TUMBUH KEMBANG

REMAJA
M. Bambang Edi Susyanto
Blok 8 2010
FKIK UMY
REMAJA
Periode yang ditandai dengan pertumbuhan
dan perkembangan yang cepat dari fisik,
emosi, kognitif dan sosial yang menjembatani
masa kanak-kanak dan dewasa
Batasan usia relative tidak jelas. Merujuk
pada periode antara anak-anak dan dewasa,
ketika perkembangan biopsikososial telah
terjadi
Umur 11-12 tahun sampai 18-21 tahun

Remaja awal (11-14 tahun)

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

Isu penting : perubahan fisik yang luar
biasa cepat (apakah saya normal?) dan
kemandirian

Remaja Tengah (15-17 tahun)

Pubertas biasanya hampir tuntas, sehingga
perhatian remaja terfokus pada identitas
pribadi dan aliansi dengan teman
sebayanya.
Isu otonomi. Pengaruh teman sebaya
sangat kuat



Remaja Lanjut
(Usia 18-21 tahun)

Perhatian remaja beralih pada masa
depan mereka. Keterlibatan dengan teman
sebaya biasanya tidak lagi dengan suatu
kelompok saja. Mulai ada komitmen dalam
hubungan antar personal. Berfikir formal
dan konseptual.

FISIOLOGI PUBERTAS

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

Biasanya awal pubertas wanita 2 tahun
lebih awal
Tanda Pubertas Perempuan
Tanda pertama : thelarche (perkembangan
payudara) dan pada !5% adrenarche
(tumbuhnya rambut pubis)
Onset perkembangan payudara kadang
unilateral, biasanya seimbang dalam 6 bulan
Sebagian besar menarche terjadi dalam
masa 6 bulan masa puncak kecepatan
pertambahan tinggi badan
Tanda Pubertas Perempuan
Tanda progresi lainnya :
Breast buding
Pubic hair growth
Peak high velocity
Menarche

Pertumbuhan biasanya berhenti 2-3 tahun
setelah menarche

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

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

Pubertas Perempuan

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


Pubertas Laki-laki

Terlalu awal jika pembesaran testis (>2,5
cm) sebelum usia 9 tahun

Terlalu lambat jika pembesaran testis tidak
terjadi hingga usia 14 tahun

Pertumbuhan fisik
Pertumbuhan fisik dan perkembangan fisik : hasil
aktivasi aksis hipotalamus-hipofisis-gonad

Pubertas : inhibisi GnRH di hipotalamus hilang -
produksi dan pelepasan pulsatil gonadotropin,
luteinizing hormone (LH) dan follicle stimulating
hormone (FSH)

Awal dan tengah masa remaja : kenaikan frekuensi
dan amplitudo stimulasi gonad produksi
estrogen atau testosteron
Pertumbuhan fisik
Wanita :
FSH stimulasi maturasi ovarium, fungsi sel
granulosa dan sekresi estradiol

awal : inhibisi pelepasan LH dan FSH
lalu : perangsang LH dan FSH siklis

LH ovulasi, pembentukan korpus luteum dan
sekresi progesteron

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

Lonjakan pertumbuhan
Biasanya 2-4 tahun
Perempuan 2 tahun lebih awal
Kecepatan tinggi puncak
W : 11,5-12 tahun
L : 13,5-14 tahun
Pertambahan BB : sampai 2 x
Pertambahan TB : 15-20 %
Perkembangan psikososial
Mencari jati diri, apa yang ingin dilakukan
dan kekuatan-kelemahan
Periode progresif dan perpisahan dari
keluarga
Fase-fase perkembangan psikososial-->
3 fase remaja (lihat bagian depan)
MASALAH-MASALAH REMAJA
Morbiditas
Mortalitas
Morbiditas
Kehamilan yang tak diinginkan
Penyakit menular seksual
Penyalahgunaan zat
Merokok
Depresi
Psikofifiologis
Kekerasan fisik
Lari dari rumah
Masalah lain
Depresi
Bunuh diri remaja
Penyalahgunaan zat
Gangguan makan
Obesitas eksogen
Kegagalan di sekolah
Gangguan payudara
Kelainan ginekologis
PMS dan Penyakit radang pelvis

Psychological Problems in
Adolescence
Depression: 1/3 of teens have
experienced some symptoms of
depression
Rates are higher among girls than boys
Rates are higher among African-American
and Native American teens
Additionally, lack of popularity, rejection,
death of a loved one contributes
Psychological Problems in
Adolescence
Teen suicide: rate has tripled in last 30
years
Annual rate now 12.2 per 100,000, 3
rd

most common cause of death for those
age 15-24
Successful suicide rate is higher in boys
(more lethal means) but girls attempt
suicide more often.
Teen suicide (contd)
Risk factors:
Depression, Social inhibition,
Perfectionism
Anxiety, Family conflicts, romantic
rejection
History of drug/alcohol abuse,
gay/lesbian orientation
Cluster Suicides
One suicide in a teen community leads to
attempts by others to kill themselves,
especially if the first suicide is high profile
and well publicized
Schools increasing using crisis teams to
counsel students after one student is
successful in suicide
Warning signs of suicide
Direct or indirect talk of suicide
School difficulties, writing a will
Giving stuff away, arranging for pet
care
Change in appetite, general
depression
Changes in behavior, preoccupation
with death in art, music, or literature
Indikator remaja berisiko tinggi
1. Penurunan kemampuan belajar
2. Absen sekolah yang berlebihan
3. Keluhan psikosomatik yang
sering/menetap
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 kelompok
8. Perilaku menentang atau kekerasan yang
hebat dan atau perubahan kepribadian
yang radikal
9. Konflik dengan orang tua
10. Perilaku seksual yang berlebihan
11. Konflik dengan hukum
12. Memperlihatkan pikiran bunuh diri
13. Penyalahgunaan obat dan alkohol
14. Melarikan diri dari rumah
Gejala psikofisiologis
Reaksi konversi : perasaan tidak
menyenangkan dikomunikasikan dengan
gejala fisik perolehan sekunder
Riwayat dan temuan fisik tidak konsisten
dengan konsep anatomi dan fisiologis
Cenderung mempunyai OT yang
overprotektif dan menjadi semakin
tergantung pada OT
Terapi gejala psikofisiologi
Jelaskan : hubungan antara penyebab
fisik dari nyeri emosional atau penyebab
emosional dari nyeri fisik
Memberi dorongan untuk mengerti bahwa
gejala dapat menetap
Membantu pasien meneruskan aktivitas
harian yang normal
Obat-obatan jarang membantu
Dokter suportif dan tidak menduga bahwa
nyeri tidak benar-benar terjadi
KLINIK REMAJA

Sikap Dokter Dalam Menghadapi
Pasien Remaja
Dokter tampil jujur, sederhana, tidak perlu
tampil profesional berlebihan
Remaja kurang PD dokter hati-hati
Sensitif terhadap tingkat perkembangan
Pemberian pelayanan kesehatan
Membangun hubungan saling percaya
merupakan dasar dalam pemenuhan
kebutuhan pelayanan kesehatan pasien
remaja pasien tidak bohong /
memberikan informasi yang penting untuk
diagnosis dan terapi yang tepat
Kerahasiaan
Beritahu remaja dