbull D Drugsbull S Sexbull S SleepSuicidebull S Shoplifting

How to Talk to Teens about Puberty

1048708 Be open and honest

1048708 Treat the teen with respect

1048708 Talk directly to the teen

1048708 Begin conversation with least

threatening topics

1048708 Provide confidentiality

Wawancara

Wawancara terpimpinPenilaian tugas-tugas psikoperkembanganPemeriksaan sistemik meliputi 1 Nutrisi2 Tidur3 Perawatan diri pengetahuan ttg

pemeriksaan sendiri 4 Olah raga5 Hubungan keluarga dan sahabat6 Teman sebaya

Wawancara

7 Sekolah8 Minat pendidikan dan pekerjaan 9 Tembakau10 Penyalahgunaan zat11 Seksualitas12 Kesehatan mental

Usahakan pasien mendapat kesan tertarik dan seperti mempunyai ldquodokternyardquo sendiri

LAMPIRAN

PHYSIOLOGY OF PUBERTYPhysical 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 25 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 134 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 25 SD below the mean and is considered to have delayed puberty

- By this definition 06 of the healthy population are classified as having constitutional delay in growth and adolescence

CASE

bull 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

bull 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)

bull 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 15 to 35 year period

bull 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 124 to 128 years of age African-American girls are maturing earlier

bull 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 115 years

bull 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 135 and 17 years of age Growth of the penis reaches a SMR (Tanner) stage V between 125 and 165 years of age Nocturnal emissions (wet dreams) may first appear during SMR stage III

bull 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

bull 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

bull 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

bull 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

bull 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)

bull

bull 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

bull 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

bull 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 50ile of the patients actual height)

bull 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 (Klinefelters syndrome)

Causes of Short Staturebull I Constitutional Short Staturebull II Primordial Dwarfism (intrauterine growth retardation)bull III Endocrine Causesbull A Growth Hormone Deficiencybull 1 Congenitalbull 2 Acquiredbull a HypothalamicPituitary Tumorsbull b Head Traumabull c CNS infectionsbull d Psychosocial Dwarfismbull 3 Laron Dwarfismbull 4 Hypothyroidismbull 5 Syndromes of Short Staturebull a Turner Syndrome (gonadal dysgenesis)bull b Noonans Syndromebull c Prader-Willi Syndromebull

Causes of Short Stature

bull IV Chronic Diseasebull A Heart Diseasebull B Pulmonarybull 1 Cystic Fibrosisbull 2 Asthmabull C GI Disordersbull D Hepatic Diseasebull E Renalbull V Iatrogenicbull A Corticosteroids anabolic steroidsbull B ADHD meds

bull Causes of Delayed Pubertybull I Constitutional Delay in Growth and Maturationbull II Hypogonadotropic hypogonadismbull A Central nervous system disordersbull 1 Tumors bull a Craniopharyngiomasbull b Gliomasbull c Germinomasbull 2 Radiation Therapybull 3 Congenital Malformationsbull

Causes of Delayed Puberty

bull B Isolated Growth Hormone Deficiencybull 1 Kallmanns Syndromebull C Miscellaneous Disordersbull 1 Prader-Willi Syndromebull 2 Hypothyroidismbull 3 Malnutritionbull 4 Anorexia Nervosabull 5 Exercise amenorrheabull 6 Cushingsbull 7 Diabetesbull

Causes of Delayed Puberty

bull III Hypergonadotropic hypogonadism

bull A Turner Syndrome

bull B XX and XY gonadal dysgenesis

bull C Polycystic ovary Syndrome

bull D Noonans 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- Kallmanns 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 Klinefelters syndrome Other forms of primary testicular failureAnorchia or

cryptorchism- Females Turners syndromeOther forms of primary ovarian failure Pseudo-Turners

syndrome- Noonans 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 2512 years of age with idiopathic true precocious

13412-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 (-45 SD) and a weight of 286 kg (-3 SD) The patient had early stage 2 breast development There was no pubic hair Karyotype was 46XX Bone age was 10 years After administration of GnRH LH and FSH rose in a pubertal pattern Estradiol was 40 pgmL She has since spontaneously progressed through pubertal development

• TUMBUH KEMBANG REMAJA
• REMAJA
• Remaja awal (11-14 tahun)
• Remaja Tengah (15-17 tahun)
• Remaja Lanjut (Usia 18-21 tahun)
• FISIOLOGI PUBERTAS
• Pubertas
• Tanda Pubertas Perempuan
• Slide 9
• Tanda Pubertas Laki-laki
• Sexual Maturity Rating
• Pubertas Perempuan
• Pubertas Laki-laki
• Pertumbuhan fisik
• Slide 15
• Slide 16
• Lonjakan pertumbuhan
• Perkembangan psikososial
• MASALAH-MASALAH REMAJA
• Morbiditas
• Masalah lain
• Psychological Problems in Adolescence
• Slide 23
• Teen suicide (contrsquod)
• Cluster Suicides
• Warning signs of suicide
• Indikator remaja berisiko tinggi
• Slide 28
• Gejala psikofisiologis
• Terapi gejala psikofisiologi
• KLINIK REMAJA
• Sikap Dokter Dalam Menghadapi Pasien Remaja
• Pemberian pelayanan kesehatan
• Kerahasiaan
• What are The importan Aspects of an Adolescent History
• How to Talk to Teens about Puberty
• Wawancara
• Slide 38
• LAMPIRAN
• 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
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• CASE
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Causes of Short Stature
• Slide 65
• Slide 66
• Causes of Delayed Puberty
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73

MASALAH-MASALAH REMAJA

bull Morbiditas

bull Mortalitas

Morbiditas

bull Kehamilan yang tak diinginkan

bull Penyakit menular seksual

bull Penyalahgunaan zat

bull Merokok

bull Depresi

bull Psikofifiologis

bull Kekerasan fisik

bull Lari dari rumah

Masalah lain

bull Depresibull Bunuh diri remajabull Penyalahgunaan zatbull Gangguan makanbull Obesitas eksogenbull Kegagalan di sekolahbull Gangguan payudarabull Kelainan ginekologis bull PMS dan Penyakit radang pelvis

Psychological Problems in Adolescence

bull Depression 13 of teens have experienced some symptoms of depression

bull Rates are higher among girls than boys

bull Rates are higher among African-American and Native American teens

bull Additionally lack of popularity rejection death of a loved one contributes

Psychological Problems in Adolescence

bull Teen suicide rate has tripled in last 30 years

bull Annual rate now 122 per 100000 3rd most common cause of death for those age 15-24

bull Successful suicide rate is higher in boys (more lethal means) but girls attempt suicide more often

Teen suicide (contrsquod)

bull Risk factors ndash Depression Social inhibition

Perfectionism

ndash Anxiety Family conflicts romantic rejection

ndash History of drugalcohol abuse gaylesbian orientation

Cluster Suicides

bull 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

bull Schools increasing using crisis teams to counsel students after one student is successful in suicide

Warning signs of suicide

bull Direct or indirect talk of suicidebull School difficulties writing a willbull Giving stuff away arranging for pet

carebull Change in appetite general

depressionbull Changes in behavior preoccupation

with death in art music or literature

Indikator remaja berisiko tinggi

1 Penurunan kemampuan belajar

2 Absen sekolah yang berlebihan

3 Keluhan psikosomatik yang seringmenetap

4 Perubahan kebiasaan tidur atau makan

5 Kesulitan konsentrasi atau kebosanan yang menetap

6 Tanda dan gejala stres atau kecemasan

Indikator remaja berisiko tinggi

7 Menarik diri atau berpindah kelompok8 Perilaku menentang atau kekerasan yang

hebat dan atau perubahan kepribadian yang radikal

9 Konflik dengan orang tua10 Perilaku seksual yang berlebihan11 Konflik dengan hukum12 Memperlihatkan pikiran bunuh diri13 Penyalahgunaan obat dan alkohol14 Melarikan diri dari rumah

Gejala psikofisiologis

bull Reaksi konversi perasaan tidak menyenangkan dikomunikasikan dengan gejala fisik ldquoperolehan sekunderrdquo

bull Riwayat dan temuan fisik tidak konsisten dengan konsep anatomi dan fisiologis

bull Cenderung mempunyai OT yang overprotektif dan menjadi semakin tergantung pada OT

Terapi gejala psikofisiologi

bull Jelaskan hubungan antara penyebab fisik dari nyeri emosional atau penyebab emosional dari nyeri fisik

bull Memberi dorongan untuk mengerti bahwa gejala dapat menetap

bull Membantu pasien meneruskan aktivitas harian yang normal

bull Obat-obatan jarang membantubull Dokter suportif dan tidak menduga bahwa

nyeri tidak benar-benar terjadi

KLINIK REMAJA

Sikap Dokter Dalam Menghadapi Pasien Remaja

bull Dokter tampil jujur sederhana tidak perlu tampil ldquoprofesionalrdquo berlebihan

bull Remaja kurang PD dokter hati-hati

bull Sensitif terhadap tingkat perkembangan

Pemberian pelayanan kesehatan

bull 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

bull Beritahu remaja dan orang tuanya tentang kerahasiaan yang akan dijaga

bull Waktu adekuat

bull Yakinkan bahwa dokter tidak akan mencampuri kehidupan pribadi remaja tetapi merupakan hal penting untuk kesehatannya

What are The importan Aspects of an Adolescent History

bull HEADSSS untuk melacak informasi psikososial yang penting dari pasien remaja

bull H Homehealthbull E EducationEmploymentEatingbull A ActivitiesAspirationAffiliationbull D Drugsbull S Sexbull S SleepSuicidebull S Shoplifting

How to Talk to Teens about Puberty

1048708 Be open and honest

1048708 Treat the teen with respect

1048708 Talk directly to the teen

1048708 Begin conversation with least

threatening topics

1048708 Provide confidentiality

Wawancara

Wawancara terpimpinPenilaian tugas-tugas psikoperkembanganPemeriksaan sistemik meliputi 1 Nutrisi2 Tidur3 Perawatan diri pengetahuan ttg

pemeriksaan sendiri 4 Olah raga5 Hubungan keluarga dan sahabat6 Teman sebaya

Wawancara

7 Sekolah8 Minat pendidikan dan pekerjaan 9 Tembakau10 Penyalahgunaan zat11 Seksualitas12 Kesehatan mental

Usahakan pasien mendapat kesan tertarik dan seperti mempunyai ldquodokternyardquo sendiri

LAMPIRAN

PHYSIOLOGY OF PUBERTYPhysical 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 25 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 134 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 25 SD below the mean and is considered to have delayed puberty

- By this definition 06 of the healthy population are classified as having constitutional delay in growth and adolescence

CASE

bull 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

bull 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)

bull 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 15 to 35 year period

bull 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 124 to 128 years of age African-American girls are maturing earlier

bull 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 115 years

bull 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 135 and 17 years of age Growth of the penis reaches a SMR (Tanner) stage V between 125 and 165 years of age Nocturnal emissions (wet dreams) may first appear during SMR stage III

bull 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

bull 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

bull 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

bull 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

bull 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)

bull

bull 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

bull 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

bull 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 50ile of the patients actual height)

bull 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 (Klinefelters syndrome)

Causes of Short Staturebull I Constitutional Short Staturebull II Primordial Dwarfism (intrauterine growth retardation)bull III Endocrine Causesbull A Growth Hormone Deficiencybull 1 Congenitalbull 2 Acquiredbull a HypothalamicPituitary Tumorsbull b Head Traumabull c CNS infectionsbull d Psychosocial Dwarfismbull 3 Laron Dwarfismbull 4 Hypothyroidismbull 5 Syndromes of Short Staturebull a Turner Syndrome (gonadal dysgenesis)bull b Noonans Syndromebull c Prader-Willi Syndromebull

Causes of Short Stature

bull IV Chronic Diseasebull A Heart Diseasebull B Pulmonarybull 1 Cystic Fibrosisbull 2 Asthmabull C GI Disordersbull D Hepatic Diseasebull E Renalbull V Iatrogenicbull A Corticosteroids anabolic steroidsbull B ADHD meds

bull Causes of Delayed Pubertybull I Constitutional Delay in Growth and Maturationbull II Hypogonadotropic hypogonadismbull A Central nervous system disordersbull 1 Tumors bull a Craniopharyngiomasbull b Gliomasbull c Germinomasbull 2 Radiation Therapybull 3 Congenital Malformationsbull

Causes of Delayed Puberty

bull B Isolated Growth Hormone Deficiencybull 1 Kallmanns Syndromebull C Miscellaneous Disordersbull 1 Prader-Willi Syndromebull 2 Hypothyroidismbull 3 Malnutritionbull 4 Anorexia Nervosabull 5 Exercise amenorrheabull 6 Cushingsbull 7 Diabetesbull

Causes of Delayed Puberty

bull III Hypergonadotropic hypogonadism

bull A Turner Syndrome

bull B XX and XY gonadal dysgenesis

bull C Polycystic ovary Syndrome

bull D Noonans 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- Kallmanns 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 Klinefelters syndrome Other forms of primary testicular failureAnorchia or

cryptorchism- Females Turners syndromeOther forms of primary ovarian failure Pseudo-Turners

syndrome- Noonans 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 2512 years of age with idiopathic true precocious

13412-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 (-45 SD) and a weight of 286 kg (-3 SD) The patient had early stage 2 breast development There was no pubic hair Karyotype was 46XX Bone age was 10 years After administration of GnRH LH and FSH rose in a pubertal pattern Estradiol was 40 pgmL She has since spontaneously progressed through pubertal development

• TUMBUH KEMBANG REMAJA
• REMAJA
• Remaja awal (11-14 tahun)
• Remaja Tengah (15-17 tahun)
• Remaja Lanjut (Usia 18-21 tahun)
• FISIOLOGI PUBERTAS
• Pubertas
• Tanda Pubertas Perempuan
• Slide 9
• Tanda Pubertas Laki-laki
• Sexual Maturity Rating
• Pubertas Perempuan
• Pubertas Laki-laki
• Pertumbuhan fisik
• Slide 15
• Slide 16
• Lonjakan pertumbuhan
• Perkembangan psikososial
• MASALAH-MASALAH REMAJA
• Morbiditas
• Masalah lain
• Psychological Problems in Adolescence
• Slide 23
• Teen suicide (contrsquod)
• Cluster Suicides
• Warning signs of suicide
• Indikator remaja berisiko tinggi
• Slide 28
• Gejala psikofisiologis
• Terapi gejala psikofisiologi
• KLINIK REMAJA
• Sikap Dokter Dalam Menghadapi Pasien Remaja
• Pemberian pelayanan kesehatan
• Kerahasiaan
• What are The importan Aspects of an Adolescent History
• How to Talk to Teens about Puberty
• Wawancara
• Slide 38
• LAMPIRAN
• 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
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• CASE
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Causes of Short Stature
• Slide 65
• Slide 66
• Causes of Delayed Puberty
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73

Morbiditas

bull Kehamilan yang tak diinginkan

bull Penyakit menular seksual

bull Penyalahgunaan zat

bull Merokok

bull Depresi

bull Psikofifiologis

bull Kekerasan fisik

bull Lari dari rumah

Masalah lain

bull Depresibull Bunuh diri remajabull Penyalahgunaan zatbull Gangguan makanbull Obesitas eksogenbull Kegagalan di sekolahbull Gangguan payudarabull Kelainan ginekologis bull PMS dan Penyakit radang pelvis

Psychological Problems in Adolescence

bull Depression 13 of teens have experienced some symptoms of depression

bull Rates are higher among girls than boys

bull Rates are higher among African-American and Native American teens

bull Additionally lack of popularity rejection death of a loved one contributes

Psychological Problems in Adolescence

bull Teen suicide rate has tripled in last 30 years

bull Annual rate now 122 per 100000 3rd most common cause of death for those age 15-24

bull Successful suicide rate is higher in boys (more lethal means) but girls attempt suicide more often

Teen suicide (contrsquod)

bull Risk factors ndash Depression Social inhibition

Perfectionism

ndash Anxiety Family conflicts romantic rejection

ndash History of drugalcohol abuse gaylesbian orientation

Cluster Suicides

bull 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

bull Schools increasing using crisis teams to counsel students after one student is successful in suicide

Warning signs of suicide

bull Direct or indirect talk of suicidebull School difficulties writing a willbull Giving stuff away arranging for pet

carebull Change in appetite general

depressionbull Changes in behavior preoccupation

with death in art music or literature

Indikator remaja berisiko tinggi

1 Penurunan kemampuan belajar

2 Absen sekolah yang berlebihan

3 Keluhan psikosomatik yang seringmenetap

4 Perubahan kebiasaan tidur atau makan

5 Kesulitan konsentrasi atau kebosanan yang menetap

6 Tanda dan gejala stres atau kecemasan

Indikator remaja berisiko tinggi

7 Menarik diri atau berpindah kelompok8 Perilaku menentang atau kekerasan yang

hebat dan atau perubahan kepribadian yang radikal

9 Konflik dengan orang tua10 Perilaku seksual yang berlebihan11 Konflik dengan hukum12 Memperlihatkan pikiran bunuh diri13 Penyalahgunaan obat dan alkohol14 Melarikan diri dari rumah

Gejala psikofisiologis

bull Reaksi konversi perasaan tidak menyenangkan dikomunikasikan dengan gejala fisik ldquoperolehan sekunderrdquo

bull Riwayat dan temuan fisik tidak konsisten dengan konsep anatomi dan fisiologis

bull Cenderung mempunyai OT yang overprotektif dan menjadi semakin tergantung pada OT

Terapi gejala psikofisiologi

bull Jelaskan hubungan antara penyebab fisik dari nyeri emosional atau penyebab emosional dari nyeri fisik

bull Memberi dorongan untuk mengerti bahwa gejala dapat menetap

bull Membantu pasien meneruskan aktivitas harian yang normal

bull Obat-obatan jarang membantubull Dokter suportif dan tidak menduga bahwa

nyeri tidak benar-benar terjadi

KLINIK REMAJA

Sikap Dokter Dalam Menghadapi Pasien Remaja

bull Dokter tampil jujur sederhana tidak perlu tampil ldquoprofesionalrdquo berlebihan

bull Remaja kurang PD dokter hati-hati

bull Sensitif terhadap tingkat perkembangan

Pemberian pelayanan kesehatan

bull 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

bull Beritahu remaja dan orang tuanya tentang kerahasiaan yang akan dijaga

bull Waktu adekuat

bull Yakinkan bahwa dokter tidak akan mencampuri kehidupan pribadi remaja tetapi merupakan hal penting untuk kesehatannya

What are The importan Aspects of an Adolescent History

bull HEADSSS untuk melacak informasi psikososial yang penting dari pasien remaja

bull H Homehealthbull E EducationEmploymentEatingbull A ActivitiesAspirationAffiliationbull D Drugsbull S Sexbull S SleepSuicidebull S Shoplifting

How to Talk to Teens about Puberty

1048708 Be open and honest

1048708 Treat the teen with respect

1048708 Talk directly to the teen

1048708 Begin conversation with least

threatening topics

1048708 Provide confidentiality

Wawancara

Wawancara terpimpinPenilaian tugas-tugas psikoperkembanganPemeriksaan sistemik meliputi 1 Nutrisi2 Tidur3 Perawatan diri pengetahuan ttg

pemeriksaan sendiri 4 Olah raga5 Hubungan keluarga dan sahabat6 Teman sebaya

Wawancara

7 Sekolah8 Minat pendidikan dan pekerjaan 9 Tembakau10 Penyalahgunaan zat11 Seksualitas12 Kesehatan mental

Usahakan pasien mendapat kesan tertarik dan seperti mempunyai ldquodokternyardquo sendiri

LAMPIRAN

PHYSIOLOGY OF PUBERTYPhysical 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 25 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 134 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 25 SD below the mean and is considered to have delayed puberty

- By this definition 06 of the healthy population are classified as having constitutional delay in growth and adolescence

CASE

bull 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

bull 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)

bull 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 15 to 35 year period

bull 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 124 to 128 years of age African-American girls are maturing earlier

bull 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 115 years

bull 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 135 and 17 years of age Growth of the penis reaches a SMR (Tanner) stage V between 125 and 165 years of age Nocturnal emissions (wet dreams) may first appear during SMR stage III

bull 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

bull 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

bull 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

bull 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

bull 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)

bull

bull 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

bull 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

bull 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 50ile of the patients actual height)

bull 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 (Klinefelters syndrome)

Causes of Short Staturebull I Constitutional Short Staturebull II Primordial Dwarfism (intrauterine growth retardation)bull III Endocrine Causesbull A Growth Hormone Deficiencybull 1 Congenitalbull 2 Acquiredbull a HypothalamicPituitary Tumorsbull b Head Traumabull c CNS infectionsbull d Psychosocial Dwarfismbull 3 Laron Dwarfismbull 4 Hypothyroidismbull 5 Syndromes of Short Staturebull a Turner Syndrome (gonadal dysgenesis)bull b Noonans Syndromebull c Prader-Willi Syndromebull

Causes of Short Stature

bull IV Chronic Diseasebull A Heart Diseasebull B Pulmonarybull 1 Cystic Fibrosisbull 2 Asthmabull C GI Disordersbull D Hepatic Diseasebull E Renalbull V Iatrogenicbull A Corticosteroids anabolic steroidsbull B ADHD meds

bull Causes of Delayed Pubertybull I Constitutional Delay in Growth and Maturationbull II Hypogonadotropic hypogonadismbull A Central nervous system disordersbull 1 Tumors bull a Craniopharyngiomasbull b Gliomasbull c Germinomasbull 2 Radiation Therapybull 3 Congenital Malformationsbull

Causes of Delayed Puberty

bull B Isolated Growth Hormone Deficiencybull 1 Kallmanns Syndromebull C Miscellaneous Disordersbull 1 Prader-Willi Syndromebull 2 Hypothyroidismbull 3 Malnutritionbull 4 Anorexia Nervosabull 5 Exercise amenorrheabull 6 Cushingsbull 7 Diabetesbull

Causes of Delayed Puberty

bull III Hypergonadotropic hypogonadism

bull A Turner Syndrome

bull B XX and XY gonadal dysgenesis

bull C Polycystic ovary Syndrome

bull D Noonans 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- Kallmanns 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 Klinefelters syndrome Other forms of primary testicular failureAnorchia or

cryptorchism- Females Turners syndromeOther forms of primary ovarian failure Pseudo-Turners

syndrome- Noonans 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 2512 years of age with idiopathic true precocious

13412-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 (-45 SD) and a weight of 286 kg (-3 SD) The patient had early stage 2 breast development There was no pubic hair Karyotype was 46XX Bone age was 10 years After administration of GnRH LH and FSH rose in a pubertal pattern Estradiol was 40 pgmL She has since spontaneously progressed through pubertal development

• TUMBUH KEMBANG REMAJA
• REMAJA
• Remaja awal (11-14 tahun)
• Remaja Tengah (15-17 tahun)
• Remaja Lanjut (Usia 18-21 tahun)
• FISIOLOGI PUBERTAS
• Pubertas
• Tanda Pubertas Perempuan
• Slide 9
• Tanda Pubertas Laki-laki
• Sexual Maturity Rating
• Pubertas Perempuan
• Pubertas Laki-laki
• Pertumbuhan fisik
• Slide 15
• Slide 16
• Lonjakan pertumbuhan
• Perkembangan psikososial
• MASALAH-MASALAH REMAJA
• Morbiditas
• Masalah lain
• Psychological Problems in Adolescence
• Slide 23
• Teen suicide (contrsquod)
• Cluster Suicides
• Warning signs of suicide
• Indikator remaja berisiko tinggi
• Slide 28
• Gejala psikofisiologis
• Terapi gejala psikofisiologi
• KLINIK REMAJA
• Sikap Dokter Dalam Menghadapi Pasien Remaja
• Pemberian pelayanan kesehatan
• Kerahasiaan
• What are The importan Aspects of an Adolescent History
• How to Talk to Teens about Puberty
• Wawancara
• Slide 38
• LAMPIRAN
• 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
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• CASE
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Causes of Short Stature
• Slide 65
• Slide 66
• Causes of Delayed Puberty
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73

Masalah lain

bull Depresibull Bunuh diri remajabull Penyalahgunaan zatbull Gangguan makanbull Obesitas eksogenbull Kegagalan di sekolahbull Gangguan payudarabull Kelainan ginekologis bull PMS dan Penyakit radang pelvis

Psychological Problems in Adolescence

bull Depression 13 of teens have experienced some symptoms of depression

bull Rates are higher among girls than boys

bull Rates are higher among African-American and Native American teens

bull Additionally lack of popularity rejection death of a loved one contributes

Psychological Problems in Adolescence

bull Teen suicide rate has tripled in last 30 years

bull Annual rate now 122 per 100000 3rd most common cause of death for those age 15-24

bull Successful suicide rate is higher in boys (more lethal means) but girls attempt suicide more often

Teen suicide (contrsquod)

bull Risk factors ndash Depression Social inhibition

Perfectionism

ndash Anxiety Family conflicts romantic rejection

ndash History of drugalcohol abuse gaylesbian orientation

Cluster Suicides

bull 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

bull Schools increasing using crisis teams to counsel students after one student is successful in suicide

Warning signs of suicide

bull Direct or indirect talk of suicidebull School difficulties writing a willbull Giving stuff away arranging for pet

carebull Change in appetite general

depressionbull Changes in behavior preoccupation

with death in art music or literature

Indikator remaja berisiko tinggi

1 Penurunan kemampuan belajar

2 Absen sekolah yang berlebihan

3 Keluhan psikosomatik yang seringmenetap

4 Perubahan kebiasaan tidur atau makan

5 Kesulitan konsentrasi atau kebosanan yang menetap

6 Tanda dan gejala stres atau kecemasan

Indikator remaja berisiko tinggi

7 Menarik diri atau berpindah kelompok8 Perilaku menentang atau kekerasan yang

hebat dan atau perubahan kepribadian yang radikal

9 Konflik dengan orang tua10 Perilaku seksual yang berlebihan11 Konflik dengan hukum12 Memperlihatkan pikiran bunuh diri13 Penyalahgunaan obat dan alkohol14 Melarikan diri dari rumah

Gejala psikofisiologis

bull Reaksi konversi perasaan tidak menyenangkan dikomunikasikan dengan gejala fisik ldquoperolehan sekunderrdquo

bull Riwayat dan temuan fisik tidak konsisten dengan konsep anatomi dan fisiologis

bull Cenderung mempunyai OT yang overprotektif dan menjadi semakin tergantung pada OT

Terapi gejala psikofisiologi

bull Jelaskan hubungan antara penyebab fisik dari nyeri emosional atau penyebab emosional dari nyeri fisik

bull Memberi dorongan untuk mengerti bahwa gejala dapat menetap

bull Membantu pasien meneruskan aktivitas harian yang normal

bull Obat-obatan jarang membantubull Dokter suportif dan tidak menduga bahwa

nyeri tidak benar-benar terjadi

KLINIK REMAJA

Sikap Dokter Dalam Menghadapi Pasien Remaja

bull Dokter tampil jujur sederhana tidak perlu tampil ldquoprofesionalrdquo berlebihan

bull Remaja kurang PD dokter hati-hati

bull Sensitif terhadap tingkat perkembangan

Pemberian pelayanan kesehatan

bull 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

bull Beritahu remaja dan orang tuanya tentang kerahasiaan yang akan dijaga

bull Waktu adekuat

bull Yakinkan bahwa dokter tidak akan mencampuri kehidupan pribadi remaja tetapi merupakan hal penting untuk kesehatannya

What are The importan Aspects of an Adolescent History

bull HEADSSS untuk melacak informasi psikososial yang penting dari pasien remaja

bull H Homehealthbull E EducationEmploymentEatingbull A ActivitiesAspirationAffiliationbull D Drugsbull S Sexbull S SleepSuicidebull S Shoplifting

How to Talk to Teens about Puberty

1048708 Be open and honest

1048708 Treat the teen with respect

1048708 Talk directly to the teen

1048708 Begin conversation with least

threatening topics

1048708 Provide confidentiality

Wawancara

Wawancara terpimpinPenilaian tugas-tugas psikoperkembanganPemeriksaan sistemik meliputi 1 Nutrisi2 Tidur3 Perawatan diri pengetahuan ttg

pemeriksaan sendiri 4 Olah raga5 Hubungan keluarga dan sahabat6 Teman sebaya

Wawancara

7 Sekolah8 Minat pendidikan dan pekerjaan 9 Tembakau10 Penyalahgunaan zat11 Seksualitas12 Kesehatan mental

Usahakan pasien mendapat kesan tertarik dan seperti mempunyai ldquodokternyardquo sendiri

LAMPIRAN

PHYSIOLOGY OF PUBERTYPhysical 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 25 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 134 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 25 SD below the mean and is considered to have delayed puberty

- By this definition 06 of the healthy population are classified as having constitutional delay in growth and adolescence

CASE

bull 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

bull 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)

bull 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 15 to 35 year period

bull 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 124 to 128 years of age African-American girls are maturing earlier

bull 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 115 years

bull 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 135 and 17 years of age Growth of the penis reaches a SMR (Tanner) stage V between 125 and 165 years of age Nocturnal emissions (wet dreams) may first appear during SMR stage III

bull 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

bull 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

bull 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

bull 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

bull 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)

bull

bull 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

bull 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

bull 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 50ile of the patients actual height)

bull 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 (Klinefelters syndrome)

Causes of Short Staturebull I Constitutional Short Staturebull II Primordial Dwarfism (intrauterine growth retardation)bull III Endocrine Causesbull A Growth Hormone Deficiencybull 1 Congenitalbull 2 Acquiredbull a HypothalamicPituitary Tumorsbull b Head Traumabull c CNS infectionsbull d Psychosocial Dwarfismbull 3 Laron Dwarfismbull 4 Hypothyroidismbull 5 Syndromes of Short Staturebull a Turner Syndrome (gonadal dysgenesis)bull b Noonans Syndromebull c Prader-Willi Syndromebull

Causes of Short Stature

bull IV Chronic Diseasebull A Heart Diseasebull B Pulmonarybull 1 Cystic Fibrosisbull 2 Asthmabull C GI Disordersbull D Hepatic Diseasebull E Renalbull V Iatrogenicbull A Corticosteroids anabolic steroidsbull B ADHD meds

bull Causes of Delayed Pubertybull I Constitutional Delay in Growth and Maturationbull II Hypogonadotropic hypogonadismbull A Central nervous system disordersbull 1 Tumors bull a Craniopharyngiomasbull b Gliomasbull c Germinomasbull 2 Radiation Therapybull 3 Congenital Malformationsbull

Causes of Delayed Puberty

bull B Isolated Growth Hormone Deficiencybull 1 Kallmanns Syndromebull C Miscellaneous Disordersbull 1 Prader-Willi Syndromebull 2 Hypothyroidismbull 3 Malnutritionbull 4 Anorexia Nervosabull 5 Exercise amenorrheabull 6 Cushingsbull 7 Diabetesbull

Causes of Delayed Puberty

bull III Hypergonadotropic hypogonadism

bull A Turner Syndrome

bull B XX and XY gonadal dysgenesis

bull C Polycystic ovary Syndrome

bull D Noonans 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- Kallmanns 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 Klinefelters syndrome Other forms of primary testicular failureAnorchia or

cryptorchism- Females Turners syndromeOther forms of primary ovarian failure Pseudo-Turners

syndrome- Noonans 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 2512 years of age with idiopathic true precocious

13412-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 (-45 SD) and a weight of 286 kg (-3 SD) The patient had early stage 2 breast development There was no pubic hair Karyotype was 46XX Bone age was 10 years After administration of GnRH LH and FSH rose in a pubertal pattern Estradiol was 40 pgmL She has since spontaneously progressed through pubertal development

• TUMBUH KEMBANG REMAJA
• REMAJA
• Remaja awal (11-14 tahun)
• Remaja Tengah (15-17 tahun)
• Remaja Lanjut (Usia 18-21 tahun)
• FISIOLOGI PUBERTAS
• Pubertas
• Tanda Pubertas Perempuan
• Slide 9
• Tanda Pubertas Laki-laki
• Sexual Maturity Rating
• Pubertas Perempuan
• Pubertas Laki-laki
• Pertumbuhan fisik
• Slide 15
• Slide 16
• Lonjakan pertumbuhan
• Perkembangan psikososial
• MASALAH-MASALAH REMAJA
• Morbiditas
• Masalah lain
• Psychological Problems in Adolescence
• Slide 23
• Teen suicide (contrsquod)
• Cluster Suicides
• Warning signs of suicide
• Indikator remaja berisiko tinggi
• Slide 28
• Gejala psikofisiologis
• Terapi gejala psikofisiologi
• KLINIK REMAJA
• Sikap Dokter Dalam Menghadapi Pasien Remaja
• Pemberian pelayanan kesehatan
• Kerahasiaan
• What are The importan Aspects of an Adolescent History
• How to Talk to Teens about Puberty
• Wawancara
• Slide 38
• LAMPIRAN
• 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
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• CASE
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Causes of Short Stature
• Slide 65
• Slide 66
• Causes of Delayed Puberty
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73

Psychological Problems in Adolescence

bull Depression 13 of teens have experienced some symptoms of depression

bull Rates are higher among girls than boys

bull Rates are higher among African-American and Native American teens

bull Additionally lack of popularity rejection death of a loved one contributes

Psychological Problems in Adolescence

bull Teen suicide rate has tripled in last 30 years

bull Annual rate now 122 per 100000 3rd most common cause of death for those age 15-24

bull Successful suicide rate is higher in boys (more lethal means) but girls attempt suicide more often

Teen suicide (contrsquod)

bull Risk factors ndash Depression Social inhibition

Perfectionism

ndash Anxiety Family conflicts romantic rejection

ndash History of drugalcohol abuse gaylesbian orientation

Cluster Suicides

bull 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

bull Schools increasing using crisis teams to counsel students after one student is successful in suicide

Warning signs of suicide

bull Direct or indirect talk of suicidebull School difficulties writing a willbull Giving stuff away arranging for pet

carebull Change in appetite general

depressionbull Changes in behavior preoccupation

with death in art music or literature

Indikator remaja berisiko tinggi

1 Penurunan kemampuan belajar

2 Absen sekolah yang berlebihan

3 Keluhan psikosomatik yang seringmenetap

4 Perubahan kebiasaan tidur atau makan

5 Kesulitan konsentrasi atau kebosanan yang menetap

6 Tanda dan gejala stres atau kecemasan

Indikator remaja berisiko tinggi

7 Menarik diri atau berpindah kelompok8 Perilaku menentang atau kekerasan yang

hebat dan atau perubahan kepribadian yang radikal

9 Konflik dengan orang tua10 Perilaku seksual yang berlebihan11 Konflik dengan hukum12 Memperlihatkan pikiran bunuh diri13 Penyalahgunaan obat dan alkohol14 Melarikan diri dari rumah

Gejala psikofisiologis

bull Reaksi konversi perasaan tidak menyenangkan dikomunikasikan dengan gejala fisik ldquoperolehan sekunderrdquo

bull Riwayat dan temuan fisik tidak konsisten dengan konsep anatomi dan fisiologis

bull Cenderung mempunyai OT yang overprotektif dan menjadi semakin tergantung pada OT

Terapi gejala psikofisiologi

bull Jelaskan hubungan antara penyebab fisik dari nyeri emosional atau penyebab emosional dari nyeri fisik

bull Memberi dorongan untuk mengerti bahwa gejala dapat menetap

bull Membantu pasien meneruskan aktivitas harian yang normal

bull Obat-obatan jarang membantubull Dokter suportif dan tidak menduga bahwa

nyeri tidak benar-benar terjadi

KLINIK REMAJA

Sikap Dokter Dalam Menghadapi Pasien Remaja

bull Dokter tampil jujur sederhana tidak perlu tampil ldquoprofesionalrdquo berlebihan

bull Remaja kurang PD dokter hati-hati

bull Sensitif terhadap tingkat perkembangan

Pemberian pelayanan kesehatan

bull 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

bull Beritahu remaja dan orang tuanya tentang kerahasiaan yang akan dijaga

bull Waktu adekuat

bull Yakinkan bahwa dokter tidak akan mencampuri kehidupan pribadi remaja tetapi merupakan hal penting untuk kesehatannya

What are The importan Aspects of an Adolescent History

bull HEADSSS untuk melacak informasi psikososial yang penting dari pasien remaja

bull H Homehealthbull E EducationEmploymentEatingbull A ActivitiesAspirationAffiliationbull D Drugsbull S Sexbull S SleepSuicidebull S Shoplifting

How to Talk to Teens about Puberty

1048708 Be open and honest

1048708 Treat the teen with respect

1048708 Talk directly to the teen

1048708 Begin conversation with least

threatening topics

1048708 Provide confidentiality

Wawancara

Wawancara terpimpinPenilaian tugas-tugas psikoperkembanganPemeriksaan sistemik meliputi 1 Nutrisi2 Tidur3 Perawatan diri pengetahuan ttg

pemeriksaan sendiri 4 Olah raga5 Hubungan keluarga dan sahabat6 Teman sebaya

Wawancara

7 Sekolah8 Minat pendidikan dan pekerjaan 9 Tembakau10 Penyalahgunaan zat11 Seksualitas12 Kesehatan mental

Usahakan pasien mendapat kesan tertarik dan seperti mempunyai ldquodokternyardquo sendiri

LAMPIRAN

PHYSIOLOGY OF PUBERTYPhysical 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 25 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 134 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 25 SD below the mean and is considered to have delayed puberty

- By this definition 06 of the healthy population are classified as having constitutional delay in growth and adolescence

CASE

bull 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

bull 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)

bull 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 15 to 35 year period

bull 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 124 to 128 years of age African-American girls are maturing earlier

bull 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 115 years

bull 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 135 and 17 years of age Growth of the penis reaches a SMR (Tanner) stage V between 125 and 165 years of age Nocturnal emissions (wet dreams) may first appear during SMR stage III

bull 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

bull 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

bull 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

bull 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

bull 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)

bull

bull 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

bull 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

bull 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 50ile of the patients actual height)

bull 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 (Klinefelters syndrome)

Causes of Short Staturebull I Constitutional Short Staturebull II Primordial Dwarfism (intrauterine growth retardation)bull III Endocrine Causesbull A Growth Hormone Deficiencybull 1 Congenitalbull 2 Acquiredbull a HypothalamicPituitary Tumorsbull b Head Traumabull c CNS infectionsbull d Psychosocial Dwarfismbull 3 Laron Dwarfismbull 4 Hypothyroidismbull 5 Syndromes of Short Staturebull a Turner Syndrome (gonadal dysgenesis)bull b Noonans Syndromebull c Prader-Willi Syndromebull

Causes of Short Stature

bull IV Chronic Diseasebull A Heart Diseasebull B Pulmonarybull 1 Cystic Fibrosisbull 2 Asthmabull C GI Disordersbull D Hepatic Diseasebull E Renalbull V Iatrogenicbull A Corticosteroids anabolic steroidsbull B ADHD meds

bull Causes of Delayed Pubertybull I Constitutional Delay in Growth and Maturationbull II Hypogonadotropic hypogonadismbull A Central nervous system disordersbull 1 Tumors bull a Craniopharyngiomasbull b Gliomasbull c Germinomasbull 2 Radiation Therapybull 3 Congenital Malformationsbull

Causes of Delayed Puberty

bull B Isolated Growth Hormone Deficiencybull 1 Kallmanns Syndromebull C Miscellaneous Disordersbull 1 Prader-Willi Syndromebull 2 Hypothyroidismbull 3 Malnutritionbull 4 Anorexia Nervosabull 5 Exercise amenorrheabull 6 Cushingsbull 7 Diabetesbull

Causes of Delayed Puberty

bull III Hypergonadotropic hypogonadism

bull A Turner Syndrome

bull B XX and XY gonadal dysgenesis

bull C Polycystic ovary Syndrome

bull D Noonans 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- Kallmanns 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 Klinefelters syndrome Other forms of primary testicular failureAnorchia or

cryptorchism- Females Turners syndromeOther forms of primary ovarian failure Pseudo-Turners

syndrome- Noonans 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 2512 years of age with idiopathic true precocious

13412-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 (-45 SD) and a weight of 286 kg (-3 SD) The patient had early stage 2 breast development There was no pubic hair Karyotype was 46XX Bone age was 10 years After administration of GnRH LH and FSH rose in a pubertal pattern Estradiol was 40 pgmL She has since spontaneously progressed through pubertal development

• TUMBUH KEMBANG REMAJA
• REMAJA
• Remaja awal (11-14 tahun)
• Remaja Tengah (15-17 tahun)
• Remaja Lanjut (Usia 18-21 tahun)
• FISIOLOGI PUBERTAS
• Pubertas
• Tanda Pubertas Perempuan
• Slide 9
• Tanda Pubertas Laki-laki
• Sexual Maturity Rating
• Pubertas Perempuan
• Pubertas Laki-laki
• Pertumbuhan fisik
• Slide 15
• Slide 16
• Lonjakan pertumbuhan
• Perkembangan psikososial
• MASALAH-MASALAH REMAJA
• Morbiditas
• Masalah lain
• Psychological Problems in Adolescence
• Slide 23
• Teen suicide (contrsquod)
• Cluster Suicides
• Warning signs of suicide
• Indikator remaja berisiko tinggi
• Slide 28
• Gejala psikofisiologis
• Terapi gejala psikofisiologi
• KLINIK REMAJA
• Sikap Dokter Dalam Menghadapi Pasien Remaja
• Pemberian pelayanan kesehatan
• Kerahasiaan
• What are The importan Aspects of an Adolescent History
• How to Talk to Teens about Puberty
• Wawancara
• Slide 38
• LAMPIRAN
• 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
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• CASE
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Causes of Short Stature
• Slide 65
• Slide 66
• Causes of Delayed Puberty
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73

Psychological Problems in Adolescence

bull Teen suicide rate has tripled in last 30 years

bull Annual rate now 122 per 100000 3rd most common cause of death for those age 15-24

bull Successful suicide rate is higher in boys (more lethal means) but girls attempt suicide more often

Teen suicide (contrsquod)

bull Risk factors ndash Depression Social inhibition

Perfectionism

ndash Anxiety Family conflicts romantic rejection

ndash History of drugalcohol abuse gaylesbian orientation

Cluster Suicides

bull 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

bull Schools increasing using crisis teams to counsel students after one student is successful in suicide

Warning signs of suicide

bull Direct or indirect talk of suicidebull School difficulties writing a willbull Giving stuff away arranging for pet

carebull Change in appetite general

depressionbull Changes in behavior preoccupation

with death in art music or literature

Indikator remaja berisiko tinggi

1 Penurunan kemampuan belajar

2 Absen sekolah yang berlebihan

3 Keluhan psikosomatik yang seringmenetap

4 Perubahan kebiasaan tidur atau makan

5 Kesulitan konsentrasi atau kebosanan yang menetap

6 Tanda dan gejala stres atau kecemasan

Indikator remaja berisiko tinggi

7 Menarik diri atau berpindah kelompok8 Perilaku menentang atau kekerasan yang

hebat dan atau perubahan kepribadian yang radikal

9 Konflik dengan orang tua10 Perilaku seksual yang berlebihan11 Konflik dengan hukum12 Memperlihatkan pikiran bunuh diri13 Penyalahgunaan obat dan alkohol14 Melarikan diri dari rumah

Gejala psikofisiologis

bull Reaksi konversi perasaan tidak menyenangkan dikomunikasikan dengan gejala fisik ldquoperolehan sekunderrdquo

bull Riwayat dan temuan fisik tidak konsisten dengan konsep anatomi dan fisiologis

bull Cenderung mempunyai OT yang overprotektif dan menjadi semakin tergantung pada OT

Terapi gejala psikofisiologi

bull Jelaskan hubungan antara penyebab fisik dari nyeri emosional atau penyebab emosional dari nyeri fisik

bull Memberi dorongan untuk mengerti bahwa gejala dapat menetap

bull Membantu pasien meneruskan aktivitas harian yang normal

bull Obat-obatan jarang membantubull Dokter suportif dan tidak menduga bahwa

nyeri tidak benar-benar terjadi

KLINIK REMAJA

Sikap Dokter Dalam Menghadapi Pasien Remaja

bull Dokter tampil jujur sederhana tidak perlu tampil ldquoprofesionalrdquo berlebihan

bull Remaja kurang PD dokter hati-hati

bull Sensitif terhadap tingkat perkembangan

Pemberian pelayanan kesehatan

bull 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

bull Beritahu remaja dan orang tuanya tentang kerahasiaan yang akan dijaga

bull Waktu adekuat

bull Yakinkan bahwa dokter tidak akan mencampuri kehidupan pribadi remaja tetapi merupakan hal penting untuk kesehatannya

What are The importan Aspects of an Adolescent History

bull HEADSSS untuk melacak informasi psikososial yang penting dari pasien remaja

bull H Homehealthbull E EducationEmploymentEatingbull A ActivitiesAspirationAffiliationbull D Drugsbull S Sexbull S SleepSuicidebull S Shoplifting

How to Talk to Teens about Puberty

1048708 Be open and honest

1048708 Treat the teen with respect

1048708 Talk directly to the teen

1048708 Begin conversation with least

threatening topics

1048708 Provide confidentiality

Wawancara

Wawancara terpimpinPenilaian tugas-tugas psikoperkembanganPemeriksaan sistemik meliputi 1 Nutrisi2 Tidur3 Perawatan diri pengetahuan ttg

pemeriksaan sendiri 4 Olah raga5 Hubungan keluarga dan sahabat6 Teman sebaya

Wawancara

7 Sekolah8 Minat pendidikan dan pekerjaan 9 Tembakau10 Penyalahgunaan zat11 Seksualitas12 Kesehatan mental

Usahakan pasien mendapat kesan tertarik dan seperti mempunyai ldquodokternyardquo sendiri

LAMPIRAN

PHYSIOLOGY OF PUBERTYPhysical 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 25 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 134 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 25 SD below the mean and is considered to have delayed puberty

- By this definition 06 of the healthy population are classified as having constitutional delay in growth and adolescence

CASE

bull 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

bull 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)

bull 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 15 to 35 year period

bull 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 124 to 128 years of age African-American girls are maturing earlier

bull 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 115 years

bull 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 135 and 17 years of age Growth of the penis reaches a SMR (Tanner) stage V between 125 and 165 years of age Nocturnal emissions (wet dreams) may first appear during SMR stage III

bull 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

bull 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

bull 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

bull 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

bull 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)

bull

bull 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

bull 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

bull 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 50ile of the patients actual height)

bull 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 (Klinefelters syndrome)

Causes of Short Staturebull I Constitutional Short Staturebull II Primordial Dwarfism (intrauterine growth retardation)bull III Endocrine Causesbull A Growth Hormone Deficiencybull 1 Congenitalbull 2 Acquiredbull a HypothalamicPituitary Tumorsbull b Head Traumabull c CNS infectionsbull d Psychosocial Dwarfismbull 3 Laron Dwarfismbull 4 Hypothyroidismbull 5 Syndromes of Short Staturebull a Turner Syndrome (gonadal dysgenesis)bull b Noonans Syndromebull c Prader-Willi Syndromebull

Causes of Short Stature

bull IV Chronic Diseasebull A Heart Diseasebull B Pulmonarybull 1 Cystic Fibrosisbull 2 Asthmabull C GI Disordersbull D Hepatic Diseasebull E Renalbull V Iatrogenicbull A Corticosteroids anabolic steroidsbull B ADHD meds

bull Causes of Delayed Pubertybull I Constitutional Delay in Growth and Maturationbull II Hypogonadotropic hypogonadismbull A Central nervous system disordersbull 1 Tumors bull a Craniopharyngiomasbull b Gliomasbull c Germinomasbull 2 Radiation Therapybull 3 Congenital Malformationsbull

Causes of Delayed Puberty

bull B Isolated Growth Hormone Deficiencybull 1 Kallmanns Syndromebull C Miscellaneous Disordersbull 1 Prader-Willi Syndromebull 2 Hypothyroidismbull 3 Malnutritionbull 4 Anorexia Nervosabull 5 Exercise amenorrheabull 6 Cushingsbull 7 Diabetesbull

Causes of Delayed Puberty

bull III Hypergonadotropic hypogonadism

bull A Turner Syndrome

bull B XX and XY gonadal dysgenesis

bull C Polycystic ovary Syndrome

bull D Noonans 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- Kallmanns 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 Klinefelters syndrome Other forms of primary testicular failureAnorchia or

cryptorchism- Females Turners syndromeOther forms of primary ovarian failure Pseudo-Turners

syndrome- Noonans 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 2512 years of age with idiopathic true precocious

13412-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 (-45 SD) and a weight of 286 kg (-3 SD) The patient had early stage 2 breast development There was no pubic hair Karyotype was 46XX Bone age was 10 years After administration of GnRH LH and FSH rose in a pubertal pattern Estradiol was 40 pgmL She has since spontaneously progressed through pubertal development

• TUMBUH KEMBANG REMAJA
• REMAJA
• Remaja awal (11-14 tahun)
• Remaja Tengah (15-17 tahun)
• Remaja Lanjut (Usia 18-21 tahun)
• FISIOLOGI PUBERTAS
• Pubertas
• Tanda Pubertas Perempuan
• Slide 9
• Tanda Pubertas Laki-laki
• Sexual Maturity Rating
• Pubertas Perempuan
• Pubertas Laki-laki
• Pertumbuhan fisik
• Slide 15
• Slide 16
• Lonjakan pertumbuhan
• Perkembangan psikososial
• MASALAH-MASALAH REMAJA
• Morbiditas
• Masalah lain
• Psychological Problems in Adolescence
• Slide 23
• Teen suicide (contrsquod)
• Cluster Suicides
• Warning signs of suicide
• Indikator remaja berisiko tinggi
• Slide 28
• Gejala psikofisiologis
• Terapi gejala psikofisiologi
• KLINIK REMAJA
• Sikap Dokter Dalam Menghadapi Pasien Remaja
• Pemberian pelayanan kesehatan
• Kerahasiaan
• What are The importan Aspects of an Adolescent History
• How to Talk to Teens about Puberty
• Wawancara
• Slide 38
• LAMPIRAN
• 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
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• CASE
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Causes of Short Stature
• Slide 65
• Slide 66
• Causes of Delayed Puberty
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73

Teen suicide (contrsquod)

bull Risk factors ndash Depression Social inhibition

Perfectionism

ndash Anxiety Family conflicts romantic rejection

ndash History of drugalcohol abuse gaylesbian orientation

Cluster Suicides

bull 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

bull Schools increasing using crisis teams to counsel students after one student is successful in suicide

Warning signs of suicide

bull Direct or indirect talk of suicidebull School difficulties writing a willbull Giving stuff away arranging for pet

carebull Change in appetite general

depressionbull Changes in behavior preoccupation

with death in art music or literature

Indikator remaja berisiko tinggi

1 Penurunan kemampuan belajar

2 Absen sekolah yang berlebihan

3 Keluhan psikosomatik yang seringmenetap

4 Perubahan kebiasaan tidur atau makan

5 Kesulitan konsentrasi atau kebosanan yang menetap

6 Tanda dan gejala stres atau kecemasan

Indikator remaja berisiko tinggi

7 Menarik diri atau berpindah kelompok8 Perilaku menentang atau kekerasan yang

hebat dan atau perubahan kepribadian yang radikal

9 Konflik dengan orang tua10 Perilaku seksual yang berlebihan11 Konflik dengan hukum12 Memperlihatkan pikiran bunuh diri13 Penyalahgunaan obat dan alkohol14 Melarikan diri dari rumah

Gejala psikofisiologis

bull Reaksi konversi perasaan tidak menyenangkan dikomunikasikan dengan gejala fisik ldquoperolehan sekunderrdquo

bull Riwayat dan temuan fisik tidak konsisten dengan konsep anatomi dan fisiologis

bull Cenderung mempunyai OT yang overprotektif dan menjadi semakin tergantung pada OT

Terapi gejala psikofisiologi

bull Jelaskan hubungan antara penyebab fisik dari nyeri emosional atau penyebab emosional dari nyeri fisik

bull Memberi dorongan untuk mengerti bahwa gejala dapat menetap

bull Membantu pasien meneruskan aktivitas harian yang normal

bull Obat-obatan jarang membantubull Dokter suportif dan tidak menduga bahwa

nyeri tidak benar-benar terjadi

KLINIK REMAJA

Sikap Dokter Dalam Menghadapi Pasien Remaja

bull Dokter tampil jujur sederhana tidak perlu tampil ldquoprofesionalrdquo berlebihan

bull Remaja kurang PD dokter hati-hati

bull Sensitif terhadap tingkat perkembangan

Pemberian pelayanan kesehatan

bull 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

bull Beritahu remaja dan orang tuanya tentang kerahasiaan yang akan dijaga

bull Waktu adekuat

bull Yakinkan bahwa dokter tidak akan mencampuri kehidupan pribadi remaja tetapi merupakan hal penting untuk kesehatannya

What are The importan Aspects of an Adolescent History

bull HEADSSS untuk melacak informasi psikososial yang penting dari pasien remaja

bull H Homehealthbull E EducationEmploymentEatingbull A ActivitiesAspirationAffiliationbull D Drugsbull S Sexbull S SleepSuicidebull S Shoplifting

How to Talk to Teens about Puberty

1048708 Be open and honest

1048708 Treat the teen with respect

1048708 Talk directly to the teen

1048708 Begin conversation with least

threatening topics

1048708 Provide confidentiality

Wawancara

Wawancara terpimpinPenilaian tugas-tugas psikoperkembanganPemeriksaan sistemik meliputi 1 Nutrisi2 Tidur3 Perawatan diri pengetahuan ttg

pemeriksaan sendiri 4 Olah raga5 Hubungan keluarga dan sahabat6 Teman sebaya

Wawancara

7 Sekolah8 Minat pendidikan dan pekerjaan 9 Tembakau10 Penyalahgunaan zat11 Seksualitas12 Kesehatan mental

Usahakan pasien mendapat kesan tertarik dan seperti mempunyai ldquodokternyardquo sendiri

LAMPIRAN

PHYSIOLOGY OF PUBERTYPhysical 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 25 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 134 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 25 SD below the mean and is considered to have delayed puberty

- By this definition 06 of the healthy population are classified as having constitutional delay in growth and adolescence

CASE

bull 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

bull 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)

bull 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 15 to 35 year period

bull 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 124 to 128 years of age African-American girls are maturing earlier

bull 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 115 years

bull 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 135 and 17 years of age Growth of the penis reaches a SMR (Tanner) stage V between 125 and 165 years of age Nocturnal emissions (wet dreams) may first appear during SMR stage III

bull 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

bull 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

bull 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

bull 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

bull 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)

bull

bull 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

bull 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

bull 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 50ile of the patients actual height)

bull 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 (Klinefelters syndrome)

Causes of Short Staturebull I Constitutional Short Staturebull II Primordial Dwarfism (intrauterine growth retardation)bull III Endocrine Causesbull A Growth Hormone Deficiencybull 1 Congenitalbull 2 Acquiredbull a HypothalamicPituitary Tumorsbull b Head Traumabull c CNS infectionsbull d Psychosocial Dwarfismbull 3 Laron Dwarfismbull 4 Hypothyroidismbull 5 Syndromes of Short Staturebull a Turner Syndrome (gonadal dysgenesis)bull b Noonans Syndromebull c Prader-Willi Syndromebull

Causes of Short Stature

bull IV Chronic Diseasebull A Heart Diseasebull B Pulmonarybull 1 Cystic Fibrosisbull 2 Asthmabull C GI Disordersbull D Hepatic Diseasebull E Renalbull V Iatrogenicbull A Corticosteroids anabolic steroidsbull B ADHD meds

bull Causes of Delayed Pubertybull I Constitutional Delay in Growth and Maturationbull II Hypogonadotropic hypogonadismbull A Central nervous system disordersbull 1 Tumors bull a Craniopharyngiomasbull b Gliomasbull c Germinomasbull 2 Radiation Therapybull 3 Congenital Malformationsbull

Causes of Delayed Puberty

bull B Isolated Growth Hormone Deficiencybull 1 Kallmanns Syndromebull C Miscellaneous Disordersbull 1 Prader-Willi Syndromebull 2 Hypothyroidismbull 3 Malnutritionbull 4 Anorexia Nervosabull 5 Exercise amenorrheabull 6 Cushingsbull 7 Diabetesbull

Causes of Delayed Puberty

bull III Hypergonadotropic hypogonadism

bull A Turner Syndrome

bull B XX and XY gonadal dysgenesis

bull C Polycystic ovary Syndrome

bull D Noonans 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- Kallmanns 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 Klinefelters syndrome Other forms of primary testicular failureAnorchia or

cryptorchism- Females Turners syndromeOther forms of primary ovarian failure Pseudo-Turners

syndrome- Noonans 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 2512 years of age with idiopathic true precocious

13412-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 (-45 SD) and a weight of 286 kg (-3 SD) The patient had early stage 2 breast development There was no pubic hair Karyotype was 46XX Bone age was 10 years After administration of GnRH LH and FSH rose in a pubertal pattern Estradiol was 40 pgmL She has since spontaneously progressed through pubertal development

• TUMBUH KEMBANG REMAJA
• REMAJA
• Remaja awal (11-14 tahun)
• Remaja Tengah (15-17 tahun)
• Remaja Lanjut (Usia 18-21 tahun)
• FISIOLOGI PUBERTAS
• Pubertas
• Tanda Pubertas Perempuan
• Slide 9
• Tanda Pubertas Laki-laki
• Sexual Maturity Rating
• Pubertas Perempuan
• Pubertas Laki-laki
• Pertumbuhan fisik
• Slide 15
• Slide 16
• Lonjakan pertumbuhan
• Perkembangan psikososial
• MASALAH-MASALAH REMAJA
• Morbiditas
• Masalah lain
• Psychological Problems in Adolescence
• Slide 23
• Teen suicide (contrsquod)
• Cluster Suicides
• Warning signs of suicide
• Indikator remaja berisiko tinggi
• Slide 28
• Gejala psikofisiologis
• Terapi gejala psikofisiologi
• KLINIK REMAJA
• Sikap Dokter Dalam Menghadapi Pasien Remaja
• Pemberian pelayanan kesehatan
• Kerahasiaan
• What are The importan Aspects of an Adolescent History
• How to Talk to Teens about Puberty
• Wawancara
• Slide 38
• LAMPIRAN
• 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
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• CASE
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Causes of Short Stature
• Slide 65
• Slide 66
• Causes of Delayed Puberty
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73

Cluster Suicides

bull 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

bull Schools increasing using crisis teams to counsel students after one student is successful in suicide

Warning signs of suicide

bull Direct or indirect talk of suicidebull School difficulties writing a willbull Giving stuff away arranging for pet

carebull Change in appetite general

depressionbull Changes in behavior preoccupation

with death in art music or literature

Indikator remaja berisiko tinggi

1 Penurunan kemampuan belajar

2 Absen sekolah yang berlebihan

3 Keluhan psikosomatik yang seringmenetap

4 Perubahan kebiasaan tidur atau makan

5 Kesulitan konsentrasi atau kebosanan yang menetap

6 Tanda dan gejala stres atau kecemasan

Indikator remaja berisiko tinggi

7 Menarik diri atau berpindah kelompok8 Perilaku menentang atau kekerasan yang

hebat dan atau perubahan kepribadian yang radikal

9 Konflik dengan orang tua10 Perilaku seksual yang berlebihan11 Konflik dengan hukum12 Memperlihatkan pikiran bunuh diri13 Penyalahgunaan obat dan alkohol14 Melarikan diri dari rumah

Gejala psikofisiologis

bull Reaksi konversi perasaan tidak menyenangkan dikomunikasikan dengan gejala fisik ldquoperolehan sekunderrdquo

bull Riwayat dan temuan fisik tidak konsisten dengan konsep anatomi dan fisiologis

bull Cenderung mempunyai OT yang overprotektif dan menjadi semakin tergantung pada OT

Terapi gejala psikofisiologi

bull Jelaskan hubungan antara penyebab fisik dari nyeri emosional atau penyebab emosional dari nyeri fisik

bull Memberi dorongan untuk mengerti bahwa gejala dapat menetap

bull Membantu pasien meneruskan aktivitas harian yang normal

bull Obat-obatan jarang membantubull Dokter suportif dan tidak menduga bahwa

nyeri tidak benar-benar terjadi

KLINIK REMAJA

Sikap Dokter Dalam Menghadapi Pasien Remaja

bull Dokter tampil jujur sederhana tidak perlu tampil ldquoprofesionalrdquo berlebihan

bull Remaja kurang PD dokter hati-hati

bull Sensitif terhadap tingkat perkembangan

Pemberian pelayanan kesehatan

bull 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

bull Beritahu remaja dan orang tuanya tentang kerahasiaan yang akan dijaga

bull Waktu adekuat

bull Yakinkan bahwa dokter tidak akan mencampuri kehidupan pribadi remaja tetapi merupakan hal penting untuk kesehatannya

What are The importan Aspects of an Adolescent History

bull HEADSSS untuk melacak informasi psikososial yang penting dari pasien remaja

bull H Homehealthbull E EducationEmploymentEatingbull A ActivitiesAspirationAffiliationbull D Drugsbull S Sexbull S SleepSuicidebull S Shoplifting

How to Talk to Teens about Puberty

1048708 Be open and honest

1048708 Treat the teen with respect

1048708 Talk directly to the teen

1048708 Begin conversation with least

threatening topics

1048708 Provide confidentiality

Wawancara

Wawancara terpimpinPenilaian tugas-tugas psikoperkembanganPemeriksaan sistemik meliputi 1 Nutrisi2 Tidur3 Perawatan diri pengetahuan ttg

pemeriksaan sendiri 4 Olah raga5 Hubungan keluarga dan sahabat6 Teman sebaya

Wawancara

7 Sekolah8 Minat pendidikan dan pekerjaan 9 Tembakau10 Penyalahgunaan zat11 Seksualitas12 Kesehatan mental

Usahakan pasien mendapat kesan tertarik dan seperti mempunyai ldquodokternyardquo sendiri

LAMPIRAN

PHYSIOLOGY OF PUBERTYPhysical 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 25 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 134 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 25 SD below the mean and is considered to have delayed puberty

- By this definition 06 of the healthy population are classified as having constitutional delay in growth and adolescence

CASE

bull 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

bull 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)

bull 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 15 to 35 year period

bull 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 124 to 128 years of age African-American girls are maturing earlier

bull 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 115 years

bull 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 135 and 17 years of age Growth of the penis reaches a SMR (Tanner) stage V between 125 and 165 years of age Nocturnal emissions (wet dreams) may first appear during SMR stage III

bull 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

bull 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

bull 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

bull 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

bull 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)

bull

bull 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

bull 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

bull 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 50ile of the patients actual height)

bull 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 (Klinefelters syndrome)

Causes of Short Staturebull I Constitutional Short Staturebull II Primordial Dwarfism (intrauterine growth retardation)bull III Endocrine Causesbull A Growth Hormone Deficiencybull 1 Congenitalbull 2 Acquiredbull a HypothalamicPituitary Tumorsbull b Head Traumabull c CNS infectionsbull d Psychosocial Dwarfismbull 3 Laron Dwarfismbull 4 Hypothyroidismbull 5 Syndromes of Short Staturebull a Turner Syndrome (gonadal dysgenesis)bull b Noonans Syndromebull c Prader-Willi Syndromebull

Causes of Short Stature

bull IV Chronic Diseasebull A Heart Diseasebull B Pulmonarybull 1 Cystic Fibrosisbull 2 Asthmabull C GI Disordersbull D Hepatic Diseasebull E Renalbull V Iatrogenicbull A Corticosteroids anabolic steroidsbull B ADHD meds

bull Causes of Delayed Pubertybull I Constitutional Delay in Growth and Maturationbull II Hypogonadotropic hypogonadismbull A Central nervous system disordersbull 1 Tumors bull a Craniopharyngiomasbull b Gliomasbull c Germinomasbull 2 Radiation Therapybull 3 Congenital Malformationsbull

Causes of Delayed Puberty

bull B Isolated Growth Hormone Deficiencybull 1 Kallmanns Syndromebull C Miscellaneous Disordersbull 1 Prader-Willi Syndromebull 2 Hypothyroidismbull 3 Malnutritionbull 4 Anorexia Nervosabull 5 Exercise amenorrheabull 6 Cushingsbull 7 Diabetesbull

Causes of Delayed Puberty

bull III Hypergonadotropic hypogonadism

bull A Turner Syndrome

bull B XX and XY gonadal dysgenesis

bull C Polycystic ovary Syndrome

bull D Noonans 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- Kallmanns 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 Klinefelters syndrome Other forms of primary testicular failureAnorchia or

cryptorchism- Females Turners syndromeOther forms of primary ovarian failure Pseudo-Turners

syndrome- Noonans 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 2512 years of age with idiopathic true precocious

13412-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 (-45 SD) and a weight of 286 kg (-3 SD) The patient had early stage 2 breast development There was no pubic hair Karyotype was 46XX Bone age was 10 years After administration of GnRH LH and FSH rose in a pubertal pattern Estradiol was 40 pgmL She has since spontaneously progressed through pubertal development

• TUMBUH KEMBANG REMAJA
• REMAJA
• Remaja awal (11-14 tahun)
• Remaja Tengah (15-17 tahun)
• Remaja Lanjut (Usia 18-21 tahun)
• FISIOLOGI PUBERTAS
• Pubertas
• Tanda Pubertas Perempuan
• Slide 9
• Tanda Pubertas Laki-laki
• Sexual Maturity Rating
• Pubertas Perempuan
• Pubertas Laki-laki
• Pertumbuhan fisik
• Slide 15
• Slide 16
• Lonjakan pertumbuhan
• Perkembangan psikososial
• MASALAH-MASALAH REMAJA
• Morbiditas
• Masalah lain
• Psychological Problems in Adolescence
• Slide 23
• Teen suicide (contrsquod)
• Cluster Suicides
• Warning signs of suicide
• Indikator remaja berisiko tinggi
• Slide 28
• Gejala psikofisiologis
• Terapi gejala psikofisiologi
• KLINIK REMAJA
• Sikap Dokter Dalam Menghadapi Pasien Remaja
• Pemberian pelayanan kesehatan
• Kerahasiaan
• What are The importan Aspects of an Adolescent History
• How to Talk to Teens about Puberty
• Wawancara
• Slide 38
• LAMPIRAN
• 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
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• CASE
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Causes of Short Stature
• Slide 65
• Slide 66
• Causes of Delayed Puberty
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73

Warning signs of suicide

bull Direct or indirect talk of suicidebull School difficulties writing a willbull Giving stuff away arranging for pet

carebull Change in appetite general

depressionbull Changes in behavior preoccupation

with death in art music or literature

Indikator remaja berisiko tinggi

1 Penurunan kemampuan belajar

2 Absen sekolah yang berlebihan

3 Keluhan psikosomatik yang seringmenetap

4 Perubahan kebiasaan tidur atau makan

5 Kesulitan konsentrasi atau kebosanan yang menetap

6 Tanda dan gejala stres atau kecemasan

Indikator remaja berisiko tinggi

7 Menarik diri atau berpindah kelompok8 Perilaku menentang atau kekerasan yang

hebat dan atau perubahan kepribadian yang radikal

9 Konflik dengan orang tua10 Perilaku seksual yang berlebihan11 Konflik dengan hukum12 Memperlihatkan pikiran bunuh diri13 Penyalahgunaan obat dan alkohol14 Melarikan diri dari rumah

Gejala psikofisiologis

bull Reaksi konversi perasaan tidak menyenangkan dikomunikasikan dengan gejala fisik ldquoperolehan sekunderrdquo

bull Riwayat dan temuan fisik tidak konsisten dengan konsep anatomi dan fisiologis

bull Cenderung mempunyai OT yang overprotektif dan menjadi semakin tergantung pada OT

Terapi gejala psikofisiologi

bull Jelaskan hubungan antara penyebab fisik dari nyeri emosional atau penyebab emosional dari nyeri fisik

bull Memberi dorongan untuk mengerti bahwa gejala dapat menetap

bull Membantu pasien meneruskan aktivitas harian yang normal

bull Obat-obatan jarang membantubull Dokter suportif dan tidak menduga bahwa

nyeri tidak benar-benar terjadi

KLINIK REMAJA

Sikap Dokter Dalam Menghadapi Pasien Remaja

bull Dokter tampil jujur sederhana tidak perlu tampil ldquoprofesionalrdquo berlebihan

bull Remaja kurang PD dokter hati-hati

bull Sensitif terhadap tingkat perkembangan

Pemberian pelayanan kesehatan

bull 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

bull Beritahu remaja dan orang tuanya tentang kerahasiaan yang akan dijaga

bull Waktu adekuat

bull Yakinkan bahwa dokter tidak akan mencampuri kehidupan pribadi remaja tetapi merupakan hal penting untuk kesehatannya

What are The importan Aspects of an Adolescent History

bull HEADSSS untuk melacak informasi psikososial yang penting dari pasien remaja

bull H Homehealthbull E EducationEmploymentEatingbull A ActivitiesAspirationAffiliationbull D Drugsbull S Sexbull S SleepSuicidebull S Shoplifting

How to Talk to Teens about Puberty

1048708 Be open and honest

1048708 Treat the teen with respect

1048708 Talk directly to the teen

1048708 Begin conversation with least

threatening topics

1048708 Provide confidentiality

Wawancara

Wawancara terpimpinPenilaian tugas-tugas psikoperkembanganPemeriksaan sistemik meliputi 1 Nutrisi2 Tidur3 Perawatan diri pengetahuan ttg

pemeriksaan sendiri 4 Olah raga5 Hubungan keluarga dan sahabat6 Teman sebaya

Wawancara

7 Sekolah8 Minat pendidikan dan pekerjaan 9 Tembakau10 Penyalahgunaan zat11 Seksualitas12 Kesehatan mental

Usahakan pasien mendapat kesan tertarik dan seperti mempunyai ldquodokternyardquo sendiri

LAMPIRAN

PHYSIOLOGY OF PUBERTYPhysical 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 25 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 134 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 25 SD below the mean and is considered to have delayed puberty

- By this definition 06 of the healthy population are classified as having constitutional delay in growth and adolescence

CASE

bull 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

bull 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)

bull 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 15 to 35 year period

bull 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 124 to 128 years of age African-American girls are maturing earlier

bull 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 115 years

bull 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 135 and 17 years of age Growth of the penis reaches a SMR (Tanner) stage V between 125 and 165 years of age Nocturnal emissions (wet dreams) may first appear during SMR stage III

bull 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

bull 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

bull 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

bull 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

bull 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)

bull

bull 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

bull 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

bull 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 50ile of the patients actual height)

bull 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 (Klinefelters syndrome)

Causes of Short Staturebull I Constitutional Short Staturebull II Primordial Dwarfism (intrauterine growth retardation)bull III Endocrine Causesbull A Growth Hormone Deficiencybull 1 Congenitalbull 2 Acquiredbull a HypothalamicPituitary Tumorsbull b Head Traumabull c CNS infectionsbull d Psychosocial Dwarfismbull 3 Laron Dwarfismbull 4 Hypothyroidismbull 5 Syndromes of Short Staturebull a Turner Syndrome (gonadal dysgenesis)bull b Noonans Syndromebull c Prader-Willi Syndromebull

Causes of Short Stature

bull IV Chronic Diseasebull A Heart Diseasebull B Pulmonarybull 1 Cystic Fibrosisbull 2 Asthmabull C GI Disordersbull D Hepatic Diseasebull E Renalbull V Iatrogenicbull A Corticosteroids anabolic steroidsbull B ADHD meds

bull Causes of Delayed Pubertybull I Constitutional Delay in Growth and Maturationbull II Hypogonadotropic hypogonadismbull A Central nervous system disordersbull 1 Tumors bull a Craniopharyngiomasbull b Gliomasbull c Germinomasbull 2 Radiation Therapybull 3 Congenital Malformationsbull

Causes of Delayed Puberty

bull B Isolated Growth Hormone Deficiencybull 1 Kallmanns Syndromebull C Miscellaneous Disordersbull 1 Prader-Willi Syndromebull 2 Hypothyroidismbull 3 Malnutritionbull 4 Anorexia Nervosabull 5 Exercise amenorrheabull 6 Cushingsbull 7 Diabetesbull

Causes of Delayed Puberty

bull III Hypergonadotropic hypogonadism

bull A Turner Syndrome

bull B XX and XY gonadal dysgenesis

bull C Polycystic ovary Syndrome

bull D Noonans 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- Kallmanns 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 Klinefelters syndrome Other forms of primary testicular failureAnorchia or

cryptorchism- Females Turners syndromeOther forms of primary ovarian failure Pseudo-Turners

syndrome- Noonans 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 2512 years of age with idiopathic true precocious

13412-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 (-45 SD) and a weight of 286 kg (-3 SD) The patient had early stage 2 breast development There was no pubic hair Karyotype was 46XX Bone age was 10 years After administration of GnRH LH and FSH rose in a pubertal pattern Estradiol was 40 pgmL She has since spontaneously progressed through pubertal development

• TUMBUH KEMBANG REMAJA
• REMAJA
• Remaja awal (11-14 tahun)
• Remaja Tengah (15-17 tahun)
• Remaja Lanjut (Usia 18-21 tahun)
• FISIOLOGI PUBERTAS
• Pubertas
• Tanda Pubertas Perempuan
• Slide 9
• Tanda Pubertas Laki-laki
• Sexual Maturity Rating
• Pubertas Perempuan
• Pubertas Laki-laki
• Pertumbuhan fisik
• Slide 15
• Slide 16
• Lonjakan pertumbuhan
• Perkembangan psikososial
• MASALAH-MASALAH REMAJA
• Morbiditas
• Masalah lain
• Psychological Problems in Adolescence
• Slide 23
• Teen suicide (contrsquod)
• Cluster Suicides
• Warning signs of suicide
• Indikator remaja berisiko tinggi
• Slide 28
• Gejala psikofisiologis
• Terapi gejala psikofisiologi
• KLINIK REMAJA
• Sikap Dokter Dalam Menghadapi Pasien Remaja
• Pemberian pelayanan kesehatan
• Kerahasiaan
• What are The importan Aspects of an Adolescent History
• How to Talk to Teens about Puberty
• Wawancara
• Slide 38
• LAMPIRAN
• 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
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• CASE
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Causes of Short Stature
• Slide 65
• Slide 66
• Causes of Delayed Puberty
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73

Indikator remaja berisiko tinggi

1 Penurunan kemampuan belajar

2 Absen sekolah yang berlebihan

3 Keluhan psikosomatik yang seringmenetap

4 Perubahan kebiasaan tidur atau makan

5 Kesulitan konsentrasi atau kebosanan yang menetap

6 Tanda dan gejala stres atau kecemasan

Indikator remaja berisiko tinggi

7 Menarik diri atau berpindah kelompok8 Perilaku menentang atau kekerasan yang

hebat dan atau perubahan kepribadian yang radikal

9 Konflik dengan orang tua10 Perilaku seksual yang berlebihan11 Konflik dengan hukum12 Memperlihatkan pikiran bunuh diri13 Penyalahgunaan obat dan alkohol14 Melarikan diri dari rumah

Gejala psikofisiologis

bull Reaksi konversi perasaan tidak menyenangkan dikomunikasikan dengan gejala fisik ldquoperolehan sekunderrdquo

bull Riwayat dan temuan fisik tidak konsisten dengan konsep anatomi dan fisiologis

bull Cenderung mempunyai OT yang overprotektif dan menjadi semakin tergantung pada OT

Terapi gejala psikofisiologi

bull Jelaskan hubungan antara penyebab fisik dari nyeri emosional atau penyebab emosional dari nyeri fisik

bull Memberi dorongan untuk mengerti bahwa gejala dapat menetap

bull Membantu pasien meneruskan aktivitas harian yang normal

bull Obat-obatan jarang membantubull Dokter suportif dan tidak menduga bahwa

nyeri tidak benar-benar terjadi

KLINIK REMAJA

Sikap Dokter Dalam Menghadapi Pasien Remaja

bull Dokter tampil jujur sederhana tidak perlu tampil ldquoprofesionalrdquo berlebihan

bull Remaja kurang PD dokter hati-hati

bull Sensitif terhadap tingkat perkembangan

Pemberian pelayanan kesehatan

bull 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

bull Beritahu remaja dan orang tuanya tentang kerahasiaan yang akan dijaga

bull Waktu adekuat

bull Yakinkan bahwa dokter tidak akan mencampuri kehidupan pribadi remaja tetapi merupakan hal penting untuk kesehatannya

What are The importan Aspects of an Adolescent History

bull HEADSSS untuk melacak informasi psikososial yang penting dari pasien remaja

bull H Homehealthbull E EducationEmploymentEatingbull A ActivitiesAspirationAffiliationbull D Drugsbull S Sexbull S SleepSuicidebull S Shoplifting

How to Talk to Teens about Puberty

1048708 Be open and honest

1048708 Treat the teen with respect

1048708 Talk directly to the teen

1048708 Begin conversation with least

threatening topics

1048708 Provide confidentiality

Wawancara

Wawancara terpimpinPenilaian tugas-tugas psikoperkembanganPemeriksaan sistemik meliputi 1 Nutrisi2 Tidur3 Perawatan diri pengetahuan ttg

pemeriksaan sendiri 4 Olah raga5 Hubungan keluarga dan sahabat6 Teman sebaya

Wawancara

7 Sekolah8 Minat pendidikan dan pekerjaan 9 Tembakau10 Penyalahgunaan zat11 Seksualitas12 Kesehatan mental

Usahakan pasien mendapat kesan tertarik dan seperti mempunyai ldquodokternyardquo sendiri

LAMPIRAN

PHYSIOLOGY OF PUBERTYPhysical 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 25 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 134 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 25 SD below the mean and is considered to have delayed puberty

- By this definition 06 of the healthy population are classified as having constitutional delay in growth and adolescence

CASE

bull 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

bull 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)

bull 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 15 to 35 year period

bull 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 124 to 128 years of age African-American girls are maturing earlier

bull 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 115 years

bull 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 135 and 17 years of age Growth of the penis reaches a SMR (Tanner) stage V between 125 and 165 years of age Nocturnal emissions (wet dreams) may first appear during SMR stage III

bull 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

bull 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

bull 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

bull 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

bull 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)

bull

bull 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

bull 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

bull 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 50ile of the patients actual height)

bull 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 (Klinefelters syndrome)

Causes of Short Staturebull I Constitutional Short Staturebull II Primordial Dwarfism (intrauterine growth retardation)bull III Endocrine Causesbull A Growth Hormone Deficiencybull 1 Congenitalbull 2 Acquiredbull a HypothalamicPituitary Tumorsbull b Head Traumabull c CNS infectionsbull d Psychosocial Dwarfismbull 3 Laron Dwarfismbull 4 Hypothyroidismbull 5 Syndromes of Short Staturebull a Turner Syndrome (gonadal dysgenesis)bull b Noonans Syndromebull c Prader-Willi Syndromebull

Causes of Short Stature

bull IV Chronic Diseasebull A Heart Diseasebull B Pulmonarybull 1 Cystic Fibrosisbull 2 Asthmabull C GI Disordersbull D Hepatic Diseasebull E Renalbull V Iatrogenicbull A Corticosteroids anabolic steroidsbull B ADHD meds

bull Causes of Delayed Pubertybull I Constitutional Delay in Growth and Maturationbull II Hypogonadotropic hypogonadismbull A Central nervous system disordersbull 1 Tumors bull a Craniopharyngiomasbull b Gliomasbull c Germinomasbull 2 Radiation Therapybull 3 Congenital Malformationsbull

Causes of Delayed Puberty

bull B Isolated Growth Hormone Deficiencybull 1 Kallmanns Syndromebull C Miscellaneous Disordersbull 1 Prader-Willi Syndromebull 2 Hypothyroidismbull 3 Malnutritionbull 4 Anorexia Nervosabull 5 Exercise amenorrheabull 6 Cushingsbull 7 Diabetesbull

Causes of Delayed Puberty

bull III Hypergonadotropic hypogonadism

bull A Turner Syndrome

bull B XX and XY gonadal dysgenesis

bull C Polycystic ovary Syndrome

bull D Noonans 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- Kallmanns 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 Klinefelters syndrome Other forms of primary testicular failureAnorchia or

cryptorchism- Females Turners syndromeOther forms of primary ovarian failure Pseudo-Turners

syndrome- Noonans 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 2512 years of age with idiopathic true precocious

13412-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 (-45 SD) and a weight of 286 kg (-3 SD) The patient had early stage 2 breast development There was no pubic hair Karyotype was 46XX Bone age was 10 years After administration of GnRH LH and FSH rose in a pubertal pattern Estradiol was 40 pgmL She has since spontaneously progressed through pubertal development

• TUMBUH KEMBANG REMAJA
• REMAJA
• Remaja awal (11-14 tahun)
• Remaja Tengah (15-17 tahun)
• Remaja Lanjut (Usia 18-21 tahun)
• FISIOLOGI PUBERTAS
• Pubertas
• Tanda Pubertas Perempuan
• Slide 9
• Tanda Pubertas Laki-laki
• Sexual Maturity Rating
• Pubertas Perempuan
• Pubertas Laki-laki
• Pertumbuhan fisik
• Slide 15
• Slide 16
• Lonjakan pertumbuhan
• Perkembangan psikososial
• MASALAH-MASALAH REMAJA
• Morbiditas
• Masalah lain
• Psychological Problems in Adolescence
• Slide 23
• Teen suicide (contrsquod)
• Cluster Suicides
• Warning signs of suicide
• Indikator remaja berisiko tinggi
• Slide 28
• Gejala psikofisiologis
• Terapi gejala psikofisiologi
• KLINIK REMAJA
• Sikap Dokter Dalam Menghadapi Pasien Remaja
• Pemberian pelayanan kesehatan
• Kerahasiaan
• What are The importan Aspects of an Adolescent History
• How to Talk to Teens about Puberty
• Wawancara
• Slide 38
• LAMPIRAN
• 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
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• CASE
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Causes of Short Stature
• Slide 65
• Slide 66
• Causes of Delayed Puberty
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73

Indikator remaja berisiko tinggi

7 Menarik diri atau berpindah kelompok8 Perilaku menentang atau kekerasan yang

hebat dan atau perubahan kepribadian yang radikal

9 Konflik dengan orang tua10 Perilaku seksual yang berlebihan11 Konflik dengan hukum12 Memperlihatkan pikiran bunuh diri13 Penyalahgunaan obat dan alkohol14 Melarikan diri dari rumah

Gejala psikofisiologis

bull Reaksi konversi perasaan tidak menyenangkan dikomunikasikan dengan gejala fisik ldquoperolehan sekunderrdquo

bull Riwayat dan temuan fisik tidak konsisten dengan konsep anatomi dan fisiologis

bull Cenderung mempunyai OT yang overprotektif dan menjadi semakin tergantung pada OT

Terapi gejala psikofisiologi

bull Jelaskan hubungan antara penyebab fisik dari nyeri emosional atau penyebab emosional dari nyeri fisik

bull Memberi dorongan untuk mengerti bahwa gejala dapat menetap

bull Membantu pasien meneruskan aktivitas harian yang normal

bull Obat-obatan jarang membantubull Dokter suportif dan tidak menduga bahwa

nyeri tidak benar-benar terjadi

KLINIK REMAJA

Sikap Dokter Dalam Menghadapi Pasien Remaja

bull Dokter tampil jujur sederhana tidak perlu tampil ldquoprofesionalrdquo berlebihan

bull Remaja kurang PD dokter hati-hati

bull Sensitif terhadap tingkat perkembangan

Pemberian pelayanan kesehatan

bull 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

bull Beritahu remaja dan orang tuanya tentang kerahasiaan yang akan dijaga

bull Waktu adekuat

bull Yakinkan bahwa dokter tidak akan mencampuri kehidupan pribadi remaja tetapi merupakan hal penting untuk kesehatannya

What are The importan Aspects of an Adolescent History

bull HEADSSS untuk melacak informasi psikososial yang penting dari pasien remaja

bull H Homehealthbull E EducationEmploymentEatingbull A ActivitiesAspirationAffiliationbull D Drugsbull S Sexbull S SleepSuicidebull S Shoplifting

How to Talk to Teens about Puberty

1048708 Be open and honest

1048708 Treat the teen with respect

1048708 Talk directly to the teen

1048708 Begin conversation with least

threatening topics

1048708 Provide confidentiality

Wawancara

Wawancara terpimpinPenilaian tugas-tugas psikoperkembanganPemeriksaan sistemik meliputi 1 Nutrisi2 Tidur3 Perawatan diri pengetahuan ttg

pemeriksaan sendiri 4 Olah raga5 Hubungan keluarga dan sahabat6 Teman sebaya

Wawancara

7 Sekolah8 Minat pendidikan dan pekerjaan 9 Tembakau10 Penyalahgunaan zat11 Seksualitas12 Kesehatan mental

Usahakan pasien mendapat kesan tertarik dan seperti mempunyai ldquodokternyardquo sendiri

LAMPIRAN

PHYSIOLOGY OF PUBERTYPhysical 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 25 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 134 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 25 SD below the mean and is considered to have delayed puberty

- By this definition 06 of the healthy population are classified as having constitutional delay in growth and adolescence

CASE

bull 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

bull 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)

bull 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 15 to 35 year period

bull 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 124 to 128 years of age African-American girls are maturing earlier

bull 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 115 years

bull 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 135 and 17 years of age Growth of the penis reaches a SMR (Tanner) stage V between 125 and 165 years of age Nocturnal emissions (wet dreams) may first appear during SMR stage III

bull 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

bull 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

bull 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

bull 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

bull 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)

bull

bull 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

bull 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

bull 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 50ile of the patients actual height)

bull 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 (Klinefelters syndrome)

Causes of Short Staturebull I Constitutional Short Staturebull II Primordial Dwarfism (intrauterine growth retardation)bull III Endocrine Causesbull A Growth Hormone Deficiencybull 1 Congenitalbull 2 Acquiredbull a HypothalamicPituitary Tumorsbull b Head Traumabull c CNS infectionsbull d Psychosocial Dwarfismbull 3 Laron Dwarfismbull 4 Hypothyroidismbull 5 Syndromes of Short Staturebull a Turner Syndrome (gonadal dysgenesis)bull b Noonans Syndromebull c Prader-Willi Syndromebull

Causes of Short Stature

bull IV Chronic Diseasebull A Heart Diseasebull B Pulmonarybull 1 Cystic Fibrosisbull 2 Asthmabull C GI Disordersbull D Hepatic Diseasebull E Renalbull V Iatrogenicbull A Corticosteroids anabolic steroidsbull B ADHD meds

bull Causes of Delayed Pubertybull I Constitutional Delay in Growth and Maturationbull II Hypogonadotropic hypogonadismbull A Central nervous system disordersbull 1 Tumors bull a Craniopharyngiomasbull b Gliomasbull c Germinomasbull 2 Radiation Therapybull 3 Congenital Malformationsbull

Causes of Delayed Puberty

bull B Isolated Growth Hormone Deficiencybull 1 Kallmanns Syndromebull C Miscellaneous Disordersbull 1 Prader-Willi Syndromebull 2 Hypothyroidismbull 3 Malnutritionbull 4 Anorexia Nervosabull 5 Exercise amenorrheabull 6 Cushingsbull 7 Diabetesbull

Causes of Delayed Puberty

bull III Hypergonadotropic hypogonadism

bull A Turner Syndrome

bull B XX and XY gonadal dysgenesis

bull C Polycystic ovary Syndrome

bull D Noonans 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- Kallmanns 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 Klinefelters syndrome Other forms of primary testicular failureAnorchia or

cryptorchism- Females Turners syndromeOther forms of primary ovarian failure Pseudo-Turners

syndrome- Noonans 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 2512 years of age with idiopathic true precocious

13412-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 (-45 SD) and a weight of 286 kg (-3 SD) The patient had early stage 2 breast development There was no pubic hair Karyotype was 46XX Bone age was 10 years After administration of GnRH LH and FSH rose in a pubertal pattern Estradiol was 40 pgmL She has since spontaneously progressed through pubertal development

• TUMBUH KEMBANG REMAJA
• REMAJA
• Remaja awal (11-14 tahun)
• Remaja Tengah (15-17 tahun)
• Remaja Lanjut (Usia 18-21 tahun)
• FISIOLOGI PUBERTAS
• Pubertas
• Tanda Pubertas Perempuan
• Slide 9
• Tanda Pubertas Laki-laki
• Sexual Maturity Rating
• Pubertas Perempuan
• Pubertas Laki-laki
• Pertumbuhan fisik
• Slide 15
• Slide 16
• Lonjakan pertumbuhan
• Perkembangan psikososial
• MASALAH-MASALAH REMAJA
• Morbiditas
• Masalah lain
• Psychological Problems in Adolescence
• Slide 23
• Teen suicide (contrsquod)
• Cluster Suicides
• Warning signs of suicide
• Indikator remaja berisiko tinggi
• Slide 28
• Gejala psikofisiologis
• Terapi gejala psikofisiologi
• KLINIK REMAJA
• Sikap Dokter Dalam Menghadapi Pasien Remaja
• Pemberian pelayanan kesehatan
• Kerahasiaan
• What are The importan Aspects of an Adolescent History
• How to Talk to Teens about Puberty
• Wawancara
• Slide 38
• LAMPIRAN
• 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
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• CASE
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Causes of Short Stature
• Slide 65
• Slide 66
• Causes of Delayed Puberty
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73

Gejala psikofisiologis

bull Reaksi konversi perasaan tidak menyenangkan dikomunikasikan dengan gejala fisik ldquoperolehan sekunderrdquo

bull Riwayat dan temuan fisik tidak konsisten dengan konsep anatomi dan fisiologis

bull Cenderung mempunyai OT yang overprotektif dan menjadi semakin tergantung pada OT

Terapi gejala psikofisiologi

bull Jelaskan hubungan antara penyebab fisik dari nyeri emosional atau penyebab emosional dari nyeri fisik

bull Memberi dorongan untuk mengerti bahwa gejala dapat menetap

bull Membantu pasien meneruskan aktivitas harian yang normal

bull Obat-obatan jarang membantubull Dokter suportif dan tidak menduga bahwa

nyeri tidak benar-benar terjadi

KLINIK REMAJA

Sikap Dokter Dalam Menghadapi Pasien Remaja

bull Dokter tampil jujur sederhana tidak perlu tampil ldquoprofesionalrdquo berlebihan

bull Remaja kurang PD dokter hati-hati

bull Sensitif terhadap tingkat perkembangan

Pemberian pelayanan kesehatan

bull 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

bull Beritahu remaja dan orang tuanya tentang kerahasiaan yang akan dijaga

bull Waktu adekuat

bull Yakinkan bahwa dokter tidak akan mencampuri kehidupan pribadi remaja tetapi merupakan hal penting untuk kesehatannya

What are The importan Aspects of an Adolescent History

bull HEADSSS untuk melacak informasi psikososial yang penting dari pasien remaja

bull H Homehealthbull E EducationEmploymentEatingbull A ActivitiesAspirationAffiliationbull D Drugsbull S Sexbull S SleepSuicidebull S Shoplifting

How to Talk to Teens about Puberty

1048708 Be open and honest

1048708 Treat the teen with respect

1048708 Talk directly to the teen

1048708 Begin conversation with least

threatening topics

1048708 Provide confidentiality

Wawancara

Wawancara terpimpinPenilaian tugas-tugas psikoperkembanganPemeriksaan sistemik meliputi 1 Nutrisi2 Tidur3 Perawatan diri pengetahuan ttg

pemeriksaan sendiri 4 Olah raga5 Hubungan keluarga dan sahabat6 Teman sebaya

Wawancara

7 Sekolah8 Minat pendidikan dan pekerjaan 9 Tembakau10 Penyalahgunaan zat11 Seksualitas12 Kesehatan mental

Usahakan pasien mendapat kesan tertarik dan seperti mempunyai ldquodokternyardquo sendiri

LAMPIRAN

PHYSIOLOGY OF PUBERTYPhysical 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 25 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 134 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 25 SD below the mean and is considered to have delayed puberty

- By this definition 06 of the healthy population are classified as having constitutional delay in growth and adolescence

CASE

bull 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

bull 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)

bull 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 15 to 35 year period

bull 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 124 to 128 years of age African-American girls are maturing earlier

bull 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 115 years

bull 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 135 and 17 years of age Growth of the penis reaches a SMR (Tanner) stage V between 125 and 165 years of age Nocturnal emissions (wet dreams) may first appear during SMR stage III

bull 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

bull 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

bull 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

bull 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

bull 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)

bull

bull 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

bull 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

bull 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 50ile of the patients actual height)

bull 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 (Klinefelters syndrome)

Causes of Short Staturebull I Constitutional Short Staturebull II Primordial Dwarfism (intrauterine growth retardation)bull III Endocrine Causesbull A Growth Hormone Deficiencybull 1 Congenitalbull 2 Acquiredbull a HypothalamicPituitary Tumorsbull b Head Traumabull c CNS infectionsbull d Psychosocial Dwarfismbull 3 Laron Dwarfismbull 4 Hypothyroidismbull 5 Syndromes of Short Staturebull a Turner Syndrome (gonadal dysgenesis)bull b Noonans Syndromebull c Prader-Willi Syndromebull

Causes of Short Stature

bull IV Chronic Diseasebull A Heart Diseasebull B Pulmonarybull 1 Cystic Fibrosisbull 2 Asthmabull C GI Disordersbull D Hepatic Diseasebull E Renalbull V Iatrogenicbull A Corticosteroids anabolic steroidsbull B ADHD meds

bull Causes of Delayed Pubertybull I Constitutional Delay in Growth and Maturationbull II Hypogonadotropic hypogonadismbull A Central nervous system disordersbull 1 Tumors bull a Craniopharyngiomasbull b Gliomasbull c Germinomasbull 2 Radiation Therapybull 3 Congenital Malformationsbull

Causes of Delayed Puberty

bull B Isolated Growth Hormone Deficiencybull 1 Kallmanns Syndromebull C Miscellaneous Disordersbull 1 Prader-Willi Syndromebull 2 Hypothyroidismbull 3 Malnutritionbull 4 Anorexia Nervosabull 5 Exercise amenorrheabull 6 Cushingsbull 7 Diabetesbull

Causes of Delayed Puberty

bull III Hypergonadotropic hypogonadism

bull A Turner Syndrome

bull B XX and XY gonadal dysgenesis

bull C Polycystic ovary Syndrome

bull D Noonans 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- Kallmanns 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 Klinefelters syndrome Other forms of primary testicular failureAnorchia or

cryptorchism- Females Turners syndromeOther forms of primary ovarian failure Pseudo-Turners

syndrome- Noonans 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 2512 years of age with idiopathic true precocious

13412-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 (-45 SD) and a weight of 286 kg (-3 SD) The patient had early stage 2 breast development There was no pubic hair Karyotype was 46XX Bone age was 10 years After administration of GnRH LH and FSH rose in a pubertal pattern Estradiol was 40 pgmL She has since spontaneously progressed through pubertal development

• TUMBUH KEMBANG REMAJA
• REMAJA
• Remaja awal (11-14 tahun)
• Remaja Tengah (15-17 tahun)
• Remaja Lanjut (Usia 18-21 tahun)
• FISIOLOGI PUBERTAS
• Pubertas
• Tanda Pubertas Perempuan
• Slide 9
• Tanda Pubertas Laki-laki
• Sexual Maturity Rating
• Pubertas Perempuan
• Pubertas Laki-laki
• Pertumbuhan fisik
• Slide 15
• Slide 16
• Lonjakan pertumbuhan
• Perkembangan psikososial
• MASALAH-MASALAH REMAJA
• Morbiditas
• Masalah lain
• Psychological Problems in Adolescence
• Slide 23
• Teen suicide (contrsquod)
• Cluster Suicides
• Warning signs of suicide
• Indikator remaja berisiko tinggi
• Slide 28
• Gejala psikofisiologis
• Terapi gejala psikofisiologi
• KLINIK REMAJA
• Sikap Dokter Dalam Menghadapi Pasien Remaja
• Pemberian pelayanan kesehatan
• Kerahasiaan
• What are The importan Aspects of an Adolescent History
• How to Talk to Teens about Puberty
• Wawancara
• Slide 38
• LAMPIRAN
• 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
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• CASE
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Causes of Short Stature
• Slide 65
• Slide 66
• Causes of Delayed Puberty
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73

Terapi gejala psikofisiologi

bull Jelaskan hubungan antara penyebab fisik dari nyeri emosional atau penyebab emosional dari nyeri fisik

bull Memberi dorongan untuk mengerti bahwa gejala dapat menetap

bull Membantu pasien meneruskan aktivitas harian yang normal

bull Obat-obatan jarang membantubull Dokter suportif dan tidak menduga bahwa

nyeri tidak benar-benar terjadi

KLINIK REMAJA

Sikap Dokter Dalam Menghadapi Pasien Remaja

bull Dokter tampil jujur sederhana tidak perlu tampil ldquoprofesionalrdquo berlebihan

bull Remaja kurang PD dokter hati-hati

bull Sensitif terhadap tingkat perkembangan

Pemberian pelayanan kesehatan

bull 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

bull Beritahu remaja dan orang tuanya tentang kerahasiaan yang akan dijaga

bull Waktu adekuat

bull Yakinkan bahwa dokter tidak akan mencampuri kehidupan pribadi remaja tetapi merupakan hal penting untuk kesehatannya

What are The importan Aspects of an Adolescent History

bull HEADSSS untuk melacak informasi psikososial yang penting dari pasien remaja

bull H Homehealthbull E EducationEmploymentEatingbull A ActivitiesAspirationAffiliationbull D Drugsbull S Sexbull S SleepSuicidebull S Shoplifting

How to Talk to Teens about Puberty

1048708 Be open and honest

1048708 Treat the teen with respect

1048708 Talk directly to the teen

1048708 Begin conversation with least

threatening topics

1048708 Provide confidentiality

Wawancara

Wawancara terpimpinPenilaian tugas-tugas psikoperkembanganPemeriksaan sistemik meliputi 1 Nutrisi2 Tidur3 Perawatan diri pengetahuan ttg

pemeriksaan sendiri 4 Olah raga5 Hubungan keluarga dan sahabat6 Teman sebaya

Wawancara

7 Sekolah8 Minat pendidikan dan pekerjaan 9 Tembakau10 Penyalahgunaan zat11 Seksualitas12 Kesehatan mental

Usahakan pasien mendapat kesan tertarik dan seperti mempunyai ldquodokternyardquo sendiri

LAMPIRAN

PHYSIOLOGY OF PUBERTYPhysical 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 25 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 134 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 25 SD below the mean and is considered to have delayed puberty

- By this definition 06 of the healthy population are classified as having constitutional delay in growth and adolescence

CASE

bull 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

bull 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)

bull 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 15 to 35 year period

bull 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 124 to 128 years of age African-American girls are maturing earlier

bull 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 115 years

bull 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 135 and 17 years of age Growth of the penis reaches a SMR (Tanner) stage V between 125 and 165 years of age Nocturnal emissions (wet dreams) may first appear during SMR stage III

bull 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

bull 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

bull 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

bull 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

bull 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)

bull

bull 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

bull 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

bull 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 50ile of the patients actual height)

bull 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 (Klinefelters syndrome)

Causes of Short Staturebull I Constitutional Short Staturebull II Primordial Dwarfism (intrauterine growth retardation)bull III Endocrine Causesbull A Growth Hormone Deficiencybull 1 Congenitalbull 2 Acquiredbull a HypothalamicPituitary Tumorsbull b Head Traumabull c CNS infectionsbull d Psychosocial Dwarfismbull 3 Laron Dwarfismbull 4 Hypothyroidismbull 5 Syndromes of Short Staturebull a Turner Syndrome (gonadal dysgenesis)bull b Noonans Syndromebull c Prader-Willi Syndromebull

Causes of Short Stature

bull IV Chronic Diseasebull A Heart Diseasebull B Pulmonarybull 1 Cystic Fibrosisbull 2 Asthmabull C GI Disordersbull D Hepatic Diseasebull E Renalbull V Iatrogenicbull A Corticosteroids anabolic steroidsbull B ADHD meds

bull Causes of Delayed Pubertybull I Constitutional Delay in Growth and Maturationbull II Hypogonadotropic hypogonadismbull A Central nervous system disordersbull 1 Tumors bull a Craniopharyngiomasbull b Gliomasbull c Germinomasbull 2 Radiation Therapybull 3 Congenital Malformationsbull

Causes of Delayed Puberty

bull B Isolated Growth Hormone Deficiencybull 1 Kallmanns Syndromebull C Miscellaneous Disordersbull 1 Prader-Willi Syndromebull 2 Hypothyroidismbull 3 Malnutritionbull 4 Anorexia Nervosabull 5 Exercise amenorrheabull 6 Cushingsbull 7 Diabetesbull

Causes of Delayed Puberty

bull III Hypergonadotropic hypogonadism

bull A Turner Syndrome

bull B XX and XY gonadal dysgenesis

bull C Polycystic ovary Syndrome

bull D Noonans 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- Kallmanns 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 Klinefelters syndrome Other forms of primary testicular failureAnorchia or

cryptorchism- Females Turners syndromeOther forms of primary ovarian failure Pseudo-Turners

syndrome- Noonans 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 2512 years of age with idiopathic true precocious

13412-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 (-45 SD) and a weight of 286 kg (-3 SD) The patient had early stage 2 breast development There was no pubic hair Karyotype was 46XX Bone age was 10 years After administration of GnRH LH and FSH rose in a pubertal pattern Estradiol was 40 pgmL She has since spontaneously progressed through pubertal development

• TUMBUH KEMBANG REMAJA
• REMAJA
• Remaja awal (11-14 tahun)
• Remaja Tengah (15-17 tahun)
• Remaja Lanjut (Usia 18-21 tahun)
• FISIOLOGI PUBERTAS
• Pubertas
• Tanda Pubertas Perempuan
• Slide 9
• Tanda Pubertas Laki-laki
• Sexual Maturity Rating
• Pubertas Perempuan
• Pubertas Laki-laki
• Pertumbuhan fisik
• Slide 15
• Slide 16
• Lonjakan pertumbuhan
• Perkembangan psikososial
• MASALAH-MASALAH REMAJA
• Morbiditas
• Masalah lain
• Psychological Problems in Adolescence
• Slide 23
• Teen suicide (contrsquod)
• Cluster Suicides
• Warning signs of suicide
• Indikator remaja berisiko tinggi
• Slide 28
• Gejala psikofisiologis
• Terapi gejala psikofisiologi
• KLINIK REMAJA
• Sikap Dokter Dalam Menghadapi Pasien Remaja
• Pemberian pelayanan kesehatan
• Kerahasiaan
• What are The importan Aspects of an Adolescent History
• How to Talk to Teens about Puberty
• Wawancara
• Slide 38
• LAMPIRAN
• 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
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• CASE
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Causes of Short Stature
• Slide 65
• Slide 66
• Causes of Delayed Puberty
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73

KLINIK REMAJA

Sikap Dokter Dalam Menghadapi Pasien Remaja

bull Dokter tampil jujur sederhana tidak perlu tampil ldquoprofesionalrdquo berlebihan

bull Remaja kurang PD dokter hati-hati

bull Sensitif terhadap tingkat perkembangan

Pemberian pelayanan kesehatan

bull 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

bull Beritahu remaja dan orang tuanya tentang kerahasiaan yang akan dijaga

bull Waktu adekuat

bull Yakinkan bahwa dokter tidak akan mencampuri kehidupan pribadi remaja tetapi merupakan hal penting untuk kesehatannya

What are The importan Aspects of an Adolescent History

bull HEADSSS untuk melacak informasi psikososial yang penting dari pasien remaja

bull H Homehealthbull E EducationEmploymentEatingbull A ActivitiesAspirationAffiliationbull D Drugsbull S Sexbull S SleepSuicidebull S Shoplifting

How to Talk to Teens about Puberty

1048708 Be open and honest

1048708 Treat the teen with respect

1048708 Talk directly to the teen

1048708 Begin conversation with least

threatening topics

1048708 Provide confidentiality

Wawancara

Wawancara terpimpinPenilaian tugas-tugas psikoperkembanganPemeriksaan sistemik meliputi 1 Nutrisi2 Tidur3 Perawatan diri pengetahuan ttg

pemeriksaan sendiri 4 Olah raga5 Hubungan keluarga dan sahabat6 Teman sebaya

Wawancara

7 Sekolah8 Minat pendidikan dan pekerjaan 9 Tembakau10 Penyalahgunaan zat11 Seksualitas12 Kesehatan mental

Usahakan pasien mendapat kesan tertarik dan seperti mempunyai ldquodokternyardquo sendiri

LAMPIRAN

PHYSIOLOGY OF PUBERTYPhysical 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 25 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 134 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 25 SD below the mean and is considered to have delayed puberty

- By this definition 06 of the healthy population are classified as having constitutional delay in growth and adolescence

CASE

bull 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

bull 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)

bull 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 15 to 35 year period

bull 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 124 to 128 years of age African-American girls are maturing earlier

bull 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 115 years

bull 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 135 and 17 years of age Growth of the penis reaches a SMR (Tanner) stage V between 125 and 165 years of age Nocturnal emissions (wet dreams) may first appear during SMR stage III

bull 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

bull 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

bull 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

bull 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

bull 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)

bull

bull 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

bull 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

bull 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 50ile of the patients actual height)

bull 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 (Klinefelters syndrome)

Causes of Short Staturebull I Constitutional Short Staturebull II Primordial Dwarfism (intrauterine growth retardation)bull III Endocrine Causesbull A Growth Hormone Deficiencybull 1 Congenitalbull 2 Acquiredbull a HypothalamicPituitary Tumorsbull b Head Traumabull c CNS infectionsbull d Psychosocial Dwarfismbull 3 Laron Dwarfismbull 4 Hypothyroidismbull 5 Syndromes of Short Staturebull a Turner Syndrome (gonadal dysgenesis)bull b Noonans Syndromebull c Prader-Willi Syndromebull

Causes of Short Stature

bull IV Chronic Diseasebull A Heart Diseasebull B Pulmonarybull 1 Cystic Fibrosisbull 2 Asthmabull C GI Disordersbull D Hepatic Diseasebull E Renalbull V Iatrogenicbull A Corticosteroids anabolic steroidsbull B ADHD meds

bull Causes of Delayed Pubertybull I Constitutional Delay in Growth and Maturationbull II Hypogonadotropic hypogonadismbull A Central nervous system disordersbull 1 Tumors bull a Craniopharyngiomasbull b Gliomasbull c Germinomasbull 2 Radiation Therapybull 3 Congenital Malformationsbull

Causes of Delayed Puberty

bull B Isolated Growth Hormone Deficiencybull 1 Kallmanns Syndromebull C Miscellaneous Disordersbull 1 Prader-Willi Syndromebull 2 Hypothyroidismbull 3 Malnutritionbull 4 Anorexia Nervosabull 5 Exercise amenorrheabull 6 Cushingsbull 7 Diabetesbull

Causes of Delayed Puberty

bull III Hypergonadotropic hypogonadism

bull A Turner Syndrome

bull B XX and XY gonadal dysgenesis

bull C Polycystic ovary Syndrome

bull D Noonans 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- Kallmanns 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 Klinefelters syndrome Other forms of primary testicular failureAnorchia or

cryptorchism- Females Turners syndromeOther forms of primary ovarian failure Pseudo-Turners

syndrome- Noonans 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 2512 years of age with idiopathic true precocious

13412-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 (-45 SD) and a weight of 286 kg (-3 SD) The patient had early stage 2 breast development There was no pubic hair Karyotype was 46XX Bone age was 10 years After administration of GnRH LH and FSH rose in a pubertal pattern Estradiol was 40 pgmL She has since spontaneously progressed through pubertal development

• TUMBUH KEMBANG REMAJA
• REMAJA
• Remaja awal (11-14 tahun)
• Remaja Tengah (15-17 tahun)
• Remaja Lanjut (Usia 18-21 tahun)
• FISIOLOGI PUBERTAS
• Pubertas
• Tanda Pubertas Perempuan
• Slide 9
• Tanda Pubertas Laki-laki
• Sexual Maturity Rating
• Pubertas Perempuan
• Pubertas Laki-laki
• Pertumbuhan fisik
• Slide 15
• Slide 16
• Lonjakan pertumbuhan
• Perkembangan psikososial
• MASALAH-MASALAH REMAJA
• Morbiditas
• Masalah lain
• Psychological Problems in Adolescence
• Slide 23
• Teen suicide (contrsquod)
• Cluster Suicides
• Warning signs of suicide
• Indikator remaja berisiko tinggi
• Slide 28
• Gejala psikofisiologis
• Terapi gejala psikofisiologi
• KLINIK REMAJA
• Sikap Dokter Dalam Menghadapi Pasien Remaja
• Pemberian pelayanan kesehatan
• Kerahasiaan
• What are The importan Aspects of an Adolescent History
• How to Talk to Teens about Puberty
• Wawancara
• Slide 38
• LAMPIRAN
• 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
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• CASE
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Causes of Short Stature
• Slide 65
• Slide 66
• Causes of Delayed Puberty
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73

Sikap Dokter Dalam Menghadapi Pasien Remaja

bull Dokter tampil jujur sederhana tidak perlu tampil ldquoprofesionalrdquo berlebihan

bull Remaja kurang PD dokter hati-hati

bull Sensitif terhadap tingkat perkembangan

Pemberian pelayanan kesehatan

bull 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

bull Beritahu remaja dan orang tuanya tentang kerahasiaan yang akan dijaga

bull Waktu adekuat

bull Yakinkan bahwa dokter tidak akan mencampuri kehidupan pribadi remaja tetapi merupakan hal penting untuk kesehatannya

What are The importan Aspects of an Adolescent History

bull HEADSSS untuk melacak informasi psikososial yang penting dari pasien remaja

bull H Homehealthbull E EducationEmploymentEatingbull A ActivitiesAspirationAffiliationbull D Drugsbull S Sexbull S SleepSuicidebull S Shoplifting

How to Talk to Teens about Puberty

1048708 Be open and honest

1048708 Treat the teen with respect

1048708 Talk directly to the teen

1048708 Begin conversation with least

threatening topics

1048708 Provide confidentiality

Wawancara

Wawancara terpimpinPenilaian tugas-tugas psikoperkembanganPemeriksaan sistemik meliputi 1 Nutrisi2 Tidur3 Perawatan diri pengetahuan ttg

pemeriksaan sendiri 4 Olah raga5 Hubungan keluarga dan sahabat6 Teman sebaya

Wawancara

7 Sekolah8 Minat pendidikan dan pekerjaan 9 Tembakau10 Penyalahgunaan zat11 Seksualitas12 Kesehatan mental

Usahakan pasien mendapat kesan tertarik dan seperti mempunyai ldquodokternyardquo sendiri

LAMPIRAN

PHYSIOLOGY OF PUBERTYPhysical 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 25 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 134 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 25 SD below the mean and is considered to have delayed puberty

- By this definition 06 of the healthy population are classified as having constitutional delay in growth and adolescence

CASE

bull 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

bull 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)

bull 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 15 to 35 year period

bull 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 124 to 128 years of age African-American girls are maturing earlier

bull 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 115 years

bull 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 135 and 17 years of age Growth of the penis reaches a SMR (Tanner) stage V between 125 and 165 years of age Nocturnal emissions (wet dreams) may first appear during SMR stage III

bull 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

bull 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

bull 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

bull 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

bull 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)

bull

bull 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

bull 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

bull 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 50ile of the patients actual height)

bull 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 (Klinefelters syndrome)

Causes of Short Staturebull I Constitutional Short Staturebull II Primordial Dwarfism (intrauterine growth retardation)bull III Endocrine Causesbull A Growth Hormone Deficiencybull 1 Congenitalbull 2 Acquiredbull a HypothalamicPituitary Tumorsbull b Head Traumabull c CNS infectionsbull d Psychosocial Dwarfismbull 3 Laron Dwarfismbull 4 Hypothyroidismbull 5 Syndromes of Short Staturebull a Turner Syndrome (gonadal dysgenesis)bull b Noonans Syndromebull c Prader-Willi Syndromebull

Causes of Short Stature

bull IV Chronic Diseasebull A Heart Diseasebull B Pulmonarybull 1 Cystic Fibrosisbull 2 Asthmabull C GI Disordersbull D Hepatic Diseasebull E Renalbull V Iatrogenicbull A Corticosteroids anabolic steroidsbull B ADHD meds

bull Causes of Delayed Pubertybull I Constitutional Delay in Growth and Maturationbull II Hypogonadotropic hypogonadismbull A Central nervous system disordersbull 1 Tumors bull a Craniopharyngiomasbull b Gliomasbull c Germinomasbull 2 Radiation Therapybull 3 Congenital Malformationsbull

Causes of Delayed Puberty

bull B Isolated Growth Hormone Deficiencybull 1 Kallmanns Syndromebull C Miscellaneous Disordersbull 1 Prader-Willi Syndromebull 2 Hypothyroidismbull 3 Malnutritionbull 4 Anorexia Nervosabull 5 Exercise amenorrheabull 6 Cushingsbull 7 Diabetesbull

Causes of Delayed Puberty

bull III Hypergonadotropic hypogonadism

bull A Turner Syndrome

bull B XX and XY gonadal dysgenesis

bull C Polycystic ovary Syndrome

bull D Noonans 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- Kallmanns 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 Klinefelters syndrome Other forms of primary testicular failureAnorchia or

cryptorchism- Females Turners syndromeOther forms of primary ovarian failure Pseudo-Turners

syndrome- Noonans 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 2512 years of age with idiopathic true precocious

13412-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 (-45 SD) and a weight of 286 kg (-3 SD) The patient had early stage 2 breast development There was no pubic hair Karyotype was 46XX Bone age was 10 years After administration of GnRH LH and FSH rose in a pubertal pattern Estradiol was 40 pgmL She has since spontaneously progressed through pubertal development

• TUMBUH KEMBANG REMAJA
• REMAJA
• Remaja awal (11-14 tahun)
• Remaja Tengah (15-17 tahun)
• Remaja Lanjut (Usia 18-21 tahun)
• FISIOLOGI PUBERTAS
• Pubertas
• Tanda Pubertas Perempuan
• Slide 9
• Tanda Pubertas Laki-laki
• Sexual Maturity Rating
• Pubertas Perempuan
• Pubertas Laki-laki
• Pertumbuhan fisik
• Slide 15
• Slide 16
• Lonjakan pertumbuhan
• Perkembangan psikososial
• MASALAH-MASALAH REMAJA
• Morbiditas
• Masalah lain
• Psychological Problems in Adolescence
• Slide 23
• Teen suicide (contrsquod)
• Cluster Suicides
• Warning signs of suicide
• Indikator remaja berisiko tinggi
• Slide 28
• Gejala psikofisiologis
• Terapi gejala psikofisiologi
• KLINIK REMAJA
• Sikap Dokter Dalam Menghadapi Pasien Remaja
• Pemberian pelayanan kesehatan
• Kerahasiaan
• What are The importan Aspects of an Adolescent History
• How to Talk to Teens about Puberty
• Wawancara
• Slide 38
• LAMPIRAN
• 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
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• CASE
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Causes of Short Stature
• Slide 65
• Slide 66
• Causes of Delayed Puberty
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73

Pemberian pelayanan kesehatan

bull 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

bull Beritahu remaja dan orang tuanya tentang kerahasiaan yang akan dijaga

bull Waktu adekuat

bull Yakinkan bahwa dokter tidak akan mencampuri kehidupan pribadi remaja tetapi merupakan hal penting untuk kesehatannya

What are The importan Aspects of an Adolescent History

bull HEADSSS untuk melacak informasi psikososial yang penting dari pasien remaja

bull H Homehealthbull E EducationEmploymentEatingbull A ActivitiesAspirationAffiliationbull D Drugsbull S Sexbull S SleepSuicidebull S Shoplifting

How to Talk to Teens about Puberty

1048708 Be open and honest

1048708 Treat the teen with respect

1048708 Talk directly to the teen

1048708 Begin conversation with least

threatening topics

1048708 Provide confidentiality

Wawancara

Wawancara terpimpinPenilaian tugas-tugas psikoperkembanganPemeriksaan sistemik meliputi 1 Nutrisi2 Tidur3 Perawatan diri pengetahuan ttg

pemeriksaan sendiri 4 Olah raga5 Hubungan keluarga dan sahabat6 Teman sebaya

Wawancara

7 Sekolah8 Minat pendidikan dan pekerjaan 9 Tembakau10 Penyalahgunaan zat11 Seksualitas12 Kesehatan mental

Usahakan pasien mendapat kesan tertarik dan seperti mempunyai ldquodokternyardquo sendiri

LAMPIRAN

PHYSIOLOGY OF PUBERTYPhysical 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 25 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 134 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 25 SD below the mean and is considered to have delayed puberty

- By this definition 06 of the healthy population are classified as having constitutional delay in growth and adolescence

CASE

bull 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

bull 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)

bull 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 15 to 35 year period

bull 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 124 to 128 years of age African-American girls are maturing earlier

bull 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 115 years

bull 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 135 and 17 years of age Growth of the penis reaches a SMR (Tanner) stage V between 125 and 165 years of age Nocturnal emissions (wet dreams) may first appear during SMR stage III

bull 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

bull 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

bull 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

bull 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

bull 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)

bull

bull 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

bull 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

bull 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 50ile of the patients actual height)

bull 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 (Klinefelters syndrome)

Causes of Short Staturebull I Constitutional Short Staturebull II Primordial Dwarfism (intrauterine growth retardation)bull III Endocrine Causesbull A Growth Hormone Deficiencybull 1 Congenitalbull 2 Acquiredbull a HypothalamicPituitary Tumorsbull b Head Traumabull c CNS infectionsbull d Psychosocial Dwarfismbull 3 Laron Dwarfismbull 4 Hypothyroidismbull 5 Syndromes of Short Staturebull a Turner Syndrome (gonadal dysgenesis)bull b Noonans Syndromebull c Prader-Willi Syndromebull

Causes of Short Stature

bull IV Chronic Diseasebull A Heart Diseasebull B Pulmonarybull 1 Cystic Fibrosisbull 2 Asthmabull C GI Disordersbull D Hepatic Diseasebull E Renalbull V Iatrogenicbull A Corticosteroids anabolic steroidsbull B ADHD meds

bull Causes of Delayed Pubertybull I Constitutional Delay in Growth and Maturationbull II Hypogonadotropic hypogonadismbull A Central nervous system disordersbull 1 Tumors bull a Craniopharyngiomasbull b Gliomasbull c Germinomasbull 2 Radiation Therapybull 3 Congenital Malformationsbull

Causes of Delayed Puberty

bull B Isolated Growth Hormone Deficiencybull 1 Kallmanns Syndromebull C Miscellaneous Disordersbull 1 Prader-Willi Syndromebull 2 Hypothyroidismbull 3 Malnutritionbull 4 Anorexia Nervosabull 5 Exercise amenorrheabull 6 Cushingsbull 7 Diabetesbull

Causes of Delayed Puberty

bull III Hypergonadotropic hypogonadism

bull A Turner Syndrome

bull B XX and XY gonadal dysgenesis

bull C Polycystic ovary Syndrome

bull D Noonans 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- Kallmanns 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 Klinefelters syndrome Other forms of primary testicular failureAnorchia or

cryptorchism- Females Turners syndromeOther forms of primary ovarian failure Pseudo-Turners

syndrome- Noonans 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 2512 years of age with idiopathic true precocious

13412-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 (-45 SD) and a weight of 286 kg (-3 SD) The patient had early stage 2 breast development There was no pubic hair Karyotype was 46XX Bone age was 10 years After administration of GnRH LH and FSH rose in a pubertal pattern Estradiol was 40 pgmL She has since spontaneously progressed through pubertal development

• TUMBUH KEMBANG REMAJA
• REMAJA
• Remaja awal (11-14 tahun)
• Remaja Tengah (15-17 tahun)
• Remaja Lanjut (Usia 18-21 tahun)
• FISIOLOGI PUBERTAS
• Pubertas
• Tanda Pubertas Perempuan
• Slide 9
• Tanda Pubertas Laki-laki
• Sexual Maturity Rating
• Pubertas Perempuan
• Pubertas Laki-laki
• Pertumbuhan fisik
• Slide 15
• Slide 16
• Lonjakan pertumbuhan
• Perkembangan psikososial
• MASALAH-MASALAH REMAJA
• Morbiditas
• Masalah lain
• Psychological Problems in Adolescence
• Slide 23
• Teen suicide (contrsquod)
• Cluster Suicides
• Warning signs of suicide
• Indikator remaja berisiko tinggi
• Slide 28
• Gejala psikofisiologis
• Terapi gejala psikofisiologi
• KLINIK REMAJA
• Sikap Dokter Dalam Menghadapi Pasien Remaja
• Pemberian pelayanan kesehatan
• Kerahasiaan
• What are The importan Aspects of an Adolescent History
• How to Talk to Teens about Puberty
• Wawancara
• Slide 38
• LAMPIRAN
• 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
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• CASE
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Causes of Short Stature
• Slide 65
• Slide 66
• Causes of Delayed Puberty
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73

Kerahasiaan

bull Beritahu remaja dan orang tuanya tentang kerahasiaan yang akan dijaga

bull Waktu adekuat

bull Yakinkan bahwa dokter tidak akan mencampuri kehidupan pribadi remaja tetapi merupakan hal penting untuk kesehatannya

What are The importan Aspects of an Adolescent History

bull HEADSSS untuk melacak informasi psikososial yang penting dari pasien remaja

bull H Homehealthbull E EducationEmploymentEatingbull A ActivitiesAspirationAffiliationbull D Drugsbull S Sexbull S SleepSuicidebull S Shoplifting

How to Talk to Teens about Puberty

1048708 Be open and honest

1048708 Treat the teen with respect

1048708 Talk directly to the teen

1048708 Begin conversation with least

threatening topics

1048708 Provide confidentiality

Wawancara

Wawancara terpimpinPenilaian tugas-tugas psikoperkembanganPemeriksaan sistemik meliputi 1 Nutrisi2 Tidur3 Perawatan diri pengetahuan ttg

pemeriksaan sendiri 4 Olah raga5 Hubungan keluarga dan sahabat6 Teman sebaya

Wawancara

7 Sekolah8 Minat pendidikan dan pekerjaan 9 Tembakau10 Penyalahgunaan zat11 Seksualitas12 Kesehatan mental

Usahakan pasien mendapat kesan tertarik dan seperti mempunyai ldquodokternyardquo sendiri

LAMPIRAN

PHYSIOLOGY OF PUBERTYPhysical 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 25 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 134 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 25 SD below the mean and is considered to have delayed puberty

- By this definition 06 of the healthy population are classified as having constitutional delay in growth and adolescence

CASE

bull 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

bull 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)

bull 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 15 to 35 year period

bull 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 124 to 128 years of age African-American girls are maturing earlier

bull 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 115 years

bull 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 135 and 17 years of age Growth of the penis reaches a SMR (Tanner) stage V between 125 and 165 years of age Nocturnal emissions (wet dreams) may first appear during SMR stage III

bull 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

bull 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

bull 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

bull 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

bull 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)

bull

bull 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

bull 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

bull 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 50ile of the patients actual height)

bull 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 (Klinefelters syndrome)

Causes of Short Staturebull I Constitutional Short Staturebull II Primordial Dwarfism (intrauterine growth retardation)bull III Endocrine Causesbull A Growth Hormone Deficiencybull 1 Congenitalbull 2 Acquiredbull a HypothalamicPituitary Tumorsbull b Head Traumabull c CNS infectionsbull d Psychosocial Dwarfismbull 3 Laron Dwarfismbull 4 Hypothyroidismbull 5 Syndromes of Short Staturebull a Turner Syndrome (gonadal dysgenesis)bull b Noonans Syndromebull c Prader-Willi Syndromebull

Causes of Short Stature

bull IV Chronic Diseasebull A Heart Diseasebull B Pulmonarybull 1 Cystic Fibrosisbull 2 Asthmabull C GI Disordersbull D Hepatic Diseasebull E Renalbull V Iatrogenicbull A Corticosteroids anabolic steroidsbull B ADHD meds

bull Causes of Delayed Pubertybull I Constitutional Delay in Growth and Maturationbull II Hypogonadotropic hypogonadismbull A Central nervous system disordersbull 1 Tumors bull a Craniopharyngiomasbull b Gliomasbull c Germinomasbull 2 Radiation Therapybull 3 Congenital Malformationsbull

Causes of Delayed Puberty

bull B Isolated Growth Hormone Deficiencybull 1 Kallmanns Syndromebull C Miscellaneous Disordersbull 1 Prader-Willi Syndromebull 2 Hypothyroidismbull 3 Malnutritionbull 4 Anorexia Nervosabull 5 Exercise amenorrheabull 6 Cushingsbull 7 Diabetesbull

Causes of Delayed Puberty

bull III Hypergonadotropic hypogonadism

bull A Turner Syndrome

bull B XX and XY gonadal dysgenesis

bull C Polycystic ovary Syndrome

bull D Noonans 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- Kallmanns 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 Klinefelters syndrome Other forms of primary testicular failureAnorchia or

cryptorchism- Females Turners syndromeOther forms of primary ovarian failure Pseudo-Turners

syndrome- Noonans 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 2512 years of age with idiopathic true precocious

13412-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 (-45 SD) and a weight of 286 kg (-3 SD) The patient had early stage 2 breast development There was no pubic hair Karyotype was 46XX Bone age was 10 years After administration of GnRH LH and FSH rose in a pubertal pattern Estradiol was 40 pgmL She has since spontaneously progressed through pubertal development

• TUMBUH KEMBANG REMAJA
• REMAJA
• Remaja awal (11-14 tahun)
• Remaja Tengah (15-17 tahun)
• Remaja Lanjut (Usia 18-21 tahun)
• FISIOLOGI PUBERTAS
• Pubertas
• Tanda Pubertas Perempuan
• Slide 9
• Tanda Pubertas Laki-laki
• Sexual Maturity Rating
• Pubertas Perempuan
• Pubertas Laki-laki
• Pertumbuhan fisik
• Slide 15
• Slide 16
• Lonjakan pertumbuhan
• Perkembangan psikososial
• MASALAH-MASALAH REMAJA
• Morbiditas
• Masalah lain
• Psychological Problems in Adolescence
• Slide 23
• Teen suicide (contrsquod)
• Cluster Suicides
• Warning signs of suicide
• Indikator remaja berisiko tinggi
• Slide 28
• Gejala psikofisiologis
• Terapi gejala psikofisiologi
• KLINIK REMAJA
• Sikap Dokter Dalam Menghadapi Pasien Remaja
• Pemberian pelayanan kesehatan
• Kerahasiaan
• What are The importan Aspects of an Adolescent History
• How to Talk to Teens about Puberty
• Wawancara
• Slide 38
• LAMPIRAN
• 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
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• CASE
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Causes of Short Stature
• Slide 65
• Slide 66
• Causes of Delayed Puberty
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73

What are The importan Aspects of an Adolescent History

bull HEADSSS untuk melacak informasi psikososial yang penting dari pasien remaja

bull H Homehealthbull E EducationEmploymentEatingbull A ActivitiesAspirationAffiliationbull D Drugsbull S Sexbull S SleepSuicidebull S Shoplifting

How to Talk to Teens about Puberty

1048708 Be open and honest

1048708 Treat the teen with respect

1048708 Talk directly to the teen

1048708 Begin conversation with least

threatening topics

1048708 Provide confidentiality

Wawancara

Wawancara terpimpinPenilaian tugas-tugas psikoperkembanganPemeriksaan sistemik meliputi 1 Nutrisi2 Tidur3 Perawatan diri pengetahuan ttg

pemeriksaan sendiri 4 Olah raga5 Hubungan keluarga dan sahabat6 Teman sebaya

Wawancara

7 Sekolah8 Minat pendidikan dan pekerjaan 9 Tembakau10 Penyalahgunaan zat11 Seksualitas12 Kesehatan mental

Usahakan pasien mendapat kesan tertarik dan seperti mempunyai ldquodokternyardquo sendiri

LAMPIRAN

PHYSIOLOGY OF PUBERTYPhysical 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 25 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 134 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 25 SD below the mean and is considered to have delayed puberty

- By this definition 06 of the healthy population are classified as having constitutional delay in growth and adolescence

CASE

bull 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

bull 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)

bull 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 15 to 35 year period

bull 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 124 to 128 years of age African-American girls are maturing earlier

bull 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 115 years

bull 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 135 and 17 years of age Growth of the penis reaches a SMR (Tanner) stage V between 125 and 165 years of age Nocturnal emissions (wet dreams) may first appear during SMR stage III

bull 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

bull 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

bull 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

bull 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

bull 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)

bull

bull 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

bull 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

bull 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 50ile of the patients actual height)

bull 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 (Klinefelters syndrome)

Causes of Short Staturebull I Constitutional Short Staturebull II Primordial Dwarfism (intrauterine growth retardation)bull III Endocrine Causesbull A Growth Hormone Deficiencybull 1 Congenitalbull 2 Acquiredbull a HypothalamicPituitary Tumorsbull b Head Traumabull c CNS infectionsbull d Psychosocial Dwarfismbull 3 Laron Dwarfismbull 4 Hypothyroidismbull 5 Syndromes of Short Staturebull a Turner Syndrome (gonadal dysgenesis)bull b Noonans Syndromebull c Prader-Willi Syndromebull

Causes of Short Stature

bull IV Chronic Diseasebull A Heart Diseasebull B Pulmonarybull 1 Cystic Fibrosisbull 2 Asthmabull C GI Disordersbull D Hepatic Diseasebull E Renalbull V Iatrogenicbull A Corticosteroids anabolic steroidsbull B ADHD meds

bull Causes of Delayed Pubertybull I Constitutional Delay in Growth and Maturationbull II Hypogonadotropic hypogonadismbull A Central nervous system disordersbull 1 Tumors bull a Craniopharyngiomasbull b Gliomasbull c Germinomasbull 2 Radiation Therapybull 3 Congenital Malformationsbull

Causes of Delayed Puberty

bull B Isolated Growth Hormone Deficiencybull 1 Kallmanns Syndromebull C Miscellaneous Disordersbull 1 Prader-Willi Syndromebull 2 Hypothyroidismbull 3 Malnutritionbull 4 Anorexia Nervosabull 5 Exercise amenorrheabull 6 Cushingsbull 7 Diabetesbull

Causes of Delayed Puberty

bull III Hypergonadotropic hypogonadism

bull A Turner Syndrome

bull B XX and XY gonadal dysgenesis

bull C Polycystic ovary Syndrome

bull D Noonans 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- Kallmanns 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 Klinefelters syndrome Other forms of primary testicular failureAnorchia or

cryptorchism- Females Turners syndromeOther forms of primary ovarian failure Pseudo-Turners

syndrome- Noonans 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 2512 years of age with idiopathic true precocious

13412-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 (-45 SD) and a weight of 286 kg (-3 SD) The patient had early stage 2 breast development There was no pubic hair Karyotype was 46XX Bone age was 10 years After administration of GnRH LH and FSH rose in a pubertal pattern Estradiol was 40 pgmL She has since spontaneously progressed through pubertal development

• TUMBUH KEMBANG REMAJA
• REMAJA
• Remaja awal (11-14 tahun)
• Remaja Tengah (15-17 tahun)
• Remaja Lanjut (Usia 18-21 tahun)
• FISIOLOGI PUBERTAS
• Pubertas
• Tanda Pubertas Perempuan
• Slide 9
• Tanda Pubertas Laki-laki
• Sexual Maturity Rating
• Pubertas Perempuan
• Pubertas Laki-laki
• Pertumbuhan fisik
• Slide 15
• Slide 16
• Lonjakan pertumbuhan
• Perkembangan psikososial
• MASALAH-MASALAH REMAJA
• Morbiditas
• Masalah lain
• Psychological Problems in Adolescence
• Slide 23
• Teen suicide (contrsquod)
• Cluster Suicides
• Warning signs of suicide
• Indikator remaja berisiko tinggi
• Slide 28
• Gejala psikofisiologis
• Terapi gejala psikofisiologi
• KLINIK REMAJA
• Sikap Dokter Dalam Menghadapi Pasien Remaja
• Pemberian pelayanan kesehatan
• Kerahasiaan
• What are The importan Aspects of an Adolescent History
• How to Talk to Teens about Puberty
• Wawancara
• Slide 38
• LAMPIRAN
• 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
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• CASE
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Causes of Short Stature
• Slide 65
• Slide 66
• Causes of Delayed Puberty
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73

How to Talk to Teens about Puberty

1048708 Be open and honest

1048708 Treat the teen with respect

1048708 Talk directly to the teen

1048708 Begin conversation with least

threatening topics

1048708 Provide confidentiality

Wawancara

Wawancara terpimpinPenilaian tugas-tugas psikoperkembanganPemeriksaan sistemik meliputi 1 Nutrisi2 Tidur3 Perawatan diri pengetahuan ttg

pemeriksaan sendiri 4 Olah raga5 Hubungan keluarga dan sahabat6 Teman sebaya

Wawancara

7 Sekolah8 Minat pendidikan dan pekerjaan 9 Tembakau10 Penyalahgunaan zat11 Seksualitas12 Kesehatan mental

Usahakan pasien mendapat kesan tertarik dan seperti mempunyai ldquodokternyardquo sendiri

LAMPIRAN

PHYSIOLOGY OF PUBERTYPhysical 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 25 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 134 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 25 SD below the mean and is considered to have delayed puberty

- By this definition 06 of the healthy population are classified as having constitutional delay in growth and adolescence

CASE

bull 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

bull 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)

bull 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 15 to 35 year period

bull 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 124 to 128 years of age African-American girls are maturing earlier

bull 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 115 years

bull 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 135 and 17 years of age Growth of the penis reaches a SMR (Tanner) stage V between 125 and 165 years of age Nocturnal emissions (wet dreams) may first appear during SMR stage III

bull 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

bull 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

bull 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

bull 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

bull 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)

bull

bull 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

bull 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

bull 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 50ile of the patients actual height)

bull 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 (Klinefelters syndrome)

Causes of Short Staturebull I Constitutional Short Staturebull II Primordial Dwarfism (intrauterine growth retardation)bull III Endocrine Causesbull A Growth Hormone Deficiencybull 1 Congenitalbull 2 Acquiredbull a HypothalamicPituitary Tumorsbull b Head Traumabull c CNS infectionsbull d Psychosocial Dwarfismbull 3 Laron Dwarfismbull 4 Hypothyroidismbull 5 Syndromes of Short Staturebull a Turner Syndrome (gonadal dysgenesis)bull b Noonans Syndromebull c Prader-Willi Syndromebull

Causes of Short Stature

bull IV Chronic Diseasebull A Heart Diseasebull B Pulmonarybull 1 Cystic Fibrosisbull 2 Asthmabull C GI Disordersbull D Hepatic Diseasebull E Renalbull V Iatrogenicbull A Corticosteroids anabolic steroidsbull B ADHD meds

bull Causes of Delayed Pubertybull I Constitutional Delay in Growth and Maturationbull II Hypogonadotropic hypogonadismbull A Central nervous system disordersbull 1 Tumors bull a Craniopharyngiomasbull b Gliomasbull c Germinomasbull 2 Radiation Therapybull 3 Congenital Malformationsbull

Causes of Delayed Puberty

bull B Isolated Growth Hormone Deficiencybull 1 Kallmanns Syndromebull C Miscellaneous Disordersbull 1 Prader-Willi Syndromebull 2 Hypothyroidismbull 3 Malnutritionbull 4 Anorexia Nervosabull 5 Exercise amenorrheabull 6 Cushingsbull 7 Diabetesbull

Causes of Delayed Puberty

bull III Hypergonadotropic hypogonadism

bull A Turner Syndrome

bull B XX and XY gonadal dysgenesis

bull C Polycystic ovary Syndrome

bull D Noonans 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- Kallmanns 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 Klinefelters syndrome Other forms of primary testicular failureAnorchia or

cryptorchism- Females Turners syndromeOther forms of primary ovarian failure Pseudo-Turners

syndrome- Noonans 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 2512 years of age with idiopathic true precocious

13412-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 (-45 SD) and a weight of 286 kg (-3 SD) The patient had early stage 2 breast development There was no pubic hair Karyotype was 46XX Bone age was 10 years After administration of GnRH LH and FSH rose in a pubertal pattern Estradiol was 40 pgmL She has since spontaneously progressed through pubertal development

• TUMBUH KEMBANG REMAJA
• REMAJA
• Remaja awal (11-14 tahun)
• Remaja Tengah (15-17 tahun)
• Remaja Lanjut (Usia 18-21 tahun)
• FISIOLOGI PUBERTAS
• Pubertas
• Tanda Pubertas Perempuan
• Slide 9
• Tanda Pubertas Laki-laki
• Sexual Maturity Rating
• Pubertas Perempuan
• Pubertas Laki-laki
• Pertumbuhan fisik
• Slide 15
• Slide 16
• Lonjakan pertumbuhan
• Perkembangan psikososial
• MASALAH-MASALAH REMAJA
• Morbiditas
• Masalah lain
• Psychological Problems in Adolescence
• Slide 23
• Teen suicide (contrsquod)
• Cluster Suicides
• Warning signs of suicide
• Indikator remaja berisiko tinggi
• Slide 28
• Gejala psikofisiologis
• Terapi gejala psikofisiologi
• KLINIK REMAJA
• Sikap Dokter Dalam Menghadapi Pasien Remaja
• Pemberian pelayanan kesehatan
• Kerahasiaan
• What are The importan Aspects of an Adolescent History
• How to Talk to Teens about Puberty
• Wawancara
• Slide 38
• LAMPIRAN
• 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
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• CASE
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Causes of Short Stature
• Slide 65
• Slide 66
• Causes of Delayed Puberty
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73

Wawancara

Wawancara terpimpinPenilaian tugas-tugas psikoperkembanganPemeriksaan sistemik meliputi 1 Nutrisi2 Tidur3 Perawatan diri pengetahuan ttg

pemeriksaan sendiri 4 Olah raga5 Hubungan keluarga dan sahabat6 Teman sebaya

Wawancara

7 Sekolah8 Minat pendidikan dan pekerjaan 9 Tembakau10 Penyalahgunaan zat11 Seksualitas12 Kesehatan mental

Usahakan pasien mendapat kesan tertarik dan seperti mempunyai ldquodokternyardquo sendiri

LAMPIRAN

PHYSIOLOGY OF PUBERTYPhysical 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 25 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 134 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 25 SD below the mean and is considered to have delayed puberty

- By this definition 06 of the healthy population are classified as having constitutional delay in growth and adolescence

CASE

bull 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

bull 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)

bull 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 15 to 35 year period

bull 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 124 to 128 years of age African-American girls are maturing earlier

bull 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 115 years

bull 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 135 and 17 years of age Growth of the penis reaches a SMR (Tanner) stage V between 125 and 165 years of age Nocturnal emissions (wet dreams) may first appear during SMR stage III

bull 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

bull 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

bull 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

bull 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

bull 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)

bull

bull 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

bull 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

bull 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 50ile of the patients actual height)

bull 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 (Klinefelters syndrome)

Causes of Short Staturebull I Constitutional Short Staturebull II Primordial Dwarfism (intrauterine growth retardation)bull III Endocrine Causesbull A Growth Hormone Deficiencybull 1 Congenitalbull 2 Acquiredbull a HypothalamicPituitary Tumorsbull b Head Traumabull c CNS infectionsbull d Psychosocial Dwarfismbull 3 Laron Dwarfismbull 4 Hypothyroidismbull 5 Syndromes of Short Staturebull a Turner Syndrome (gonadal dysgenesis)bull b Noonans Syndromebull c Prader-Willi Syndromebull

Causes of Short Stature

bull IV Chronic Diseasebull A Heart Diseasebull B Pulmonarybull 1 Cystic Fibrosisbull 2 Asthmabull C GI Disordersbull D Hepatic Diseasebull E Renalbull V Iatrogenicbull A Corticosteroids anabolic steroidsbull B ADHD meds

bull Causes of Delayed Pubertybull I Constitutional Delay in Growth and Maturationbull II Hypogonadotropic hypogonadismbull A Central nervous system disordersbull 1 Tumors bull a Craniopharyngiomasbull b Gliomasbull c Germinomasbull 2 Radiation Therapybull 3 Congenital Malformationsbull

Causes of Delayed Puberty

bull B Isolated Growth Hormone Deficiencybull 1 Kallmanns Syndromebull C Miscellaneous Disordersbull 1 Prader-Willi Syndromebull 2 Hypothyroidismbull 3 Malnutritionbull 4 Anorexia Nervosabull 5 Exercise amenorrheabull 6 Cushingsbull 7 Diabetesbull

Causes of Delayed Puberty

bull III Hypergonadotropic hypogonadism

bull A Turner Syndrome

bull B XX and XY gonadal dysgenesis

bull C Polycystic ovary Syndrome

bull D Noonans 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- Kallmanns 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 Klinefelters syndrome Other forms of primary testicular failureAnorchia or

cryptorchism- Females Turners syndromeOther forms of primary ovarian failure Pseudo-Turners

syndrome- Noonans 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 2512 years of age with idiopathic true precocious

13412-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 (-45 SD) and a weight of 286 kg (-3 SD) The patient had early stage 2 breast development There was no pubic hair Karyotype was 46XX Bone age was 10 years After administration of GnRH LH and FSH rose in a pubertal pattern Estradiol was 40 pgmL She has since spontaneously progressed through pubertal development

• TUMBUH KEMBANG REMAJA
• REMAJA
• Remaja awal (11-14 tahun)
• Remaja Tengah (15-17 tahun)
• Remaja Lanjut (Usia 18-21 tahun)
• FISIOLOGI PUBERTAS
• Pubertas
• Tanda Pubertas Perempuan
• Slide 9
• Tanda Pubertas Laki-laki
• Sexual Maturity Rating
• Pubertas Perempuan
• Pubertas Laki-laki
• Pertumbuhan fisik
• Slide 15
• Slide 16
• Lonjakan pertumbuhan
• Perkembangan psikososial
• MASALAH-MASALAH REMAJA
• Morbiditas
• Masalah lain
• Psychological Problems in Adolescence
• Slide 23
• Teen suicide (contrsquod)
• Cluster Suicides
• Warning signs of suicide
• Indikator remaja berisiko tinggi
• Slide 28
• Gejala psikofisiologis
• Terapi gejala psikofisiologi
• KLINIK REMAJA
• Sikap Dokter Dalam Menghadapi Pasien Remaja
• Pemberian pelayanan kesehatan
• Kerahasiaan
• What are The importan Aspects of an Adolescent History
• How to Talk to Teens about Puberty
• Wawancara
• Slide 38
• LAMPIRAN
• 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
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• CASE
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Causes of Short Stature
• Slide 65
• Slide 66
• Causes of Delayed Puberty
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73

Wawancara

7 Sekolah8 Minat pendidikan dan pekerjaan 9 Tembakau10 Penyalahgunaan zat11 Seksualitas12 Kesehatan mental

Usahakan pasien mendapat kesan tertarik dan seperti mempunyai ldquodokternyardquo sendiri

LAMPIRAN

PHYSIOLOGY OF PUBERTYPhysical 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 25 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 134 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 25 SD below the mean and is considered to have delayed puberty

- By this definition 06 of the healthy population are classified as having constitutional delay in growth and adolescence

CASE

bull 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

bull 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)

bull 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 15 to 35 year period

bull 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 124 to 128 years of age African-American girls are maturing earlier

bull 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 115 years

bull 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 135 and 17 years of age Growth of the penis reaches a SMR (Tanner) stage V between 125 and 165 years of age Nocturnal emissions (wet dreams) may first appear during SMR stage III

bull 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

bull 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

bull 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

bull 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

bull 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)

bull

bull 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

bull 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

bull 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 50ile of the patients actual height)

bull 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 (Klinefelters syndrome)

Causes of Short Staturebull I Constitutional Short Staturebull II Primordial Dwarfism (intrauterine growth retardation)bull III Endocrine Causesbull A Growth Hormone Deficiencybull 1 Congenitalbull 2 Acquiredbull a HypothalamicPituitary Tumorsbull b Head Traumabull c CNS infectionsbull d Psychosocial Dwarfismbull 3 Laron Dwarfismbull 4 Hypothyroidismbull 5 Syndromes of Short Staturebull a Turner Syndrome (gonadal dysgenesis)bull b Noonans Syndromebull c Prader-Willi Syndromebull

Causes of Short Stature

bull IV Chronic Diseasebull A Heart Diseasebull B Pulmonarybull 1 Cystic Fibrosisbull 2 Asthmabull C GI Disordersbull D Hepatic Diseasebull E Renalbull V Iatrogenicbull A Corticosteroids anabolic steroidsbull B ADHD meds

bull Causes of Delayed Pubertybull I Constitutional Delay in Growth and Maturationbull II Hypogonadotropic hypogonadismbull A Central nervous system disordersbull 1 Tumors bull a Craniopharyngiomasbull b Gliomasbull c Germinomasbull 2 Radiation Therapybull 3 Congenital Malformationsbull

Causes of Delayed Puberty

bull B Isolated Growth Hormone Deficiencybull 1 Kallmanns Syndromebull C Miscellaneous Disordersbull 1 Prader-Willi Syndromebull 2 Hypothyroidismbull 3 Malnutritionbull 4 Anorexia Nervosabull 5 Exercise amenorrheabull 6 Cushingsbull 7 Diabetesbull

Causes of Delayed Puberty

bull III Hypergonadotropic hypogonadism

bull A Turner Syndrome

bull B XX and XY gonadal dysgenesis

bull C Polycystic ovary Syndrome

bull D Noonans 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- Kallmanns 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 Klinefelters syndrome Other forms of primary testicular failureAnorchia or

cryptorchism- Females Turners syndromeOther forms of primary ovarian failure Pseudo-Turners

syndrome- Noonans 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 2512 years of age with idiopathic true precocious

13412-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 (-45 SD) and a weight of 286 kg (-3 SD) The patient had early stage 2 breast development There was no pubic hair Karyotype was 46XX Bone age was 10 years After administration of GnRH LH and FSH rose in a pubertal pattern Estradiol was 40 pgmL She has since spontaneously progressed through pubertal development

• TUMBUH KEMBANG REMAJA
• REMAJA
• Remaja awal (11-14 tahun)
• Remaja Tengah (15-17 tahun)
• Remaja Lanjut (Usia 18-21 tahun)
• FISIOLOGI PUBERTAS
• Pubertas
• Tanda Pubertas Perempuan
• Slide 9
• Tanda Pubertas Laki-laki
• Sexual Maturity Rating
• Pubertas Perempuan
• Pubertas Laki-laki
• Pertumbuhan fisik
• Slide 15
• Slide 16
• Lonjakan pertumbuhan
• Perkembangan psikososial
• MASALAH-MASALAH REMAJA
• Morbiditas
• Masalah lain
• Psychological Problems in Adolescence
• Slide 23
• Teen suicide (contrsquod)
• Cluster Suicides
• Warning signs of suicide
• Indikator remaja berisiko tinggi
• Slide 28
• Gejala psikofisiologis
• Terapi gejala psikofisiologi
• KLINIK REMAJA
• Sikap Dokter Dalam Menghadapi Pasien Remaja
• Pemberian pelayanan kesehatan
• Kerahasiaan
• What are The importan Aspects of an Adolescent History
• How to Talk to Teens about Puberty
• Wawancara
• Slide 38
• LAMPIRAN
• 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
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• CASE
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Causes of Short Stature
• Slide 65
• Slide 66
• Causes of Delayed Puberty
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73

LAMPIRAN

PHYSIOLOGY OF PUBERTYPhysical 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 25 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 134 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 25 SD below the mean and is considered to have delayed puberty

- By this definition 06 of the healthy population are classified as having constitutional delay in growth and adolescence

CASE

bull 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

bull 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)

bull 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 15 to 35 year period

bull 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 124 to 128 years of age African-American girls are maturing earlier

bull 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 115 years

bull 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 135 and 17 years of age Growth of the penis reaches a SMR (Tanner) stage V between 125 and 165 years of age Nocturnal emissions (wet dreams) may first appear during SMR stage III

bull 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

bull 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

bull 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

bull 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

bull 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)

bull

bull 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

bull 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

bull 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 50ile of the patients actual height)

bull 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 (Klinefelters syndrome)

Causes of Short Staturebull I Constitutional Short Staturebull II Primordial Dwarfism (intrauterine growth retardation)bull III Endocrine Causesbull A Growth Hormone Deficiencybull 1 Congenitalbull 2 Acquiredbull a HypothalamicPituitary Tumorsbull b Head Traumabull c CNS infectionsbull d Psychosocial Dwarfismbull 3 Laron Dwarfismbull 4 Hypothyroidismbull 5 Syndromes of Short Staturebull a Turner Syndrome (gonadal dysgenesis)bull b Noonans Syndromebull c Prader-Willi Syndromebull

Causes of Short Stature

bull IV Chronic Diseasebull A Heart Diseasebull B Pulmonarybull 1 Cystic Fibrosisbull 2 Asthmabull C GI Disordersbull D Hepatic Diseasebull E Renalbull V Iatrogenicbull A Corticosteroids anabolic steroidsbull B ADHD meds

bull Causes of Delayed Pubertybull I Constitutional Delay in Growth and Maturationbull II Hypogonadotropic hypogonadismbull A Central nervous system disordersbull 1 Tumors bull a Craniopharyngiomasbull b Gliomasbull c Germinomasbull 2 Radiation Therapybull 3 Congenital Malformationsbull

Causes of Delayed Puberty

bull B Isolated Growth Hormone Deficiencybull 1 Kallmanns Syndromebull C Miscellaneous Disordersbull 1 Prader-Willi Syndromebull 2 Hypothyroidismbull 3 Malnutritionbull 4 Anorexia Nervosabull 5 Exercise amenorrheabull 6 Cushingsbull 7 Diabetesbull

Causes of Delayed Puberty

bull III Hypergonadotropic hypogonadism

bull A Turner Syndrome

bull B XX and XY gonadal dysgenesis

bull C Polycystic ovary Syndrome

bull D Noonans 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- Kallmanns 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 Klinefelters syndrome Other forms of primary testicular failureAnorchia or

cryptorchism- Females Turners syndromeOther forms of primary ovarian failure Pseudo-Turners

syndrome- Noonans 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 2512 years of age with idiopathic true precocious

13412-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 (-45 SD) and a weight of 286 kg (-3 SD) The patient had early stage 2 breast development There was no pubic hair Karyotype was 46XX Bone age was 10 years After administration of GnRH LH and FSH rose in a pubertal pattern Estradiol was 40 pgmL She has since spontaneously progressed through pubertal development

• TUMBUH KEMBANG REMAJA
• REMAJA
• Remaja awal (11-14 tahun)
• Remaja Tengah (15-17 tahun)
• Remaja Lanjut (Usia 18-21 tahun)
• FISIOLOGI PUBERTAS
• Pubertas
• Tanda Pubertas Perempuan
• Slide 9
• Tanda Pubertas Laki-laki
• Sexual Maturity Rating
• Pubertas Perempuan
• Pubertas Laki-laki
• Pertumbuhan fisik
• Slide 15
• Slide 16
• Lonjakan pertumbuhan
• Perkembangan psikososial
• MASALAH-MASALAH REMAJA
• Morbiditas
• Masalah lain
• Psychological Problems in Adolescence
• Slide 23
• Teen suicide (contrsquod)
• Cluster Suicides
• Warning signs of suicide
• Indikator remaja berisiko tinggi
• Slide 28
• Gejala psikofisiologis
• Terapi gejala psikofisiologi
• KLINIK REMAJA
• Sikap Dokter Dalam Menghadapi Pasien Remaja
• Pemberian pelayanan kesehatan
• Kerahasiaan
• What are The importan Aspects of an Adolescent History
• How to Talk to Teens about Puberty
• Wawancara
• Slide 38
• LAMPIRAN
• 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
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• CASE
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Causes of Short Stature
• Slide 65
• Slide 66
• Causes of Delayed Puberty
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73

PHYSIOLOGY OF PUBERTYPhysical 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 25 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 134 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 25 SD below the mean and is considered to have delayed puberty

- By this definition 06 of the healthy population are classified as having constitutional delay in growth and adolescence

CASE

bull 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

bull 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)

bull 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 15 to 35 year period

bull 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 124 to 128 years of age African-American girls are maturing earlier

bull 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 115 years

bull 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 135 and 17 years of age Growth of the penis reaches a SMR (Tanner) stage V between 125 and 165 years of age Nocturnal emissions (wet dreams) may first appear during SMR stage III

bull 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

bull 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

bull 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

bull 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

bull 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)

bull

bull 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

bull 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

bull 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 50ile of the patients actual height)

bull 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 (Klinefelters syndrome)

Causes of Short Staturebull I Constitutional Short Staturebull II Primordial Dwarfism (intrauterine growth retardation)bull III Endocrine Causesbull A Growth Hormone Deficiencybull 1 Congenitalbull 2 Acquiredbull a HypothalamicPituitary Tumorsbull b Head Traumabull c CNS infectionsbull d Psychosocial Dwarfismbull 3 Laron Dwarfismbull 4 Hypothyroidismbull 5 Syndromes of Short Staturebull a Turner Syndrome (gonadal dysgenesis)bull b Noonans Syndromebull c Prader-Willi Syndromebull

Causes of Short Stature

bull IV Chronic Diseasebull A Heart Diseasebull B Pulmonarybull 1 Cystic Fibrosisbull 2 Asthmabull C GI Disordersbull D Hepatic Diseasebull E Renalbull V Iatrogenicbull A Corticosteroids anabolic steroidsbull B ADHD meds

bull Causes of Delayed Pubertybull I Constitutional Delay in Growth and Maturationbull II Hypogonadotropic hypogonadismbull A Central nervous system disordersbull 1 Tumors bull a Craniopharyngiomasbull b Gliomasbull c Germinomasbull 2 Radiation Therapybull 3 Congenital Malformationsbull

Causes of Delayed Puberty

bull B Isolated Growth Hormone Deficiencybull 1 Kallmanns Syndromebull C Miscellaneous Disordersbull 1 Prader-Willi Syndromebull 2 Hypothyroidismbull 3 Malnutritionbull 4 Anorexia Nervosabull 5 Exercise amenorrheabull 6 Cushingsbull 7 Diabetesbull

Causes of Delayed Puberty

bull III Hypergonadotropic hypogonadism

bull A Turner Syndrome

bull B XX and XY gonadal dysgenesis

bull C Polycystic ovary Syndrome

bull D Noonans 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- Kallmanns 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 Klinefelters syndrome Other forms of primary testicular failureAnorchia or

cryptorchism- Females Turners syndromeOther forms of primary ovarian failure Pseudo-Turners

syndrome- Noonans 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 2512 years of age with idiopathic true precocious

13412-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 (-45 SD) and a weight of 286 kg (-3 SD) The patient had early stage 2 breast development There was no pubic hair Karyotype was 46XX Bone age was 10 years After administration of GnRH LH and FSH rose in a pubertal pattern Estradiol was 40 pgmL She has since spontaneously progressed through pubertal development

• TUMBUH KEMBANG REMAJA
• REMAJA
• Remaja awal (11-14 tahun)
• Remaja Tengah (15-17 tahun)
• Remaja Lanjut (Usia 18-21 tahun)
• FISIOLOGI PUBERTAS
• Pubertas
• Tanda Pubertas Perempuan
• Slide 9
• Tanda Pubertas Laki-laki
• Sexual Maturity Rating
• Pubertas Perempuan
• Pubertas Laki-laki
• Pertumbuhan fisik
• Slide 15
• Slide 16
• Lonjakan pertumbuhan
• Perkembangan psikososial
• MASALAH-MASALAH REMAJA
• Morbiditas
• Masalah lain
• Psychological Problems in Adolescence
• Slide 23
• Teen suicide (contrsquod)
• Cluster Suicides
• Warning signs of suicide
• Indikator remaja berisiko tinggi
• Slide 28
• Gejala psikofisiologis
• Terapi gejala psikofisiologi
• KLINIK REMAJA
• Sikap Dokter Dalam Menghadapi Pasien Remaja
• Pemberian pelayanan kesehatan
• Kerahasiaan
• What are The importan Aspects of an Adolescent History
• How to Talk to Teens about Puberty
• Wawancara
• Slide 38
• LAMPIRAN
• 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
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• CASE
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Causes of Short Stature
• Slide 65
• Slide 66
• Causes of Delayed Puberty
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73

- 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 25 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 134 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 25 SD below the mean and is considered to have delayed puberty

- By this definition 06 of the healthy population are classified as having constitutional delay in growth and adolescence

CASE

bull 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

bull 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)

bull 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 15 to 35 year period

bull 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 124 to 128 years of age African-American girls are maturing earlier

bull 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 115 years

bull 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 135 and 17 years of age Growth of the penis reaches a SMR (Tanner) stage V between 125 and 165 years of age Nocturnal emissions (wet dreams) may first appear during SMR stage III

bull 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

bull 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

bull 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

bull 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

bull 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)

bull

bull 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

bull 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

bull 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 50ile of the patients actual height)

bull 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 (Klinefelters syndrome)

Causes of Short Staturebull I Constitutional Short Staturebull II Primordial Dwarfism (intrauterine growth retardation)bull III Endocrine Causesbull A Growth Hormone Deficiencybull 1 Congenitalbull 2 Acquiredbull a HypothalamicPituitary Tumorsbull b Head Traumabull c CNS infectionsbull d Psychosocial Dwarfismbull 3 Laron Dwarfismbull 4 Hypothyroidismbull 5 Syndromes of Short Staturebull a Turner Syndrome (gonadal dysgenesis)bull b Noonans Syndromebull c Prader-Willi Syndromebull

Causes of Short Stature

bull IV Chronic Diseasebull A Heart Diseasebull B Pulmonarybull 1 Cystic Fibrosisbull 2 Asthmabull C GI Disordersbull D Hepatic Diseasebull E Renalbull V Iatrogenicbull A Corticosteroids anabolic steroidsbull B ADHD meds

bull Causes of Delayed Pubertybull I Constitutional Delay in Growth and Maturationbull II Hypogonadotropic hypogonadismbull A Central nervous system disordersbull 1 Tumors bull a Craniopharyngiomasbull b Gliomasbull c Germinomasbull 2 Radiation Therapybull 3 Congenital Malformationsbull

Causes of Delayed Puberty

bull B Isolated Growth Hormone Deficiencybull 1 Kallmanns Syndromebull C Miscellaneous Disordersbull 1 Prader-Willi Syndromebull 2 Hypothyroidismbull 3 Malnutritionbull 4 Anorexia Nervosabull 5 Exercise amenorrheabull 6 Cushingsbull 7 Diabetesbull

Causes of Delayed Puberty

bull III Hypergonadotropic hypogonadism

bull A Turner Syndrome

bull B XX and XY gonadal dysgenesis

bull C Polycystic ovary Syndrome

bull D Noonans 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- Kallmanns 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 Klinefelters syndrome Other forms of primary testicular failureAnorchia or

cryptorchism- Females Turners syndromeOther forms of primary ovarian failure Pseudo-Turners

syndrome- Noonans 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 2512 years of age with idiopathic true precocious

13412-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 (-45 SD) and a weight of 286 kg (-3 SD) The patient had early stage 2 breast development There was no pubic hair Karyotype was 46XX Bone age was 10 years After administration of GnRH LH and FSH rose in a pubertal pattern Estradiol was 40 pgmL She has since spontaneously progressed through pubertal development

• TUMBUH KEMBANG REMAJA
• REMAJA
• Remaja awal (11-14 tahun)
• Remaja Tengah (15-17 tahun)
• Remaja Lanjut (Usia 18-21 tahun)
• FISIOLOGI PUBERTAS
• Pubertas
• Tanda Pubertas Perempuan
• Slide 9
• Tanda Pubertas Laki-laki
• Sexual Maturity Rating
• Pubertas Perempuan
• Pubertas Laki-laki
• Pertumbuhan fisik
• Slide 15
• Slide 16
• Lonjakan pertumbuhan
• Perkembangan psikososial
• MASALAH-MASALAH REMAJA
• Morbiditas
• Masalah lain
• Psychological Problems in Adolescence
• Slide 23
• Teen suicide (contrsquod)
• Cluster Suicides
• Warning signs of suicide
• Indikator remaja berisiko tinggi
• Slide 28
• Gejala psikofisiologis
• Terapi gejala psikofisiologi
• KLINIK REMAJA
• Sikap Dokter Dalam Menghadapi Pasien Remaja
• Pemberian pelayanan kesehatan
• Kerahasiaan
• What are The importan Aspects of an Adolescent History
• How to Talk to Teens about Puberty
• Wawancara
• Slide 38
• LAMPIRAN
• 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
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• CASE
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Causes of Short Stature
• Slide 65
• Slide 66
• Causes of Delayed Puberty
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73

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 25 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 134 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 25 SD below the mean and is considered to have delayed puberty

- By this definition 06 of the healthy population are classified as having constitutional delay in growth and adolescence

CASE

bull 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

bull 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)

bull 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 15 to 35 year period

bull 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 124 to 128 years of age African-American girls are maturing earlier

bull 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 115 years

bull 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 135 and 17 years of age Growth of the penis reaches a SMR (Tanner) stage V between 125 and 165 years of age Nocturnal emissions (wet dreams) may first appear during SMR stage III

bull 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

bull 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

bull 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

bull 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

bull 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)

bull

bull 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

bull 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

bull 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 50ile of the patients actual height)

bull 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 (Klinefelters syndrome)

Causes of Short Staturebull I Constitutional Short Staturebull II Primordial Dwarfism (intrauterine growth retardation)bull III Endocrine Causesbull A Growth Hormone Deficiencybull 1 Congenitalbull 2 Acquiredbull a HypothalamicPituitary Tumorsbull b Head Traumabull c CNS infectionsbull d Psychosocial Dwarfismbull 3 Laron Dwarfismbull 4 Hypothyroidismbull 5 Syndromes of Short Staturebull a Turner Syndrome (gonadal dysgenesis)bull b Noonans Syndromebull c Prader-Willi Syndromebull

Causes of Short Stature

bull IV Chronic Diseasebull A Heart Diseasebull B Pulmonarybull 1 Cystic Fibrosisbull 2 Asthmabull C GI Disordersbull D Hepatic Diseasebull E Renalbull V Iatrogenicbull A Corticosteroids anabolic steroidsbull B ADHD meds

bull Causes of Delayed Pubertybull I Constitutional Delay in Growth and Maturationbull II Hypogonadotropic hypogonadismbull A Central nervous system disordersbull 1 Tumors bull a Craniopharyngiomasbull b Gliomasbull c Germinomasbull 2 Radiation Therapybull 3 Congenital Malformationsbull

Causes of Delayed Puberty

bull B Isolated Growth Hormone Deficiencybull 1 Kallmanns Syndromebull C Miscellaneous Disordersbull 1 Prader-Willi Syndromebull 2 Hypothyroidismbull 3 Malnutritionbull 4 Anorexia Nervosabull 5 Exercise amenorrheabull 6 Cushingsbull 7 Diabetesbull

Causes of Delayed Puberty

bull III Hypergonadotropic hypogonadism

bull A Turner Syndrome

bull B XX and XY gonadal dysgenesis

bull C Polycystic ovary Syndrome

bull D Noonans 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- Kallmanns 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 Klinefelters syndrome Other forms of primary testicular failureAnorchia or

cryptorchism- Females Turners syndromeOther forms of primary ovarian failure Pseudo-Turners

syndrome- Noonans 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 2512 years of age with idiopathic true precocious

13412-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 (-45 SD) and a weight of 286 kg (-3 SD) The patient had early stage 2 breast development There was no pubic hair Karyotype was 46XX Bone age was 10 years After administration of GnRH LH and FSH rose in a pubertal pattern Estradiol was 40 pgmL She has since spontaneously progressed through pubertal development

• TUMBUH KEMBANG REMAJA
• REMAJA
• Remaja awal (11-14 tahun)
• Remaja Tengah (15-17 tahun)
• Remaja Lanjut (Usia 18-21 tahun)
• FISIOLOGI PUBERTAS
• Pubertas
• Tanda Pubertas Perempuan
• Slide 9
• Tanda Pubertas Laki-laki
• Sexual Maturity Rating
• Pubertas Perempuan
• Pubertas Laki-laki
• Pertumbuhan fisik
• Slide 15
• Slide 16
• Lonjakan pertumbuhan
• Perkembangan psikososial
• MASALAH-MASALAH REMAJA
• Morbiditas
• Masalah lain
• Psychological Problems in Adolescence
• Slide 23
• Teen suicide (contrsquod)
• Cluster Suicides
• Warning signs of suicide
• Indikator remaja berisiko tinggi
• Slide 28
• Gejala psikofisiologis
• Terapi gejala psikofisiologi
• KLINIK REMAJA
• Sikap Dokter Dalam Menghadapi Pasien Remaja
• Pemberian pelayanan kesehatan
• Kerahasiaan
• What are The importan Aspects of an Adolescent History
• How to Talk to Teens about Puberty
• Wawancara
• Slide 38
• LAMPIRAN
• 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
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• CASE
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Causes of Short Stature
• Slide 65
• Slide 66
• Causes of Delayed Puberty
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73

B Male Changes - The first sign of normal puberty in boys is usually

increase in the size of the testes to over 25 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 134 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 25 SD below the mean and is considered to have delayed puberty

- By this definition 06 of the healthy population are classified as having constitutional delay in growth and adolescence

CASE

bull 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

bull 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)

bull 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 15 to 35 year period

bull 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 124 to 128 years of age African-American girls are maturing earlier

bull 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 115 years

bull 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 135 and 17 years of age Growth of the penis reaches a SMR (Tanner) stage V between 125 and 165 years of age Nocturnal emissions (wet dreams) may first appear during SMR stage III

bull 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

bull 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

bull 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

bull 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

bull 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)

bull

bull 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

bull 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

bull 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 50ile of the patients actual height)

bull 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 (Klinefelters syndrome)

Causes of Short Staturebull I Constitutional Short Staturebull II Primordial Dwarfism (intrauterine growth retardation)bull III Endocrine Causesbull A Growth Hormone Deficiencybull 1 Congenitalbull 2 Acquiredbull a HypothalamicPituitary Tumorsbull b Head Traumabull c CNS infectionsbull d Psychosocial Dwarfismbull 3 Laron Dwarfismbull 4 Hypothyroidismbull 5 Syndromes of Short Staturebull a Turner Syndrome (gonadal dysgenesis)bull b Noonans Syndromebull c Prader-Willi Syndromebull

Causes of Short Stature

bull IV Chronic Diseasebull A Heart Diseasebull B Pulmonarybull 1 Cystic Fibrosisbull 2 Asthmabull C GI Disordersbull D Hepatic Diseasebull E Renalbull V Iatrogenicbull A Corticosteroids anabolic steroidsbull B ADHD meds

bull Causes of Delayed Pubertybull I Constitutional Delay in Growth and Maturationbull II Hypogonadotropic hypogonadismbull A Central nervous system disordersbull 1 Tumors bull a Craniopharyngiomasbull b Gliomasbull c Germinomasbull 2 Radiation Therapybull 3 Congenital Malformationsbull

Causes of Delayed Puberty

bull B Isolated Growth Hormone Deficiencybull 1 Kallmanns Syndromebull C Miscellaneous Disordersbull 1 Prader-Willi Syndromebull 2 Hypothyroidismbull 3 Malnutritionbull 4 Anorexia Nervosabull 5 Exercise amenorrheabull 6 Cushingsbull 7 Diabetesbull

Causes of Delayed Puberty

bull III Hypergonadotropic hypogonadism

bull A Turner Syndrome

bull B XX and XY gonadal dysgenesis

bull C Polycystic ovary Syndrome

bull D Noonans 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- Kallmanns 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 Klinefelters syndrome Other forms of primary testicular failureAnorchia or

cryptorchism- Females Turners syndromeOther forms of primary ovarian failure Pseudo-Turners

syndrome- Noonans 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 2512 years of age with idiopathic true precocious

13412-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 (-45 SD) and a weight of 286 kg (-3 SD) The patient had early stage 2 breast development There was no pubic hair Karyotype was 46XX Bone age was 10 years After administration of GnRH LH and FSH rose in a pubertal pattern Estradiol was 40 pgmL She has since spontaneously progressed through pubertal development

• TUMBUH KEMBANG REMAJA
• REMAJA
• Remaja awal (11-14 tahun)
• Remaja Tengah (15-17 tahun)
• Remaja Lanjut (Usia 18-21 tahun)
• FISIOLOGI PUBERTAS
• Pubertas
• Tanda Pubertas Perempuan
• Slide 9
• Tanda Pubertas Laki-laki
• Sexual Maturity Rating
• Pubertas Perempuan
• Pubertas Laki-laki
• Pertumbuhan fisik
• Slide 15
• Slide 16
• Lonjakan pertumbuhan
• Perkembangan psikososial
• MASALAH-MASALAH REMAJA
• Morbiditas
• Masalah lain
• Psychological Problems in Adolescence
• Slide 23
• Teen suicide (contrsquod)
• Cluster Suicides
• Warning signs of suicide
• Indikator remaja berisiko tinggi
• Slide 28
• Gejala psikofisiologis
• Terapi gejala psikofisiologi
• KLINIK REMAJA
• Sikap Dokter Dalam Menghadapi Pasien Remaja
• Pemberian pelayanan kesehatan
• Kerahasiaan
• What are The importan Aspects of an Adolescent History
• How to Talk to Teens about Puberty
• Wawancara
• Slide 38
• LAMPIRAN
• 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
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• CASE
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Causes of Short Stature
• Slide 65
• Slide 66
• Causes of Delayed Puberty
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73

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 25 SD below the mean and is considered to have delayed puberty

- By this definition 06 of the healthy population are classified as having constitutional delay in growth and adolescence

CASE

bull 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

bull 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)

bull 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 15 to 35 year period

bull 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 124 to 128 years of age African-American girls are maturing earlier

bull 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 115 years

bull 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 135 and 17 years of age Growth of the penis reaches a SMR (Tanner) stage V between 125 and 165 years of age Nocturnal emissions (wet dreams) may first appear during SMR stage III

bull 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

bull 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

bull 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

bull 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

bull 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)

bull

bull 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

bull 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

bull 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 50ile of the patients actual height)

bull 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 (Klinefelters syndrome)

Causes of Short Staturebull I Constitutional Short Staturebull II Primordial Dwarfism (intrauterine growth retardation)bull III Endocrine Causesbull A Growth Hormone Deficiencybull 1 Congenitalbull 2 Acquiredbull a HypothalamicPituitary Tumorsbull b Head Traumabull c CNS infectionsbull d Psychosocial Dwarfismbull 3 Laron Dwarfismbull 4 Hypothyroidismbull 5 Syndromes of Short Staturebull a Turner Syndrome (gonadal dysgenesis)bull b Noonans Syndromebull c Prader-Willi Syndromebull

Causes of Short Stature

bull IV Chronic Diseasebull A Heart Diseasebull B Pulmonarybull 1 Cystic Fibrosisbull 2 Asthmabull C GI Disordersbull D Hepatic Diseasebull E Renalbull V Iatrogenicbull A Corticosteroids anabolic steroidsbull B ADHD meds

bull Causes of Delayed Pubertybull I Constitutional Delay in Growth and Maturationbull II Hypogonadotropic hypogonadismbull A Central nervous system disordersbull 1 Tumors bull a Craniopharyngiomasbull b Gliomasbull c Germinomasbull 2 Radiation Therapybull 3 Congenital Malformationsbull

Causes of Delayed Puberty

bull B Isolated Growth Hormone Deficiencybull 1 Kallmanns Syndromebull C Miscellaneous Disordersbull 1 Prader-Willi Syndromebull 2 Hypothyroidismbull 3 Malnutritionbull 4 Anorexia Nervosabull 5 Exercise amenorrheabull 6 Cushingsbull 7 Diabetesbull

Causes of Delayed Puberty

bull III Hypergonadotropic hypogonadism

bull A Turner Syndrome

bull B XX and XY gonadal dysgenesis

bull C Polycystic ovary Syndrome

bull D Noonans 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- Kallmanns 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 Klinefelters syndrome Other forms of primary testicular failureAnorchia or

cryptorchism- Females Turners syndromeOther forms of primary ovarian failure Pseudo-Turners

syndrome- Noonans 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 2512 years of age with idiopathic true precocious

13412-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 (-45 SD) and a weight of 286 kg (-3 SD) The patient had early stage 2 breast development There was no pubic hair Karyotype was 46XX Bone age was 10 years After administration of GnRH LH and FSH rose in a pubertal pattern Estradiol was 40 pgmL She has since spontaneously progressed through pubertal development

• TUMBUH KEMBANG REMAJA
• REMAJA
• Remaja awal (11-14 tahun)
• Remaja Tengah (15-17 tahun)
• Remaja Lanjut (Usia 18-21 tahun)
• FISIOLOGI PUBERTAS
• Pubertas
• Tanda Pubertas Perempuan
• Slide 9
• Tanda Pubertas Laki-laki
• Sexual Maturity Rating
• Pubertas Perempuan
• Pubertas Laki-laki
• Pertumbuhan fisik
• Slide 15
• Slide 16
• Lonjakan pertumbuhan
• Perkembangan psikososial
• MASALAH-MASALAH REMAJA
• Morbiditas
• Masalah lain
• Psychological Problems in Adolescence
• Slide 23
• Teen suicide (contrsquod)
• Cluster Suicides
• Warning signs of suicide
• Indikator remaja berisiko tinggi
• Slide 28
• Gejala psikofisiologis
• Terapi gejala psikofisiologi
• KLINIK REMAJA
• Sikap Dokter Dalam Menghadapi Pasien Remaja
• Pemberian pelayanan kesehatan
• Kerahasiaan
• What are The importan Aspects of an Adolescent History
• How to Talk to Teens about Puberty
• Wawancara
• Slide 38
• LAMPIRAN
• 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
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• CASE
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Causes of Short Stature
• Slide 65
• Slide 66
• Causes of Delayed Puberty
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73

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 25 SD below the mean and is considered to have delayed puberty

- By this definition 06 of the healthy population are classified as having constitutional delay in growth and adolescence

CASE

bull 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

bull 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)

bull 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 15 to 35 year period

bull 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 124 to 128 years of age African-American girls are maturing earlier

bull 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 115 years

bull 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 135 and 17 years of age Growth of the penis reaches a SMR (Tanner) stage V between 125 and 165 years of age Nocturnal emissions (wet dreams) may first appear during SMR stage III

bull 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

bull 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

bull 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

bull 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

bull 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)

bull

bull 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

bull 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

bull 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 50ile of the patients actual height)

bull 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 (Klinefelters syndrome)

Causes of Short Staturebull I Constitutional Short Staturebull II Primordial Dwarfism (intrauterine growth retardation)bull III Endocrine Causesbull A Growth Hormone Deficiencybull 1 Congenitalbull 2 Acquiredbull a HypothalamicPituitary Tumorsbull b Head Traumabull c CNS infectionsbull d Psychosocial Dwarfismbull 3 Laron Dwarfismbull 4 Hypothyroidismbull 5 Syndromes of Short Staturebull a Turner Syndrome (gonadal dysgenesis)bull b Noonans Syndromebull c Prader-Willi Syndromebull

Causes of Short Stature

bull IV Chronic Diseasebull A Heart Diseasebull B Pulmonarybull 1 Cystic Fibrosisbull 2 Asthmabull C GI Disordersbull D Hepatic Diseasebull E Renalbull V Iatrogenicbull A Corticosteroids anabolic steroidsbull B ADHD meds

bull Causes of Delayed Pubertybull I Constitutional Delay in Growth and Maturationbull II Hypogonadotropic hypogonadismbull A Central nervous system disordersbull 1 Tumors bull a Craniopharyngiomasbull b Gliomasbull c Germinomasbull 2 Radiation Therapybull 3 Congenital Malformationsbull

Causes of Delayed Puberty

bull B Isolated Growth Hormone Deficiencybull 1 Kallmanns Syndromebull C Miscellaneous Disordersbull 1 Prader-Willi Syndromebull 2 Hypothyroidismbull 3 Malnutritionbull 4 Anorexia Nervosabull 5 Exercise amenorrheabull 6 Cushingsbull 7 Diabetesbull

Causes of Delayed Puberty

bull III Hypergonadotropic hypogonadism

bull A Turner Syndrome

bull B XX and XY gonadal dysgenesis

bull C Polycystic ovary Syndrome

bull D Noonans 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- Kallmanns 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 Klinefelters syndrome Other forms of primary testicular failureAnorchia or

cryptorchism- Females Turners syndromeOther forms of primary ovarian failure Pseudo-Turners

syndrome- Noonans 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 2512 years of age with idiopathic true precocious

13412-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 (-45 SD) and a weight of 286 kg (-3 SD) The patient had early stage 2 breast development There was no pubic hair Karyotype was 46XX Bone age was 10 years After administration of GnRH LH and FSH rose in a pubertal pattern Estradiol was 40 pgmL She has since spontaneously progressed through pubertal development

• TUMBUH KEMBANG REMAJA
• REMAJA
• Remaja awal (11-14 tahun)
• Remaja Tengah (15-17 tahun)
• Remaja Lanjut (Usia 18-21 tahun)
• FISIOLOGI PUBERTAS
• Pubertas
• Tanda Pubertas Perempuan
• Slide 9
• Tanda Pubertas Laki-laki
• Sexual Maturity Rating
• Pubertas Perempuan
• Pubertas Laki-laki
• Pertumbuhan fisik
• Slide 15
• Slide 16
• Lonjakan pertumbuhan
• Perkembangan psikososial
• MASALAH-MASALAH REMAJA
• Morbiditas
• Masalah lain
• Psychological Problems in Adolescence
• Slide 23
• Teen suicide (contrsquod)
• Cluster Suicides
• Warning signs of suicide
• Indikator remaja berisiko tinggi
• Slide 28
• Gejala psikofisiologis
• Terapi gejala psikofisiologi
• KLINIK REMAJA
• Sikap Dokter Dalam Menghadapi Pasien Remaja
• Pemberian pelayanan kesehatan
• Kerahasiaan
• What are The importan Aspects of an Adolescent History
• How to Talk to Teens about Puberty
• Wawancara
• Slide 38
• LAMPIRAN
• 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
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• CASE
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Causes of Short Stature
• Slide 65
• Slide 66
• Causes of Delayed Puberty
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73

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 25 SD below the mean and is considered to have delayed puberty

- By this definition 06 of the healthy population are classified as having constitutional delay in growth and adolescence

CASE

bull 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

bull 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)

bull 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 15 to 35 year period

bull 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 124 to 128 years of age African-American girls are maturing earlier

bull 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 115 years

bull 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 135 and 17 years of age Growth of the penis reaches a SMR (Tanner) stage V between 125 and 165 years of age Nocturnal emissions (wet dreams) may first appear during SMR stage III

bull 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

bull 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

bull 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

bull 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

bull 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)

bull

bull 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

bull 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

bull 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 50ile of the patients actual height)

bull 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 (Klinefelters syndrome)

Causes of Short Staturebull I Constitutional Short Staturebull II Primordial Dwarfism (intrauterine growth retardation)bull III Endocrine Causesbull A Growth Hormone Deficiencybull 1 Congenitalbull 2 Acquiredbull a HypothalamicPituitary Tumorsbull b Head Traumabull c CNS infectionsbull d Psychosocial Dwarfismbull 3 Laron Dwarfismbull 4 Hypothyroidismbull 5 Syndromes of Short Staturebull a Turner Syndrome (gonadal dysgenesis)bull b Noonans Syndromebull c Prader-Willi Syndromebull

Causes of Short Stature

bull IV Chronic Diseasebull A Heart Diseasebull B Pulmonarybull 1 Cystic Fibrosisbull 2 Asthmabull C GI Disordersbull D Hepatic Diseasebull E Renalbull V Iatrogenicbull A Corticosteroids anabolic steroidsbull B ADHD meds

bull Causes of Delayed Pubertybull I Constitutional Delay in Growth and Maturationbull II Hypogonadotropic hypogonadismbull A Central nervous system disordersbull 1 Tumors bull a Craniopharyngiomasbull b Gliomasbull c Germinomasbull 2 Radiation Therapybull 3 Congenital Malformationsbull

Causes of Delayed Puberty

bull B Isolated Growth Hormone Deficiencybull 1 Kallmanns Syndromebull C Miscellaneous Disordersbull 1 Prader-Willi Syndromebull 2 Hypothyroidismbull 3 Malnutritionbull 4 Anorexia Nervosabull 5 Exercise amenorrheabull 6 Cushingsbull 7 Diabetesbull

Causes of Delayed Puberty

bull III Hypergonadotropic hypogonadism

bull A Turner Syndrome

bull B XX and XY gonadal dysgenesis

bull C Polycystic ovary Syndrome

bull D Noonans 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- Kallmanns 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 Klinefelters syndrome Other forms of primary testicular failureAnorchia or

cryptorchism- Females Turners syndromeOther forms of primary ovarian failure Pseudo-Turners

syndrome- Noonans 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 2512 years of age with idiopathic true precocious

13412-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 (-45 SD) and a weight of 286 kg (-3 SD) The patient had early stage 2 breast development There was no pubic hair Karyotype was 46XX Bone age was 10 years After administration of GnRH LH and FSH rose in a pubertal pattern Estradiol was 40 pgmL She has since spontaneously progressed through pubertal development

• TUMBUH KEMBANG REMAJA
• REMAJA
• Remaja awal (11-14 tahun)
• Remaja Tengah (15-17 tahun)
• Remaja Lanjut (Usia 18-21 tahun)
• FISIOLOGI PUBERTAS
• Pubertas
• Tanda Pubertas Perempuan
• Slide 9
• Tanda Pubertas Laki-laki
• Sexual Maturity Rating
• Pubertas Perempuan
• Pubertas Laki-laki
• Pertumbuhan fisik
• Slide 15
• Slide 16
• Lonjakan pertumbuhan
• Perkembangan psikososial
• MASALAH-MASALAH REMAJA
• Morbiditas
• Masalah lain
• Psychological Problems in Adolescence
• Slide 23
• Teen suicide (contrsquod)
• Cluster Suicides
• Warning signs of suicide
• Indikator remaja berisiko tinggi
• Slide 28
• Gejala psikofisiologis
• Terapi gejala psikofisiologi
• KLINIK REMAJA
• Sikap Dokter Dalam Menghadapi Pasien Remaja
• Pemberian pelayanan kesehatan
• Kerahasiaan
• What are The importan Aspects of an Adolescent History
• How to Talk to Teens about Puberty
• Wawancara
• Slide 38
• LAMPIRAN
• 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
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• CASE
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Causes of Short Stature
• Slide 65
• Slide 66
• Causes of Delayed Puberty
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73

CASE

bull 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

bull 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)

bull 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 15 to 35 year period

bull 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 124 to 128 years of age African-American girls are maturing earlier

bull 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 115 years

bull 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 135 and 17 years of age Growth of the penis reaches a SMR (Tanner) stage V between 125 and 165 years of age Nocturnal emissions (wet dreams) may first appear during SMR stage III

bull 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

bull 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

bull 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

bull 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

bull 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)

bull

bull 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

bull 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

bull 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 50ile of the patients actual height)

bull 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 (Klinefelters syndrome)

Causes of Short Staturebull I Constitutional Short Staturebull II Primordial Dwarfism (intrauterine growth retardation)bull III Endocrine Causesbull A Growth Hormone Deficiencybull 1 Congenitalbull 2 Acquiredbull a HypothalamicPituitary Tumorsbull b Head Traumabull c CNS infectionsbull d Psychosocial Dwarfismbull 3 Laron Dwarfismbull 4 Hypothyroidismbull 5 Syndromes of Short Staturebull a Turner Syndrome (gonadal dysgenesis)bull b Noonans Syndromebull c Prader-Willi Syndromebull

Causes of Short Stature

bull IV Chronic Diseasebull A Heart Diseasebull B Pulmonarybull 1 Cystic Fibrosisbull 2 Asthmabull C GI Disordersbull D Hepatic Diseasebull E Renalbull V Iatrogenicbull A Corticosteroids anabolic steroidsbull B ADHD meds

bull Causes of Delayed Pubertybull I Constitutional Delay in Growth and Maturationbull II Hypogonadotropic hypogonadismbull A Central nervous system disordersbull 1 Tumors bull a Craniopharyngiomasbull b Gliomasbull c Germinomasbull 2 Radiation Therapybull 3 Congenital Malformationsbull

Causes of Delayed Puberty

bull B Isolated Growth Hormone Deficiencybull 1 Kallmanns Syndromebull C Miscellaneous Disordersbull 1 Prader-Willi Syndromebull 2 Hypothyroidismbull 3 Malnutritionbull 4 Anorexia Nervosabull 5 Exercise amenorrheabull 6 Cushingsbull 7 Diabetesbull

Causes of Delayed Puberty

bull III Hypergonadotropic hypogonadism

bull A Turner Syndrome

bull B XX and XY gonadal dysgenesis

bull C Polycystic ovary Syndrome

bull D Noonans 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- Kallmanns 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 Klinefelters syndrome Other forms of primary testicular failureAnorchia or

cryptorchism- Females Turners syndromeOther forms of primary ovarian failure Pseudo-Turners

syndrome- Noonans 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 2512 years of age with idiopathic true precocious

13412-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 (-45 SD) and a weight of 286 kg (-3 SD) The patient had early stage 2 breast development There was no pubic hair Karyotype was 46XX Bone age was 10 years After administration of GnRH LH and FSH rose in a pubertal pattern Estradiol was 40 pgmL She has since spontaneously progressed through pubertal development

• TUMBUH KEMBANG REMAJA
• REMAJA
• Remaja awal (11-14 tahun)
• Remaja Tengah (15-17 tahun)
• Remaja Lanjut (Usia 18-21 tahun)
• FISIOLOGI PUBERTAS
• Pubertas
• Tanda Pubertas Perempuan
• Slide 9
• Tanda Pubertas Laki-laki
• Sexual Maturity Rating
• Pubertas Perempuan
• Pubertas Laki-laki
• Pertumbuhan fisik
• Slide 15
• Slide 16
• Lonjakan pertumbuhan
• Perkembangan psikososial
• MASALAH-MASALAH REMAJA
• Morbiditas
• Masalah lain
• Psychological Problems in Adolescence
• Slide 23
• Teen suicide (contrsquod)
• Cluster Suicides
• Warning signs of suicide
• Indikator remaja berisiko tinggi
• Slide 28
• Gejala psikofisiologis
• Terapi gejala psikofisiologi
• KLINIK REMAJA
• Sikap Dokter Dalam Menghadapi Pasien Remaja
• Pemberian pelayanan kesehatan
• Kerahasiaan
• What are The importan Aspects of an Adolescent History
• How to Talk to Teens about Puberty
• Wawancara
• Slide 38
• LAMPIRAN
• 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
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• CASE
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Causes of Short Stature
• Slide 65
• Slide 66
• Causes of Delayed Puberty
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73

bull 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)

bull 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 15 to 35 year period

bull 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 124 to 128 years of age African-American girls are maturing earlier

bull 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 115 years

bull 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 135 and 17 years of age Growth of the penis reaches a SMR (Tanner) stage V between 125 and 165 years of age Nocturnal emissions (wet dreams) may first appear during SMR stage III

bull 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

bull 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

bull 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

bull 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

bull 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)

bull

bull 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

bull 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

bull 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 50ile of the patients actual height)

bull 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 (Klinefelters syndrome)

Causes of Short Staturebull I Constitutional Short Staturebull II Primordial Dwarfism (intrauterine growth retardation)bull III Endocrine Causesbull A Growth Hormone Deficiencybull 1 Congenitalbull 2 Acquiredbull a HypothalamicPituitary Tumorsbull b Head Traumabull c CNS infectionsbull d Psychosocial Dwarfismbull 3 Laron Dwarfismbull 4 Hypothyroidismbull 5 Syndromes of Short Staturebull a Turner Syndrome (gonadal dysgenesis)bull b Noonans Syndromebull c Prader-Willi Syndromebull

Causes of Short Stature

bull IV Chronic Diseasebull A Heart Diseasebull B Pulmonarybull 1 Cystic Fibrosisbull 2 Asthmabull C GI Disordersbull D Hepatic Diseasebull E Renalbull V Iatrogenicbull A Corticosteroids anabolic steroidsbull B ADHD meds

bull Causes of Delayed Pubertybull I Constitutional Delay in Growth and Maturationbull II Hypogonadotropic hypogonadismbull A Central nervous system disordersbull 1 Tumors bull a Craniopharyngiomasbull b Gliomasbull c Germinomasbull 2 Radiation Therapybull 3 Congenital Malformationsbull

Causes of Delayed Puberty

bull B Isolated Growth Hormone Deficiencybull 1 Kallmanns Syndromebull C Miscellaneous Disordersbull 1 Prader-Willi Syndromebull 2 Hypothyroidismbull 3 Malnutritionbull 4 Anorexia Nervosabull 5 Exercise amenorrheabull 6 Cushingsbull 7 Diabetesbull

Causes of Delayed Puberty

bull III Hypergonadotropic hypogonadism

bull A Turner Syndrome

bull B XX and XY gonadal dysgenesis

bull C Polycystic ovary Syndrome

bull D Noonans 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- Kallmanns 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 Klinefelters syndrome Other forms of primary testicular failureAnorchia or

cryptorchism- Females Turners syndromeOther forms of primary ovarian failure Pseudo-Turners

syndrome- Noonans 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 2512 years of age with idiopathic true precocious

13412-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 (-45 SD) and a weight of 286 kg (-3 SD) The patient had early stage 2 breast development There was no pubic hair Karyotype was 46XX Bone age was 10 years After administration of GnRH LH and FSH rose in a pubertal pattern Estradiol was 40 pgmL She has since spontaneously progressed through pubertal development

• TUMBUH KEMBANG REMAJA
• REMAJA
• Remaja awal (11-14 tahun)
• Remaja Tengah (15-17 tahun)
• Remaja Lanjut (Usia 18-21 tahun)
• FISIOLOGI PUBERTAS
• Pubertas
• Tanda Pubertas Perempuan
• Slide 9
• Tanda Pubertas Laki-laki
• Sexual Maturity Rating
• Pubertas Perempuan
• Pubertas Laki-laki
• Pertumbuhan fisik
• Slide 15
• Slide 16
• Lonjakan pertumbuhan
• Perkembangan psikososial
• MASALAH-MASALAH REMAJA
• Morbiditas
• Masalah lain
• Psychological Problems in Adolescence
• Slide 23
• Teen suicide (contrsquod)
• Cluster Suicides
• Warning signs of suicide
• Indikator remaja berisiko tinggi
• Slide 28
• Gejala psikofisiologis
• Terapi gejala psikofisiologi
• KLINIK REMAJA
• Sikap Dokter Dalam Menghadapi Pasien Remaja
• Pemberian pelayanan kesehatan
• Kerahasiaan
• What are The importan Aspects of an Adolescent History
• How to Talk to Teens about Puberty
• Wawancara
• Slide 38
• LAMPIRAN
• 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
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• CASE
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Causes of Short Stature
• Slide 65
• Slide 66
• Causes of Delayed Puberty
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73

bull 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 15 to 35 year period

bull 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 124 to 128 years of age African-American girls are maturing earlier

bull 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 115 years

bull 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 135 and 17 years of age Growth of the penis reaches a SMR (Tanner) stage V between 125 and 165 years of age Nocturnal emissions (wet dreams) may first appear during SMR stage III

bull 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

bull 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

bull 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

bull 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

bull 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)

bull

bull 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

bull 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

bull 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 50ile of the patients actual height)

bull 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 (Klinefelters syndrome)

Causes of Short Staturebull I Constitutional Short Staturebull II Primordial Dwarfism (intrauterine growth retardation)bull III Endocrine Causesbull A Growth Hormone Deficiencybull 1 Congenitalbull 2 Acquiredbull a HypothalamicPituitary Tumorsbull b Head Traumabull c CNS infectionsbull d Psychosocial Dwarfismbull 3 Laron Dwarfismbull 4 Hypothyroidismbull 5 Syndromes of Short Staturebull a Turner Syndrome (gonadal dysgenesis)bull b Noonans Syndromebull c Prader-Willi Syndromebull

Causes of Short Stature

bull IV Chronic Diseasebull A Heart Diseasebull B Pulmonarybull 1 Cystic Fibrosisbull 2 Asthmabull C GI Disordersbull D Hepatic Diseasebull E Renalbull V Iatrogenicbull A Corticosteroids anabolic steroidsbull B ADHD meds

bull Causes of Delayed Pubertybull I Constitutional Delay in Growth and Maturationbull II Hypogonadotropic hypogonadismbull A Central nervous system disordersbull 1 Tumors bull a Craniopharyngiomasbull b Gliomasbull c Germinomasbull 2 Radiation Therapybull 3 Congenital Malformationsbull

Causes of Delayed Puberty

bull B Isolated Growth Hormone Deficiencybull 1 Kallmanns Syndromebull C Miscellaneous Disordersbull 1 Prader-Willi Syndromebull 2 Hypothyroidismbull 3 Malnutritionbull 4 Anorexia Nervosabull 5 Exercise amenorrheabull 6 Cushingsbull 7 Diabetesbull

Causes of Delayed Puberty

bull III Hypergonadotropic hypogonadism

bull A Turner Syndrome

bull B XX and XY gonadal dysgenesis

bull C Polycystic ovary Syndrome

bull D Noonans 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- Kallmanns 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 Klinefelters syndrome Other forms of primary testicular failureAnorchia or

cryptorchism- Females Turners syndromeOther forms of primary ovarian failure Pseudo-Turners

syndrome- Noonans 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 2512 years of age with idiopathic true precocious

13412-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 (-45 SD) and a weight of 286 kg (-3 SD) The patient had early stage 2 breast development There was no pubic hair Karyotype was 46XX Bone age was 10 years After administration of GnRH LH and FSH rose in a pubertal pattern Estradiol was 40 pgmL She has since spontaneously progressed through pubertal development

• TUMBUH KEMBANG REMAJA
• REMAJA
• Remaja awal (11-14 tahun)
• Remaja Tengah (15-17 tahun)
• Remaja Lanjut (Usia 18-21 tahun)
• FISIOLOGI PUBERTAS
• Pubertas
• Tanda Pubertas Perempuan
• Slide 9
• Tanda Pubertas Laki-laki
• Sexual Maturity Rating
• Pubertas Perempuan
• Pubertas Laki-laki
• Pertumbuhan fisik
• Slide 15
• Slide 16
• Lonjakan pertumbuhan
• Perkembangan psikososial
• MASALAH-MASALAH REMAJA
• Morbiditas
• Masalah lain
• Psychological Problems in Adolescence
• Slide 23
• Teen suicide (contrsquod)
• Cluster Suicides
• Warning signs of suicide
• Indikator remaja berisiko tinggi
• Slide 28
• Gejala psikofisiologis
• Terapi gejala psikofisiologi
• KLINIK REMAJA
• Sikap Dokter Dalam Menghadapi Pasien Remaja
• Pemberian pelayanan kesehatan
• Kerahasiaan
• What are The importan Aspects of an Adolescent History
• How to Talk to Teens about Puberty
• Wawancara
• Slide 38
• LAMPIRAN
• 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
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• CASE
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Causes of Short Stature
• Slide 65
• Slide 66
• Causes of Delayed Puberty
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73

bull 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 115 years

bull 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 135 and 17 years of age Growth of the penis reaches a SMR (Tanner) stage V between 125 and 165 years of age Nocturnal emissions (wet dreams) may first appear during SMR stage III

bull 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

bull 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

bull 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

bull 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

bull 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)

bull

bull 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

bull 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

bull 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 50ile of the patients actual height)

bull 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 (Klinefelters syndrome)

Causes of Short Staturebull I Constitutional Short Staturebull II Primordial Dwarfism (intrauterine growth retardation)bull III Endocrine Causesbull A Growth Hormone Deficiencybull 1 Congenitalbull 2 Acquiredbull a HypothalamicPituitary Tumorsbull b Head Traumabull c CNS infectionsbull d Psychosocial Dwarfismbull 3 Laron Dwarfismbull 4 Hypothyroidismbull 5 Syndromes of Short Staturebull a Turner Syndrome (gonadal dysgenesis)bull b Noonans Syndromebull c Prader-Willi Syndromebull

Causes of Short Stature

bull IV Chronic Diseasebull A Heart Diseasebull B Pulmonarybull 1 Cystic Fibrosisbull 2 Asthmabull C GI Disordersbull D Hepatic Diseasebull E Renalbull V Iatrogenicbull A Corticosteroids anabolic steroidsbull B ADHD meds

bull Causes of Delayed Pubertybull I Constitutional Delay in Growth and Maturationbull II Hypogonadotropic hypogonadismbull A Central nervous system disordersbull 1 Tumors bull a Craniopharyngiomasbull b Gliomasbull c Germinomasbull 2 Radiation Therapybull 3 Congenital Malformationsbull

Causes of Delayed Puberty

bull B Isolated Growth Hormone Deficiencybull 1 Kallmanns Syndromebull C Miscellaneous Disordersbull 1 Prader-Willi Syndromebull 2 Hypothyroidismbull 3 Malnutritionbull 4 Anorexia Nervosabull 5 Exercise amenorrheabull 6 Cushingsbull 7 Diabetesbull

Causes of Delayed Puberty

bull III Hypergonadotropic hypogonadism

bull A Turner Syndrome

bull B XX and XY gonadal dysgenesis

bull C Polycystic ovary Syndrome

bull D Noonans 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- Kallmanns 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 Klinefelters syndrome Other forms of primary testicular failureAnorchia or

cryptorchism- Females Turners syndromeOther forms of primary ovarian failure Pseudo-Turners

syndrome- Noonans 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 2512 years of age with idiopathic true precocious

13412-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 (-45 SD) and a weight of 286 kg (-3 SD) The patient had early stage 2 breast development There was no pubic hair Karyotype was 46XX Bone age was 10 years After administration of GnRH LH and FSH rose in a pubertal pattern Estradiol was 40 pgmL She has since spontaneously progressed through pubertal development

• TUMBUH KEMBANG REMAJA
• REMAJA
• Remaja awal (11-14 tahun)
• Remaja Tengah (15-17 tahun)
• Remaja Lanjut (Usia 18-21 tahun)
• FISIOLOGI PUBERTAS
• Pubertas
• Tanda Pubertas Perempuan
• Slide 9
• Tanda Pubertas Laki-laki
• Sexual Maturity Rating
• Pubertas Perempuan
• Pubertas Laki-laki
• Pertumbuhan fisik
• Slide 15
• Slide 16
• Lonjakan pertumbuhan
• Perkembangan psikososial
• MASALAH-MASALAH REMAJA
• Morbiditas
• Masalah lain
• Psychological Problems in Adolescence
• Slide 23
• Teen suicide (contrsquod)
• Cluster Suicides
• Warning signs of suicide
• Indikator remaja berisiko tinggi
• Slide 28
• Gejala psikofisiologis
• Terapi gejala psikofisiologi
• KLINIK REMAJA
• Sikap Dokter Dalam Menghadapi Pasien Remaja
• Pemberian pelayanan kesehatan
• Kerahasiaan
• What are The importan Aspects of an Adolescent History
• How to Talk to Teens about Puberty
• Wawancara
• Slide 38
• LAMPIRAN
• 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
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• CASE
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Causes of Short Stature
• Slide 65
• Slide 66
• Causes of Delayed Puberty
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73

bull 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 135 and 17 years of age Growth of the penis reaches a SMR (Tanner) stage V between 125 and 165 years of age Nocturnal emissions (wet dreams) may first appear during SMR stage III

bull 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

bull 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

bull 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

bull 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

bull 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)

bull

bull 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

bull 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

bull 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 50ile of the patients actual height)

bull 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 (Klinefelters syndrome)

Causes of Short Staturebull I Constitutional Short Staturebull II Primordial Dwarfism (intrauterine growth retardation)bull III Endocrine Causesbull A Growth Hormone Deficiencybull 1 Congenitalbull 2 Acquiredbull a HypothalamicPituitary Tumorsbull b Head Traumabull c CNS infectionsbull d Psychosocial Dwarfismbull 3 Laron Dwarfismbull 4 Hypothyroidismbull 5 Syndromes of Short Staturebull a Turner Syndrome (gonadal dysgenesis)bull b Noonans Syndromebull c Prader-Willi Syndromebull

Causes of Short Stature

bull IV Chronic Diseasebull A Heart Diseasebull B Pulmonarybull 1 Cystic Fibrosisbull 2 Asthmabull C GI Disordersbull D Hepatic Diseasebull E Renalbull V Iatrogenicbull A Corticosteroids anabolic steroidsbull B ADHD meds

bull Causes of Delayed Pubertybull I Constitutional Delay in Growth and Maturationbull II Hypogonadotropic hypogonadismbull A Central nervous system disordersbull 1 Tumors bull a Craniopharyngiomasbull b Gliomasbull c Germinomasbull 2 Radiation Therapybull 3 Congenital Malformationsbull

Causes of Delayed Puberty

bull B Isolated Growth Hormone Deficiencybull 1 Kallmanns Syndromebull C Miscellaneous Disordersbull 1 Prader-Willi Syndromebull 2 Hypothyroidismbull 3 Malnutritionbull 4 Anorexia Nervosabull 5 Exercise amenorrheabull 6 Cushingsbull 7 Diabetesbull

Causes of Delayed Puberty

bull III Hypergonadotropic hypogonadism

bull A Turner Syndrome

bull B XX and XY gonadal dysgenesis

bull C Polycystic ovary Syndrome

bull D Noonans 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- Kallmanns 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 Klinefelters syndrome Other forms of primary testicular failureAnorchia or

cryptorchism- Females Turners syndromeOther forms of primary ovarian failure Pseudo-Turners

syndrome- Noonans 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 2512 years of age with idiopathic true precocious

13412-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 (-45 SD) and a weight of 286 kg (-3 SD) The patient had early stage 2 breast development There was no pubic hair Karyotype was 46XX Bone age was 10 years After administration of GnRH LH and FSH rose in a pubertal pattern Estradiol was 40 pgmL She has since spontaneously progressed through pubertal development

• TUMBUH KEMBANG REMAJA
• REMAJA
• Remaja awal (11-14 tahun)
• Remaja Tengah (15-17 tahun)
• Remaja Lanjut (Usia 18-21 tahun)
• FISIOLOGI PUBERTAS
• Pubertas
• Tanda Pubertas Perempuan
• Slide 9
• Tanda Pubertas Laki-laki
• Sexual Maturity Rating
• Pubertas Perempuan
• Pubertas Laki-laki
• Pertumbuhan fisik
• Slide 15
• Slide 16
• Lonjakan pertumbuhan
• Perkembangan psikososial
• MASALAH-MASALAH REMAJA
• Morbiditas
• Masalah lain
• Psychological Problems in Adolescence
• Slide 23
• Teen suicide (contrsquod)
• Cluster Suicides
• Warning signs of suicide
• Indikator remaja berisiko tinggi
• Slide 28
• Gejala psikofisiologis
• Terapi gejala psikofisiologi
• KLINIK REMAJA
• Sikap Dokter Dalam Menghadapi Pasien Remaja
• Pemberian pelayanan kesehatan
• Kerahasiaan
• What are The importan Aspects of an Adolescent History
• How to Talk to Teens about Puberty
• Wawancara
• Slide 38
• LAMPIRAN
• 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
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• CASE
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Causes of Short Stature
• Slide 65
• Slide 66
• Causes of Delayed Puberty
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73

bull 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

bull 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

bull 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

bull 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

bull 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)

bull

bull 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

bull 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

bull 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 50ile of the patients actual height)

bull 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 (Klinefelters syndrome)

Causes of Short Staturebull I Constitutional Short Staturebull II Primordial Dwarfism (intrauterine growth retardation)bull III Endocrine Causesbull A Growth Hormone Deficiencybull 1 Congenitalbull 2 Acquiredbull a HypothalamicPituitary Tumorsbull b Head Traumabull c CNS infectionsbull d Psychosocial Dwarfismbull 3 Laron Dwarfismbull 4 Hypothyroidismbull 5 Syndromes of Short Staturebull a Turner Syndrome (gonadal dysgenesis)bull b Noonans Syndromebull c Prader-Willi Syndromebull

Causes of Short Stature

bull IV Chronic Diseasebull A Heart Diseasebull B Pulmonarybull 1 Cystic Fibrosisbull 2 Asthmabull C GI Disordersbull D Hepatic Diseasebull E Renalbull V Iatrogenicbull A Corticosteroids anabolic steroidsbull B ADHD meds

bull Causes of Delayed Pubertybull I Constitutional Delay in Growth and Maturationbull II Hypogonadotropic hypogonadismbull A Central nervous system disordersbull 1 Tumors bull a Craniopharyngiomasbull b Gliomasbull c Germinomasbull 2 Radiation Therapybull 3 Congenital Malformationsbull

Causes of Delayed Puberty

bull B Isolated Growth Hormone Deficiencybull 1 Kallmanns Syndromebull C Miscellaneous Disordersbull 1 Prader-Willi Syndromebull 2 Hypothyroidismbull 3 Malnutritionbull 4 Anorexia Nervosabull 5 Exercise amenorrheabull 6 Cushingsbull 7 Diabetesbull

Causes of Delayed Puberty

bull III Hypergonadotropic hypogonadism

bull A Turner Syndrome

bull B XX and XY gonadal dysgenesis

bull C Polycystic ovary Syndrome

bull D Noonans 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- Kallmanns 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 Klinefelters syndrome Other forms of primary testicular failureAnorchia or

cryptorchism- Females Turners syndromeOther forms of primary ovarian failure Pseudo-Turners

syndrome- Noonans 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 2512 years of age with idiopathic true precocious

13412-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 (-45 SD) and a weight of 286 kg (-3 SD) The patient had early stage 2 breast development There was no pubic hair Karyotype was 46XX Bone age was 10 years After administration of GnRH LH and FSH rose in a pubertal pattern Estradiol was 40 pgmL She has since spontaneously progressed through pubertal development

• TUMBUH KEMBANG REMAJA
• REMAJA
• Remaja awal (11-14 tahun)
• Remaja Tengah (15-17 tahun)
• Remaja Lanjut (Usia 18-21 tahun)
• FISIOLOGI PUBERTAS
• Pubertas
• Tanda Pubertas Perempuan
• Slide 9
• Tanda Pubertas Laki-laki
• Sexual Maturity Rating
• Pubertas Perempuan
• Pubertas Laki-laki
• Pertumbuhan fisik
• Slide 15
• Slide 16
• Lonjakan pertumbuhan
• Perkembangan psikososial
• MASALAH-MASALAH REMAJA
• Morbiditas
• Masalah lain
• Psychological Problems in Adolescence
• Slide 23
• Teen suicide (contrsquod)
• Cluster Suicides
• Warning signs of suicide
• Indikator remaja berisiko tinggi
• Slide 28
• Gejala psikofisiologis
• Terapi gejala psikofisiologi
• KLINIK REMAJA
• Sikap Dokter Dalam Menghadapi Pasien Remaja
• Pemberian pelayanan kesehatan
• Kerahasiaan
• What are The importan Aspects of an Adolescent History
• How to Talk to Teens about Puberty
• Wawancara
• Slide 38
• LAMPIRAN
• 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
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• CASE
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Causes of Short Stature
• Slide 65
• Slide 66
• Causes of Delayed Puberty
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73

bull 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

bull 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

bull 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

bull 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)

bull

bull 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

bull 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

bull 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 50ile of the patients actual height)

bull 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 (Klinefelters syndrome)

Causes of Short Staturebull I Constitutional Short Staturebull II Primordial Dwarfism (intrauterine growth retardation)bull III Endocrine Causesbull A Growth Hormone Deficiencybull 1 Congenitalbull 2 Acquiredbull a HypothalamicPituitary Tumorsbull b Head Traumabull c CNS infectionsbull d Psychosocial Dwarfismbull 3 Laron Dwarfismbull 4 Hypothyroidismbull 5 Syndromes of Short Staturebull a Turner Syndrome (gonadal dysgenesis)bull b Noonans Syndromebull c Prader-Willi Syndromebull

Causes of Short Stature

bull IV Chronic Diseasebull A Heart Diseasebull B Pulmonarybull 1 Cystic Fibrosisbull 2 Asthmabull C GI Disordersbull D Hepatic Diseasebull E Renalbull V Iatrogenicbull A Corticosteroids anabolic steroidsbull B ADHD meds

bull Causes of Delayed Pubertybull I Constitutional Delay in Growth and Maturationbull II Hypogonadotropic hypogonadismbull A Central nervous system disordersbull 1 Tumors bull a Craniopharyngiomasbull b Gliomasbull c Germinomasbull 2 Radiation Therapybull 3 Congenital Malformationsbull

Causes of Delayed Puberty

bull B Isolated Growth Hormone Deficiencybull 1 Kallmanns Syndromebull C Miscellaneous Disordersbull 1 Prader-Willi Syndromebull 2 Hypothyroidismbull 3 Malnutritionbull 4 Anorexia Nervosabull 5 Exercise amenorrheabull 6 Cushingsbull 7 Diabetesbull

Causes of Delayed Puberty

bull III Hypergonadotropic hypogonadism

bull A Turner Syndrome

bull B XX and XY gonadal dysgenesis

bull C Polycystic ovary Syndrome

bull D Noonans 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- Kallmanns 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 Klinefelters syndrome Other forms of primary testicular failureAnorchia or

cryptorchism- Females Turners syndromeOther forms of primary ovarian failure Pseudo-Turners

syndrome- Noonans 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 2512 years of age with idiopathic true precocious

13412-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 (-45 SD) and a weight of 286 kg (-3 SD) The patient had early stage 2 breast development There was no pubic hair Karyotype was 46XX Bone age was 10 years After administration of GnRH LH and FSH rose in a pubertal pattern Estradiol was 40 pgmL She has since spontaneously progressed through pubertal development

• TUMBUH KEMBANG REMAJA
• REMAJA
• Remaja awal (11-14 tahun)
• Remaja Tengah (15-17 tahun)
• Remaja Lanjut (Usia 18-21 tahun)
• FISIOLOGI PUBERTAS
• Pubertas
• Tanda Pubertas Perempuan
• Slide 9
• Tanda Pubertas Laki-laki
• Sexual Maturity Rating
• Pubertas Perempuan
• Pubertas Laki-laki
• Pertumbuhan fisik
• Slide 15
• Slide 16
• Lonjakan pertumbuhan
• Perkembangan psikososial
• MASALAH-MASALAH REMAJA
• Morbiditas
• Masalah lain
• Psychological Problems in Adolescence
• Slide 23
• Teen suicide (contrsquod)
• Cluster Suicides
• Warning signs of suicide
• Indikator remaja berisiko tinggi
• Slide 28
• Gejala psikofisiologis
• Terapi gejala psikofisiologi
• KLINIK REMAJA
• Sikap Dokter Dalam Menghadapi Pasien Remaja
• Pemberian pelayanan kesehatan
• Kerahasiaan
• What are The importan Aspects of an Adolescent History
• How to Talk to Teens about Puberty
• Wawancara
• Slide 38
• LAMPIRAN
• 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
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• CASE
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Causes of Short Stature
• Slide 65
• Slide 66
• Causes of Delayed Puberty
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73

bull 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

bull 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

bull 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)

bull

bull 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

bull 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

bull 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 50ile of the patients actual height)

bull 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 (Klinefelters syndrome)

Causes of Short Staturebull I Constitutional Short Staturebull II Primordial Dwarfism (intrauterine growth retardation)bull III Endocrine Causesbull A Growth Hormone Deficiencybull 1 Congenitalbull 2 Acquiredbull a HypothalamicPituitary Tumorsbull b Head Traumabull c CNS infectionsbull d Psychosocial Dwarfismbull 3 Laron Dwarfismbull 4 Hypothyroidismbull 5 Syndromes of Short Staturebull a Turner Syndrome (gonadal dysgenesis)bull b Noonans Syndromebull c Prader-Willi Syndromebull

Causes of Short Stature

bull IV Chronic Diseasebull A Heart Diseasebull B Pulmonarybull 1 Cystic Fibrosisbull 2 Asthmabull C GI Disordersbull D Hepatic Diseasebull E Renalbull V Iatrogenicbull A Corticosteroids anabolic steroidsbull B ADHD meds

bull Causes of Delayed Pubertybull I Constitutional Delay in Growth and Maturationbull II Hypogonadotropic hypogonadismbull A Central nervous system disordersbull 1 Tumors bull a Craniopharyngiomasbull b Gliomasbull c Germinomasbull 2 Radiation Therapybull 3 Congenital Malformationsbull

Causes of Delayed Puberty

bull B Isolated Growth Hormone Deficiencybull 1 Kallmanns Syndromebull C Miscellaneous Disordersbull 1 Prader-Willi Syndromebull 2 Hypothyroidismbull 3 Malnutritionbull 4 Anorexia Nervosabull 5 Exercise amenorrheabull 6 Cushingsbull 7 Diabetesbull

Causes of Delayed Puberty

bull III Hypergonadotropic hypogonadism

bull A Turner Syndrome

bull B XX and XY gonadal dysgenesis

bull C Polycystic ovary Syndrome

bull D Noonans 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- Kallmanns 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 Klinefelters syndrome Other forms of primary testicular failureAnorchia or

cryptorchism- Females Turners syndromeOther forms of primary ovarian failure Pseudo-Turners

syndrome- Noonans 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 2512 years of age with idiopathic true precocious

13412-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 (-45 SD) and a weight of 286 kg (-3 SD) The patient had early stage 2 breast development There was no pubic hair Karyotype was 46XX Bone age was 10 years After administration of GnRH LH and FSH rose in a pubertal pattern Estradiol was 40 pgmL She has since spontaneously progressed through pubertal development

• TUMBUH KEMBANG REMAJA
• REMAJA
• Remaja awal (11-14 tahun)
• Remaja Tengah (15-17 tahun)
• Remaja Lanjut (Usia 18-21 tahun)
• FISIOLOGI PUBERTAS
• Pubertas
• Tanda Pubertas Perempuan
• Slide 9
• Tanda Pubertas Laki-laki
• Sexual Maturity Rating
• Pubertas Perempuan
• Pubertas Laki-laki
• Pertumbuhan fisik
• Slide 15
• Slide 16
• Lonjakan pertumbuhan
• Perkembangan psikososial
• MASALAH-MASALAH REMAJA
• Morbiditas
• Masalah lain
• Psychological Problems in Adolescence
• Slide 23
• Teen suicide (contrsquod)
• Cluster Suicides
• Warning signs of suicide
• Indikator remaja berisiko tinggi
• Slide 28
• Gejala psikofisiologis
• Terapi gejala psikofisiologi
• KLINIK REMAJA
• Sikap Dokter Dalam Menghadapi Pasien Remaja
• Pemberian pelayanan kesehatan
• Kerahasiaan
• What are The importan Aspects of an Adolescent History
• How to Talk to Teens about Puberty
• Wawancara
• Slide 38
• LAMPIRAN
• 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
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• CASE
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Causes of Short Stature
• Slide 65
• Slide 66
• Causes of Delayed Puberty
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73

bull 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

bull 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)

bull

bull 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

bull 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

bull 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 50ile of the patients actual height)

bull 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 (Klinefelters syndrome)

Causes of Short Staturebull I Constitutional Short Staturebull II Primordial Dwarfism (intrauterine growth retardation)bull III Endocrine Causesbull A Growth Hormone Deficiencybull 1 Congenitalbull 2 Acquiredbull a HypothalamicPituitary Tumorsbull b Head Traumabull c CNS infectionsbull d Psychosocial Dwarfismbull 3 Laron Dwarfismbull 4 Hypothyroidismbull 5 Syndromes of Short Staturebull a Turner Syndrome (gonadal dysgenesis)bull b Noonans Syndromebull c Prader-Willi Syndromebull

Causes of Short Stature

bull IV Chronic Diseasebull A Heart Diseasebull B Pulmonarybull 1 Cystic Fibrosisbull 2 Asthmabull C GI Disordersbull D Hepatic Diseasebull E Renalbull V Iatrogenicbull A Corticosteroids anabolic steroidsbull B ADHD meds

bull Causes of Delayed Pubertybull I Constitutional Delay in Growth and Maturationbull II Hypogonadotropic hypogonadismbull A Central nervous system disordersbull 1 Tumors bull a Craniopharyngiomasbull b Gliomasbull c Germinomasbull 2 Radiation Therapybull 3 Congenital Malformationsbull

Causes of Delayed Puberty

bull B Isolated Growth Hormone Deficiencybull 1 Kallmanns Syndromebull C Miscellaneous Disordersbull 1 Prader-Willi Syndromebull 2 Hypothyroidismbull 3 Malnutritionbull 4 Anorexia Nervosabull 5 Exercise amenorrheabull 6 Cushingsbull 7 Diabetesbull

Causes of Delayed Puberty

bull III Hypergonadotropic hypogonadism

bull A Turner Syndrome

bull B XX and XY gonadal dysgenesis

bull C Polycystic ovary Syndrome

bull D Noonans 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- Kallmanns 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 Klinefelters syndrome Other forms of primary testicular failureAnorchia or

cryptorchism- Females Turners syndromeOther forms of primary ovarian failure Pseudo-Turners

syndrome- Noonans 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 2512 years of age with idiopathic true precocious

13412-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 (-45 SD) and a weight of 286 kg (-3 SD) The patient had early stage 2 breast development There was no pubic hair Karyotype was 46XX Bone age was 10 years After administration of GnRH LH and FSH rose in a pubertal pattern Estradiol was 40 pgmL She has since spontaneously progressed through pubertal development

• TUMBUH KEMBANG REMAJA
• REMAJA
• Remaja awal (11-14 tahun)
• Remaja Tengah (15-17 tahun)
• Remaja Lanjut (Usia 18-21 tahun)
• FISIOLOGI PUBERTAS
• Pubertas
• Tanda Pubertas Perempuan
• Slide 9
• Tanda Pubertas Laki-laki
• Sexual Maturity Rating
• Pubertas Perempuan
• Pubertas Laki-laki
• Pertumbuhan fisik
• Slide 15
• Slide 16
• Lonjakan pertumbuhan
• Perkembangan psikososial
• MASALAH-MASALAH REMAJA
• Morbiditas
• Masalah lain
• Psychological Problems in Adolescence
• Slide 23
• Teen suicide (contrsquod)
• Cluster Suicides
• Warning signs of suicide
• Indikator remaja berisiko tinggi
• Slide 28
• Gejala psikofisiologis
• Terapi gejala psikofisiologi
• KLINIK REMAJA
• Sikap Dokter Dalam Menghadapi Pasien Remaja
• Pemberian pelayanan kesehatan
• Kerahasiaan
• What are The importan Aspects of an Adolescent History
• How to Talk to Teens about Puberty
• Wawancara
• Slide 38
• LAMPIRAN
• 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
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• CASE
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Causes of Short Stature
• Slide 65
• Slide 66
• Causes of Delayed Puberty
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73

bull 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)

bull

bull 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

bull 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

bull 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 50ile of the patients actual height)

bull 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 (Klinefelters syndrome)

Causes of Short Staturebull I Constitutional Short Staturebull II Primordial Dwarfism (intrauterine growth retardation)bull III Endocrine Causesbull A Growth Hormone Deficiencybull 1 Congenitalbull 2 Acquiredbull a HypothalamicPituitary Tumorsbull b Head Traumabull c CNS infectionsbull d Psychosocial Dwarfismbull 3 Laron Dwarfismbull 4 Hypothyroidismbull 5 Syndromes of Short Staturebull a Turner Syndrome (gonadal dysgenesis)bull b Noonans Syndromebull c Prader-Willi Syndromebull

Causes of Short Stature

bull IV Chronic Diseasebull A Heart Diseasebull B Pulmonarybull 1 Cystic Fibrosisbull 2 Asthmabull C GI Disordersbull D Hepatic Diseasebull E Renalbull V Iatrogenicbull A Corticosteroids anabolic steroidsbull B ADHD meds

bull Causes of Delayed Pubertybull I Constitutional Delay in Growth and Maturationbull II Hypogonadotropic hypogonadismbull A Central nervous system disordersbull 1 Tumors bull a Craniopharyngiomasbull b Gliomasbull c Germinomasbull 2 Radiation Therapybull 3 Congenital Malformationsbull

Causes of Delayed Puberty

bull B Isolated Growth Hormone Deficiencybull 1 Kallmanns Syndromebull C Miscellaneous Disordersbull 1 Prader-Willi Syndromebull 2 Hypothyroidismbull 3 Malnutritionbull 4 Anorexia Nervosabull 5 Exercise amenorrheabull 6 Cushingsbull 7 Diabetesbull

Causes of Delayed Puberty

bull III Hypergonadotropic hypogonadism

bull A Turner Syndrome

bull B XX and XY gonadal dysgenesis

bull C Polycystic ovary Syndrome

bull D Noonans 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- Kallmanns 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 Klinefelters syndrome Other forms of primary testicular failureAnorchia or

cryptorchism- Females Turners syndromeOther forms of primary ovarian failure Pseudo-Turners

syndrome- Noonans 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 2512 years of age with idiopathic true precocious

13412-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 (-45 SD) and a weight of 286 kg (-3 SD) The patient had early stage 2 breast development There was no pubic hair Karyotype was 46XX Bone age was 10 years After administration of GnRH LH and FSH rose in a pubertal pattern Estradiol was 40 pgmL She has since spontaneously progressed through pubertal development

• TUMBUH KEMBANG REMAJA
• REMAJA
• Remaja awal (11-14 tahun)
• Remaja Tengah (15-17 tahun)
• Remaja Lanjut (Usia 18-21 tahun)
• FISIOLOGI PUBERTAS
• Pubertas
• Tanda Pubertas Perempuan
• Slide 9
• Tanda Pubertas Laki-laki
• Sexual Maturity Rating
• Pubertas Perempuan
• Pubertas Laki-laki
• Pertumbuhan fisik
• Slide 15
• Slide 16
• Lonjakan pertumbuhan
• Perkembangan psikososial
• MASALAH-MASALAH REMAJA
• Morbiditas
• Masalah lain
• Psychological Problems in Adolescence
• Slide 23
• Teen suicide (contrsquod)
• Cluster Suicides
• Warning signs of suicide
• Indikator remaja berisiko tinggi
• Slide 28
• Gejala psikofisiologis
• Terapi gejala psikofisiologi
• KLINIK REMAJA
• Sikap Dokter Dalam Menghadapi Pasien Remaja
• Pemberian pelayanan kesehatan
• Kerahasiaan
• What are The importan Aspects of an Adolescent History
• How to Talk to Teens about Puberty
• Wawancara
• Slide 38
• LAMPIRAN
• 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
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• CASE
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Causes of Short Stature
• Slide 65
• Slide 66
• Causes of Delayed Puberty
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73

bull 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

bull 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

bull 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 50ile of the patients actual height)

bull 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 (Klinefelters syndrome)

Causes of Short Staturebull I Constitutional Short Staturebull II Primordial Dwarfism (intrauterine growth retardation)bull III Endocrine Causesbull A Growth Hormone Deficiencybull 1 Congenitalbull 2 Acquiredbull a HypothalamicPituitary Tumorsbull b Head Traumabull c CNS infectionsbull d Psychosocial Dwarfismbull 3 Laron Dwarfismbull 4 Hypothyroidismbull 5 Syndromes of Short Staturebull a Turner Syndrome (gonadal dysgenesis)bull b Noonans Syndromebull c Prader-Willi Syndromebull

Causes of Short Stature

bull IV Chronic Diseasebull A Heart Diseasebull B Pulmonarybull 1 Cystic Fibrosisbull 2 Asthmabull C GI Disordersbull D Hepatic Diseasebull E Renalbull V Iatrogenicbull A Corticosteroids anabolic steroidsbull B ADHD meds

bull Causes of Delayed Pubertybull I Constitutional Delay in Growth and Maturationbull II Hypogonadotropic hypogonadismbull A Central nervous system disordersbull 1 Tumors bull a Craniopharyngiomasbull b Gliomasbull c Germinomasbull 2 Radiation Therapybull 3 Congenital Malformationsbull

Causes of Delayed Puberty

bull B Isolated Growth Hormone Deficiencybull 1 Kallmanns Syndromebull C Miscellaneous Disordersbull 1 Prader-Willi Syndromebull 2 Hypothyroidismbull 3 Malnutritionbull 4 Anorexia Nervosabull 5 Exercise amenorrheabull 6 Cushingsbull 7 Diabetesbull

Causes of Delayed Puberty

bull III Hypergonadotropic hypogonadism

bull A Turner Syndrome

bull B XX and XY gonadal dysgenesis

bull C Polycystic ovary Syndrome

bull D Noonans 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- Kallmanns 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 Klinefelters syndrome Other forms of primary testicular failureAnorchia or

cryptorchism- Females Turners syndromeOther forms of primary ovarian failure Pseudo-Turners

syndrome- Noonans 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 2512 years of age with idiopathic true precocious

13412-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 (-45 SD) and a weight of 286 kg (-3 SD) The patient had early stage 2 breast development There was no pubic hair Karyotype was 46XX Bone age was 10 years After administration of GnRH LH and FSH rose in a pubertal pattern Estradiol was 40 pgmL She has since spontaneously progressed through pubertal development

• TUMBUH KEMBANG REMAJA
• REMAJA
• Remaja awal (11-14 tahun)
• Remaja Tengah (15-17 tahun)
• Remaja Lanjut (Usia 18-21 tahun)
• FISIOLOGI PUBERTAS
• Pubertas
• Tanda Pubertas Perempuan
• Slide 9
• Tanda Pubertas Laki-laki
• Sexual Maturity Rating
• Pubertas Perempuan
• Pubertas Laki-laki
• Pertumbuhan fisik
• Slide 15
• Slide 16
• Lonjakan pertumbuhan
• Perkembangan psikososial
• MASALAH-MASALAH REMAJA
• Morbiditas
• Masalah lain
• Psychological Problems in Adolescence
• Slide 23
• Teen suicide (contrsquod)
• Cluster Suicides
• Warning signs of suicide
• Indikator remaja berisiko tinggi
• Slide 28
• Gejala psikofisiologis
• Terapi gejala psikofisiologi
• KLINIK REMAJA
• Sikap Dokter Dalam Menghadapi Pasien Remaja
• Pemberian pelayanan kesehatan
• Kerahasiaan
• What are The importan Aspects of an Adolescent History
• How to Talk to Teens about Puberty
• Wawancara
• Slide 38
• LAMPIRAN
• 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
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• CASE
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Causes of Short Stature
• Slide 65
• Slide 66
• Causes of Delayed Puberty
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73

bull 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

bull 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 50ile of the patients actual height)

bull 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 (Klinefelters syndrome)

Causes of Short Staturebull I Constitutional Short Staturebull II Primordial Dwarfism (intrauterine growth retardation)bull III Endocrine Causesbull A Growth Hormone Deficiencybull 1 Congenitalbull 2 Acquiredbull a HypothalamicPituitary Tumorsbull b Head Traumabull c CNS infectionsbull d Psychosocial Dwarfismbull 3 Laron Dwarfismbull 4 Hypothyroidismbull 5 Syndromes of Short Staturebull a Turner Syndrome (gonadal dysgenesis)bull b Noonans Syndromebull c Prader-Willi Syndromebull

Causes of Short Stature

bull IV Chronic Diseasebull A Heart Diseasebull B Pulmonarybull 1 Cystic Fibrosisbull 2 Asthmabull C GI Disordersbull D Hepatic Diseasebull E Renalbull V Iatrogenicbull A Corticosteroids anabolic steroidsbull B ADHD meds

bull Causes of Delayed Pubertybull I Constitutional Delay in Growth and Maturationbull II Hypogonadotropic hypogonadismbull A Central nervous system disordersbull 1 Tumors bull a Craniopharyngiomasbull b Gliomasbull c Germinomasbull 2 Radiation Therapybull 3 Congenital Malformationsbull

Causes of Delayed Puberty

bull B Isolated Growth Hormone Deficiencybull 1 Kallmanns Syndromebull C Miscellaneous Disordersbull 1 Prader-Willi Syndromebull 2 Hypothyroidismbull 3 Malnutritionbull 4 Anorexia Nervosabull 5 Exercise amenorrheabull 6 Cushingsbull 7 Diabetesbull

Causes of Delayed Puberty

bull III Hypergonadotropic hypogonadism

bull A Turner Syndrome

bull B XX and XY gonadal dysgenesis

bull C Polycystic ovary Syndrome

bull D Noonans 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- Kallmanns 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 Klinefelters syndrome Other forms of primary testicular failureAnorchia or

cryptorchism- Females Turners syndromeOther forms of primary ovarian failure Pseudo-Turners

syndrome- Noonans 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 2512 years of age with idiopathic true precocious

13412-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 (-45 SD) and a weight of 286 kg (-3 SD) The patient had early stage 2 breast development There was no pubic hair Karyotype was 46XX Bone age was 10 years After administration of GnRH LH and FSH rose in a pubertal pattern Estradiol was 40 pgmL She has since spontaneously progressed through pubertal development

• TUMBUH KEMBANG REMAJA
• REMAJA
• Remaja awal (11-14 tahun)
• Remaja Tengah (15-17 tahun)
• Remaja Lanjut (Usia 18-21 tahun)
• FISIOLOGI PUBERTAS
• Pubertas
• Tanda Pubertas Perempuan
• Slide 9
• Tanda Pubertas Laki-laki
• Sexual Maturity Rating
• Pubertas Perempuan
• Pubertas Laki-laki
• Pertumbuhan fisik
• Slide 15
• Slide 16
• Lonjakan pertumbuhan
• Perkembangan psikososial
• MASALAH-MASALAH REMAJA
• Morbiditas
• Masalah lain
• Psychological Problems in Adolescence
• Slide 23
• Teen suicide (contrsquod)
• Cluster Suicides
• Warning signs of suicide
• Indikator remaja berisiko tinggi
• Slide 28
• Gejala psikofisiologis
• Terapi gejala psikofisiologi
• KLINIK REMAJA
• Sikap Dokter Dalam Menghadapi Pasien Remaja
• Pemberian pelayanan kesehatan
• Kerahasiaan
• What are The importan Aspects of an Adolescent History
• How to Talk to Teens about Puberty
• Wawancara
• Slide 38
• LAMPIRAN
• 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
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• CASE
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Causes of Short Stature
• Slide 65
• Slide 66
• Causes of Delayed Puberty
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73

bull 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 50ile of the patients actual height)

bull 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 (Klinefelters syndrome)

Causes of Short Staturebull I Constitutional Short Staturebull II Primordial Dwarfism (intrauterine growth retardation)bull III Endocrine Causesbull A Growth Hormone Deficiencybull 1 Congenitalbull 2 Acquiredbull a HypothalamicPituitary Tumorsbull b Head Traumabull c CNS infectionsbull d Psychosocial Dwarfismbull 3 Laron Dwarfismbull 4 Hypothyroidismbull 5 Syndromes of Short Staturebull a Turner Syndrome (gonadal dysgenesis)bull b Noonans Syndromebull c Prader-Willi Syndromebull

Causes of Short Stature

bull IV Chronic Diseasebull A Heart Diseasebull B Pulmonarybull 1 Cystic Fibrosisbull 2 Asthmabull C GI Disordersbull D Hepatic Diseasebull E Renalbull V Iatrogenicbull A Corticosteroids anabolic steroidsbull B ADHD meds

bull Causes of Delayed Pubertybull I Constitutional Delay in Growth and Maturationbull II Hypogonadotropic hypogonadismbull A Central nervous system disordersbull 1 Tumors bull a Craniopharyngiomasbull b Gliomasbull c Germinomasbull 2 Radiation Therapybull 3 Congenital Malformationsbull

Causes of Delayed Puberty

bull B Isolated Growth Hormone Deficiencybull 1 Kallmanns Syndromebull C Miscellaneous Disordersbull 1 Prader-Willi Syndromebull 2 Hypothyroidismbull 3 Malnutritionbull 4 Anorexia Nervosabull 5 Exercise amenorrheabull 6 Cushingsbull 7 Diabetesbull

Causes of Delayed Puberty

bull III Hypergonadotropic hypogonadism

bull A Turner Syndrome

bull B XX and XY gonadal dysgenesis

bull C Polycystic ovary Syndrome

bull D Noonans 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- Kallmanns 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 Klinefelters syndrome Other forms of primary testicular failureAnorchia or

cryptorchism- Females Turners syndromeOther forms of primary ovarian failure Pseudo-Turners

syndrome- Noonans 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 2512 years of age with idiopathic true precocious

13412-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 (-45 SD) and a weight of 286 kg (-3 SD) The patient had early stage 2 breast development There was no pubic hair Karyotype was 46XX Bone age was 10 years After administration of GnRH LH and FSH rose in a pubertal pattern Estradiol was 40 pgmL She has since spontaneously progressed through pubertal development

• TUMBUH KEMBANG REMAJA
• REMAJA
• Remaja awal (11-14 tahun)
• Remaja Tengah (15-17 tahun)
• Remaja Lanjut (Usia 18-21 tahun)
• FISIOLOGI PUBERTAS
• Pubertas
• Tanda Pubertas Perempuan
• Slide 9
• Tanda Pubertas Laki-laki
• Sexual Maturity Rating
• Pubertas Perempuan
• Pubertas Laki-laki
• Pertumbuhan fisik
• Slide 15
• Slide 16
• Lonjakan pertumbuhan
• Perkembangan psikososial
• MASALAH-MASALAH REMAJA
• Morbiditas
• Masalah lain
• Psychological Problems in Adolescence
• Slide 23
• Teen suicide (contrsquod)
• Cluster Suicides
• Warning signs of suicide
• Indikator remaja berisiko tinggi
• Slide 28
• Gejala psikofisiologis
• Terapi gejala psikofisiologi
• KLINIK REMAJA
• Sikap Dokter Dalam Menghadapi Pasien Remaja
• Pemberian pelayanan kesehatan
• Kerahasiaan
• What are The importan Aspects of an Adolescent History
• How to Talk to Teens about Puberty
• Wawancara
• Slide 38
• LAMPIRAN
• 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
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• CASE
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Causes of Short Stature
• Slide 65
• Slide 66
• Causes of Delayed Puberty
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73

bull 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 (Klinefelters syndrome)

Causes of Short Staturebull I Constitutional Short Staturebull II Primordial Dwarfism (intrauterine growth retardation)bull III Endocrine Causesbull A Growth Hormone Deficiencybull 1 Congenitalbull 2 Acquiredbull a HypothalamicPituitary Tumorsbull b Head Traumabull c CNS infectionsbull d Psychosocial Dwarfismbull 3 Laron Dwarfismbull 4 Hypothyroidismbull 5 Syndromes of Short Staturebull a Turner Syndrome (gonadal dysgenesis)bull b Noonans Syndromebull c Prader-Willi Syndromebull

Causes of Short Stature

bull IV Chronic Diseasebull A Heart Diseasebull B Pulmonarybull 1 Cystic Fibrosisbull 2 Asthmabull C GI Disordersbull D Hepatic Diseasebull E Renalbull V Iatrogenicbull A Corticosteroids anabolic steroidsbull B ADHD meds

bull Causes of Delayed Pubertybull I Constitutional Delay in Growth and Maturationbull II Hypogonadotropic hypogonadismbull A Central nervous system disordersbull 1 Tumors bull a Craniopharyngiomasbull b Gliomasbull c Germinomasbull 2 Radiation Therapybull 3 Congenital Malformationsbull

Causes of Delayed Puberty

bull B Isolated Growth Hormone Deficiencybull 1 Kallmanns Syndromebull C Miscellaneous Disordersbull 1 Prader-Willi Syndromebull 2 Hypothyroidismbull 3 Malnutritionbull 4 Anorexia Nervosabull 5 Exercise amenorrheabull 6 Cushingsbull 7 Diabetesbull

Causes of Delayed Puberty

bull III Hypergonadotropic hypogonadism

bull A Turner Syndrome

bull B XX and XY gonadal dysgenesis

bull C Polycystic ovary Syndrome

bull D Noonans 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- Kallmanns 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 Klinefelters syndrome Other forms of primary testicular failureAnorchia or

cryptorchism- Females Turners syndromeOther forms of primary ovarian failure Pseudo-Turners

syndrome- Noonans 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 2512 years of age with idiopathic true precocious

13412-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 (-45 SD) and a weight of 286 kg (-3 SD) The patient had early stage 2 breast development There was no pubic hair Karyotype was 46XX Bone age was 10 years After administration of GnRH LH and FSH rose in a pubertal pattern Estradiol was 40 pgmL She has since spontaneously progressed through pubertal development

• TUMBUH KEMBANG REMAJA
• REMAJA
• Remaja awal (11-14 tahun)
• Remaja Tengah (15-17 tahun)
• Remaja Lanjut (Usia 18-21 tahun)
• FISIOLOGI PUBERTAS
• Pubertas
• Tanda Pubertas Perempuan
• Slide 9
• Tanda Pubertas Laki-laki
• Sexual Maturity Rating
• Pubertas Perempuan
• Pubertas Laki-laki
• Pertumbuhan fisik
• Slide 15
• Slide 16
• Lonjakan pertumbuhan
• Perkembangan psikososial
• MASALAH-MASALAH REMAJA
• Morbiditas
• Masalah lain
• Psychological Problems in Adolescence
• Slide 23
• Teen suicide (contrsquod)
• Cluster Suicides
• Warning signs of suicide
• Indikator remaja berisiko tinggi
• Slide 28
• Gejala psikofisiologis
• Terapi gejala psikofisiologi
• KLINIK REMAJA
• Sikap Dokter Dalam Menghadapi Pasien Remaja
• Pemberian pelayanan kesehatan
• Kerahasiaan
• What are The importan Aspects of an Adolescent History
• How to Talk to Teens about Puberty
• Wawancara
• Slide 38
• LAMPIRAN
• 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
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• CASE
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Causes of Short Stature
• Slide 65
• Slide 66
• Causes of Delayed Puberty
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73

Causes of Short Staturebull I Constitutional Short Staturebull II Primordial Dwarfism (intrauterine growth retardation)bull III Endocrine Causesbull A Growth Hormone Deficiencybull 1 Congenitalbull 2 Acquiredbull a HypothalamicPituitary Tumorsbull b Head Traumabull c CNS infectionsbull d Psychosocial Dwarfismbull 3 Laron Dwarfismbull 4 Hypothyroidismbull 5 Syndromes of Short Staturebull a Turner Syndrome (gonadal dysgenesis)bull b Noonans Syndromebull c Prader-Willi Syndromebull

Causes of Short Stature

bull IV Chronic Diseasebull A Heart Diseasebull B Pulmonarybull 1 Cystic Fibrosisbull 2 Asthmabull C GI Disordersbull D Hepatic Diseasebull E Renalbull V Iatrogenicbull A Corticosteroids anabolic steroidsbull B ADHD meds

bull Causes of Delayed Pubertybull I Constitutional Delay in Growth and Maturationbull II Hypogonadotropic hypogonadismbull A Central nervous system disordersbull 1 Tumors bull a Craniopharyngiomasbull b Gliomasbull c Germinomasbull 2 Radiation Therapybull 3 Congenital Malformationsbull

Causes of Delayed Puberty

bull B Isolated Growth Hormone Deficiencybull 1 Kallmanns Syndromebull C Miscellaneous Disordersbull 1 Prader-Willi Syndromebull 2 Hypothyroidismbull 3 Malnutritionbull 4 Anorexia Nervosabull 5 Exercise amenorrheabull 6 Cushingsbull 7 Diabetesbull

Causes of Delayed Puberty

bull III Hypergonadotropic hypogonadism

bull A Turner Syndrome

bull B XX and XY gonadal dysgenesis

bull C Polycystic ovary Syndrome

bull D Noonans 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- Kallmanns 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 Klinefelters syndrome Other forms of primary testicular failureAnorchia or

cryptorchism- Females Turners syndromeOther forms of primary ovarian failure Pseudo-Turners

syndrome- Noonans 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 2512 years of age with idiopathic true precocious

13412-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 (-45 SD) and a weight of 286 kg (-3 SD) The patient had early stage 2 breast development There was no pubic hair Karyotype was 46XX Bone age was 10 years After administration of GnRH LH and FSH rose in a pubertal pattern Estradiol was 40 pgmL She has since spontaneously progressed through pubertal development

• TUMBUH KEMBANG REMAJA
• REMAJA
• Remaja awal (11-14 tahun)
• Remaja Tengah (15-17 tahun)
• Remaja Lanjut (Usia 18-21 tahun)
• FISIOLOGI PUBERTAS
• Pubertas
• Tanda Pubertas Perempuan
• Slide 9
• Tanda Pubertas Laki-laki
• Sexual Maturity Rating
• Pubertas Perempuan
• Pubertas Laki-laki
• Pertumbuhan fisik
• Slide 15
• Slide 16
• Lonjakan pertumbuhan
• Perkembangan psikososial
• MASALAH-MASALAH REMAJA
• Morbiditas
• Masalah lain
• Psychological Problems in Adolescence
• Slide 23
• Teen suicide (contrsquod)
• Cluster Suicides
• Warning signs of suicide
• Indikator remaja berisiko tinggi
• Slide 28
• Gejala psikofisiologis
• Terapi gejala psikofisiologi
• KLINIK REMAJA
• Sikap Dokter Dalam Menghadapi Pasien Remaja
• Pemberian pelayanan kesehatan
• Kerahasiaan
• What are The importan Aspects of an Adolescent History
• How to Talk to Teens about Puberty
• Wawancara
• Slide 38
• LAMPIRAN
• 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
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• CASE
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Causes of Short Stature
• Slide 65
• Slide 66
• Causes of Delayed Puberty
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73

Causes of Short Stature

bull IV Chronic Diseasebull A Heart Diseasebull B Pulmonarybull 1 Cystic Fibrosisbull 2 Asthmabull C GI Disordersbull D Hepatic Diseasebull E Renalbull V Iatrogenicbull A Corticosteroids anabolic steroidsbull B ADHD meds

bull Causes of Delayed Pubertybull I Constitutional Delay in Growth and Maturationbull II Hypogonadotropic hypogonadismbull A Central nervous system disordersbull 1 Tumors bull a Craniopharyngiomasbull b Gliomasbull c Germinomasbull 2 Radiation Therapybull 3 Congenital Malformationsbull

Causes of Delayed Puberty

bull B Isolated Growth Hormone Deficiencybull 1 Kallmanns Syndromebull C Miscellaneous Disordersbull 1 Prader-Willi Syndromebull 2 Hypothyroidismbull 3 Malnutritionbull 4 Anorexia Nervosabull 5 Exercise amenorrheabull 6 Cushingsbull 7 Diabetesbull

Causes of Delayed Puberty

bull III Hypergonadotropic hypogonadism

bull A Turner Syndrome

bull B XX and XY gonadal dysgenesis

bull C Polycystic ovary Syndrome

bull D Noonans 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- Kallmanns 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 Klinefelters syndrome Other forms of primary testicular failureAnorchia or

cryptorchism- Females Turners syndromeOther forms of primary ovarian failure Pseudo-Turners

syndrome- Noonans 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 2512 years of age with idiopathic true precocious

13412-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 (-45 SD) and a weight of 286 kg (-3 SD) The patient had early stage 2 breast development There was no pubic hair Karyotype was 46XX Bone age was 10 years After administration of GnRH LH and FSH rose in a pubertal pattern Estradiol was 40 pgmL She has since spontaneously progressed through pubertal development

• TUMBUH KEMBANG REMAJA
• REMAJA
• Remaja awal (11-14 tahun)
• Remaja Tengah (15-17 tahun)
• Remaja Lanjut (Usia 18-21 tahun)
• FISIOLOGI PUBERTAS
• Pubertas
• Tanda Pubertas Perempuan
• Slide 9
• Tanda Pubertas Laki-laki
• Sexual Maturity Rating
• Pubertas Perempuan
• Pubertas Laki-laki
• Pertumbuhan fisik
• Slide 15
• Slide 16
• Lonjakan pertumbuhan
• Perkembangan psikososial
• MASALAH-MASALAH REMAJA
• Morbiditas
• Masalah lain
• Psychological Problems in Adolescence
• Slide 23
• Teen suicide (contrsquod)
• Cluster Suicides
• Warning signs of suicide
• Indikator remaja berisiko tinggi
• Slide 28
• Gejala psikofisiologis
• Terapi gejala psikofisiologi
• KLINIK REMAJA
• Sikap Dokter Dalam Menghadapi Pasien Remaja
• Pemberian pelayanan kesehatan
• Kerahasiaan
• What are The importan Aspects of an Adolescent History
• How to Talk to Teens about Puberty
• Wawancara
• Slide 38
• LAMPIRAN
• 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
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• CASE
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Causes of Short Stature
• Slide 65
• Slide 66
• Causes of Delayed Puberty
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73

bull Causes of Delayed Pubertybull I Constitutional Delay in Growth and Maturationbull II Hypogonadotropic hypogonadismbull A Central nervous system disordersbull 1 Tumors bull a Craniopharyngiomasbull b Gliomasbull c Germinomasbull 2 Radiation Therapybull 3 Congenital Malformationsbull

Causes of Delayed Puberty

bull B Isolated Growth Hormone Deficiencybull 1 Kallmanns Syndromebull C Miscellaneous Disordersbull 1 Prader-Willi Syndromebull 2 Hypothyroidismbull 3 Malnutritionbull 4 Anorexia Nervosabull 5 Exercise amenorrheabull 6 Cushingsbull 7 Diabetesbull

Causes of Delayed Puberty

bull III Hypergonadotropic hypogonadism

bull A Turner Syndrome

bull B XX and XY gonadal dysgenesis

bull C Polycystic ovary Syndrome

bull D Noonans 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- Kallmanns 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 Klinefelters syndrome Other forms of primary testicular failureAnorchia or

cryptorchism- Females Turners syndromeOther forms of primary ovarian failure Pseudo-Turners

syndrome- Noonans 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 2512 years of age with idiopathic true precocious

13412-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 (-45 SD) and a weight of 286 kg (-3 SD) The patient had early stage 2 breast development There was no pubic hair Karyotype was 46XX Bone age was 10 years After administration of GnRH LH and FSH rose in a pubertal pattern Estradiol was 40 pgmL She has since spontaneously progressed through pubertal development

• TUMBUH KEMBANG REMAJA
• REMAJA
• Remaja awal (11-14 tahun)
• Remaja Tengah (15-17 tahun)
• Remaja Lanjut (Usia 18-21 tahun)
• FISIOLOGI PUBERTAS
• Pubertas
• Tanda Pubertas Perempuan
• Slide 9
• Tanda Pubertas Laki-laki
• Sexual Maturity Rating
• Pubertas Perempuan
• Pubertas Laki-laki
• Pertumbuhan fisik
• Slide 15
• Slide 16
• Lonjakan pertumbuhan
• Perkembangan psikososial
• MASALAH-MASALAH REMAJA
• Morbiditas
• Masalah lain
• Psychological Problems in Adolescence
• Slide 23
• Teen suicide (contrsquod)
• Cluster Suicides
• Warning signs of suicide
• Indikator remaja berisiko tinggi
• Slide 28
• Gejala psikofisiologis
• Terapi gejala psikofisiologi
• KLINIK REMAJA
• Sikap Dokter Dalam Menghadapi Pasien Remaja
• Pemberian pelayanan kesehatan
• Kerahasiaan
• What are The importan Aspects of an Adolescent History
• How to Talk to Teens about Puberty
• Wawancara
• Slide 38
• LAMPIRAN
• 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
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• CASE
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Causes of Short Stature
• Slide 65
• Slide 66
• Causes of Delayed Puberty
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73

Causes of Delayed Puberty

bull B Isolated Growth Hormone Deficiencybull 1 Kallmanns Syndromebull C Miscellaneous Disordersbull 1 Prader-Willi Syndromebull 2 Hypothyroidismbull 3 Malnutritionbull 4 Anorexia Nervosabull 5 Exercise amenorrheabull 6 Cushingsbull 7 Diabetesbull

Causes of Delayed Puberty

bull III Hypergonadotropic hypogonadism

bull A Turner Syndrome

bull B XX and XY gonadal dysgenesis

bull C Polycystic ovary Syndrome

bull D Noonans 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- Kallmanns 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 Klinefelters syndrome Other forms of primary testicular failureAnorchia or

cryptorchism- Females Turners syndromeOther forms of primary ovarian failure Pseudo-Turners

syndrome- Noonans 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 2512 years of age with idiopathic true precocious

13412-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 (-45 SD) and a weight of 286 kg (-3 SD) The patient had early stage 2 breast development There was no pubic hair Karyotype was 46XX Bone age was 10 years After administration of GnRH LH and FSH rose in a pubertal pattern Estradiol was 40 pgmL She has since spontaneously progressed through pubertal development

• TUMBUH KEMBANG REMAJA
• REMAJA
• Remaja awal (11-14 tahun)
• Remaja Tengah (15-17 tahun)
• Remaja Lanjut (Usia 18-21 tahun)
• FISIOLOGI PUBERTAS
• Pubertas
• Tanda Pubertas Perempuan
• Slide 9
• Tanda Pubertas Laki-laki
• Sexual Maturity Rating
• Pubertas Perempuan
• Pubertas Laki-laki
• Pertumbuhan fisik
• Slide 15
• Slide 16
• Lonjakan pertumbuhan
• Perkembangan psikososial
• MASALAH-MASALAH REMAJA
• Morbiditas
• Masalah lain
• Psychological Problems in Adolescence
• Slide 23
• Teen suicide (contrsquod)
• Cluster Suicides
• Warning signs of suicide
• Indikator remaja berisiko tinggi
• Slide 28
• Gejala psikofisiologis
• Terapi gejala psikofisiologi
• KLINIK REMAJA
• Sikap Dokter Dalam Menghadapi Pasien Remaja
• Pemberian pelayanan kesehatan
• Kerahasiaan
• What are The importan Aspects of an Adolescent History
• How to Talk to Teens about Puberty
• Wawancara
• Slide 38
• LAMPIRAN
• 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
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• CASE
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Causes of Short Stature
• Slide 65
• Slide 66
• Causes of Delayed Puberty
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73

Causes of Delayed Puberty

bull III Hypergonadotropic hypogonadism

bull A Turner Syndrome

bull B XX and XY gonadal dysgenesis

bull C Polycystic ovary Syndrome

bull D Noonans 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- Kallmanns 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 Klinefelters syndrome Other forms of primary testicular failureAnorchia or

cryptorchism- Females Turners syndromeOther forms of primary ovarian failure Pseudo-Turners

syndrome- Noonans 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 2512 years of age with idiopathic true precocious

13412-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 (-45 SD) and a weight of 286 kg (-3 SD) The patient had early stage 2 breast development There was no pubic hair Karyotype was 46XX Bone age was 10 years After administration of GnRH LH and FSH rose in a pubertal pattern Estradiol was 40 pgmL She has since spontaneously progressed through pubertal development

• TUMBUH KEMBANG REMAJA
• REMAJA
• Remaja awal (11-14 tahun)
• Remaja Tengah (15-17 tahun)
• Remaja Lanjut (Usia 18-21 tahun)
• FISIOLOGI PUBERTAS
• Pubertas
• Tanda Pubertas Perempuan
• Slide 9
• Tanda Pubertas Laki-laki
• Sexual Maturity Rating
• Pubertas Perempuan
• Pubertas Laki-laki
• Pertumbuhan fisik
• Slide 15
• Slide 16
• Lonjakan pertumbuhan
• Perkembangan psikososial
• MASALAH-MASALAH REMAJA
• Morbiditas
• Masalah lain
• Psychological Problems in Adolescence
• Slide 23
• Teen suicide (contrsquod)
• Cluster Suicides
• Warning signs of suicide
• Indikator remaja berisiko tinggi
• Slide 28
• Gejala psikofisiologis
• Terapi gejala psikofisiologi
• KLINIK REMAJA
• Sikap Dokter Dalam Menghadapi Pasien Remaja
• Pemberian pelayanan kesehatan
• Kerahasiaan
• What are The importan Aspects of an Adolescent History
• How to Talk to Teens about Puberty
• Wawancara
• Slide 38
• LAMPIRAN
• 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
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• CASE
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Causes of Short Stature
• Slide 65
• Slide 66
• Causes of Delayed Puberty
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73

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- Kallmanns 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 Klinefelters syndrome Other forms of primary testicular failureAnorchia or

cryptorchism- Females Turners syndromeOther forms of primary ovarian failure Pseudo-Turners

syndrome- Noonans 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 2512 years of age with idiopathic true precocious

13412-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 (-45 SD) and a weight of 286 kg (-3 SD) The patient had early stage 2 breast development There was no pubic hair Karyotype was 46XX Bone age was 10 years After administration of GnRH LH and FSH rose in a pubertal pattern Estradiol was 40 pgmL She has since spontaneously progressed through pubertal development

• TUMBUH KEMBANG REMAJA
• REMAJA
• Remaja awal (11-14 tahun)
• Remaja Tengah (15-17 tahun)
• Remaja Lanjut (Usia 18-21 tahun)
• FISIOLOGI PUBERTAS
• Pubertas
• Tanda Pubertas Perempuan
• Slide 9
• Tanda Pubertas Laki-laki
• Sexual Maturity Rating
• Pubertas Perempuan
• Pubertas Laki-laki
• Pertumbuhan fisik
• Slide 15
• Slide 16
• Lonjakan pertumbuhan
• Perkembangan psikososial
• MASALAH-MASALAH REMAJA
• Morbiditas
• Masalah lain
• Psychological Problems in Adolescence
• Slide 23
• Teen suicide (contrsquod)
• Cluster Suicides
• Warning signs of suicide
• Indikator remaja berisiko tinggi
• Slide 28
• Gejala psikofisiologis
• Terapi gejala psikofisiologi
• KLINIK REMAJA
• Sikap Dokter Dalam Menghadapi Pasien Remaja
• Pemberian pelayanan kesehatan
• Kerahasiaan
• What are The importan Aspects of an Adolescent History
• How to Talk to Teens about Puberty
• Wawancara
• Slide 38
• LAMPIRAN
• 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
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• CASE
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Causes of Short Stature
• Slide 65
• Slide 66
• Causes of Delayed Puberty
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73

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 2512 years of age with idiopathic true precocious

13412-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 (-45 SD) and a weight of 286 kg (-3 SD) The patient had early stage 2 breast development There was no pubic hair Karyotype was 46XX Bone age was 10 years After administration of GnRH LH and FSH rose in a pubertal pattern Estradiol was 40 pgmL She has since spontaneously progressed through pubertal development

• TUMBUH KEMBANG REMAJA
• REMAJA
• Remaja awal (11-14 tahun)
• Remaja Tengah (15-17 tahun)
• Remaja Lanjut (Usia 18-21 tahun)
• FISIOLOGI PUBERTAS
• Pubertas
• Tanda Pubertas Perempuan
• Slide 9
• Tanda Pubertas Laki-laki
• Sexual Maturity Rating
• Pubertas Perempuan
• Pubertas Laki-laki
• Pertumbuhan fisik
• Slide 15
• Slide 16
• Lonjakan pertumbuhan
• Perkembangan psikososial
• MASALAH-MASALAH REMAJA
• Morbiditas
• Masalah lain
• Psychological Problems in Adolescence
• Slide 23
• Teen suicide (contrsquod)
• Cluster Suicides
• Warning signs of suicide
• Indikator remaja berisiko tinggi
• Slide 28
• Gejala psikofisiologis
• Terapi gejala psikofisiologi
• KLINIK REMAJA
• Sikap Dokter Dalam Menghadapi Pasien Remaja
• Pemberian pelayanan kesehatan
• Kerahasiaan
• What are The importan Aspects of an Adolescent History
• How to Talk to Teens about Puberty
• Wawancara
• Slide 38
• LAMPIRAN
• 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
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• CASE
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Causes of Short Stature
• Slide 65
• Slide 66
• Causes of Delayed Puberty
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73

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 2512 years of age with idiopathic true precocious

13412-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 (-45 SD) and a weight of 286 kg (-3 SD) The patient had early stage 2 breast development There was no pubic hair Karyotype was 46XX Bone age was 10 years After administration of GnRH LH and FSH rose in a pubertal pattern Estradiol was 40 pgmL She has since spontaneously progressed through pubertal development

• TUMBUH KEMBANG REMAJA
• REMAJA
• Remaja awal (11-14 tahun)
• Remaja Tengah (15-17 tahun)
• Remaja Lanjut (Usia 18-21 tahun)
• FISIOLOGI PUBERTAS
• Pubertas
• Tanda Pubertas Perempuan
• Slide 9
• Tanda Pubertas Laki-laki
• Sexual Maturity Rating
• Pubertas Perempuan
• Pubertas Laki-laki
• Pertumbuhan fisik
• Slide 15
• Slide 16
• Lonjakan pertumbuhan
• Perkembangan psikososial
• MASALAH-MASALAH REMAJA
• Morbiditas
• Masalah lain
• Psychological Problems in Adolescence
• Slide 23
• Teen suicide (contrsquod)
• Cluster Suicides
• Warning signs of suicide
• Indikator remaja berisiko tinggi
• Slide 28
• Gejala psikofisiologis
• Terapi gejala psikofisiologi
• KLINIK REMAJA
• Sikap Dokter Dalam Menghadapi Pasien Remaja
• Pemberian pelayanan kesehatan
• Kerahasiaan
• What are The importan Aspects of an Adolescent History
• How to Talk to Teens about Puberty
• Wawancara
• Slide 38
• LAMPIRAN
• 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
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• CASE
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Causes of Short Stature
• Slide 65
• Slide 66
• Causes of Delayed Puberty
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73

Boy 2512 years of age with idiopathic true precocious

13412-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 (-45 SD) and a weight of 286 kg (-3 SD) The patient had early stage 2 breast development There was no pubic hair Karyotype was 46XX Bone age was 10 years After administration of GnRH LH and FSH rose in a pubertal pattern Estradiol was 40 pgmL She has since spontaneously progressed through pubertal development

• TUMBUH KEMBANG REMAJA
• REMAJA
• Remaja awal (11-14 tahun)
• Remaja Tengah (15-17 tahun)
• Remaja Lanjut (Usia 18-21 tahun)
• FISIOLOGI PUBERTAS
• Pubertas
• Tanda Pubertas Perempuan
• Slide 9
• Tanda Pubertas Laki-laki
• Sexual Maturity Rating
• Pubertas Perempuan
• Pubertas Laki-laki
• Pertumbuhan fisik
• Slide 15
• Slide 16
• Lonjakan pertumbuhan
• Perkembangan psikososial
• MASALAH-MASALAH REMAJA
• Morbiditas
• Masalah lain
• Psychological Problems in Adolescence
• Slide 23
• Teen suicide (contrsquod)
• Cluster Suicides
• Warning signs of suicide
• Indikator remaja berisiko tinggi
• Slide 28
• Gejala psikofisiologis
• Terapi gejala psikofisiologi
• KLINIK REMAJA
• Sikap Dokter Dalam Menghadapi Pasien Remaja
• Pemberian pelayanan kesehatan
• Kerahasiaan
• What are The importan Aspects of an Adolescent History
• How to Talk to Teens about Puberty
• Wawancara
• Slide 38
• LAMPIRAN
• 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
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• CASE
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Causes of Short Stature
• Slide 65
• Slide 66
• Causes of Delayed Puberty
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73

13412-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 (-45 SD) and a weight of 286 kg (-3 SD) The patient had early stage 2 breast development There was no pubic hair Karyotype was 46XX Bone age was 10 years After administration of GnRH LH and FSH rose in a pubertal pattern Estradiol was 40 pgmL She has since spontaneously progressed through pubertal development

• TUMBUH KEMBANG REMAJA
• REMAJA
• Remaja awal (11-14 tahun)
• Remaja Tengah (15-17 tahun)
• Remaja Lanjut (Usia 18-21 tahun)
• FISIOLOGI PUBERTAS
• Pubertas
• Tanda Pubertas Perempuan
• Slide 9
• Tanda Pubertas Laki-laki
• Sexual Maturity Rating
• Pubertas Perempuan
• Pubertas Laki-laki
• Pertumbuhan fisik
• Slide 15
• Slide 16
• Lonjakan pertumbuhan
• Perkembangan psikososial
• MASALAH-MASALAH REMAJA
• Morbiditas
• Masalah lain
• Psychological Problems in Adolescence
• Slide 23
• Teen suicide (contrsquod)
• Cluster Suicides
• Warning signs of suicide
• Indikator remaja berisiko tinggi
• Slide 28
• Gejala psikofisiologis
• Terapi gejala psikofisiologi
• KLINIK REMAJA
• Sikap Dokter Dalam Menghadapi Pasien Remaja
• Pemberian pelayanan kesehatan
• Kerahasiaan
• What are The importan Aspects of an Adolescent History
• How to Talk to Teens about Puberty
• Wawancara
• Slide 38
• LAMPIRAN
• 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
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• CASE
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Causes of Short Stature
• Slide 65
• Slide 66
• Causes of Delayed Puberty
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73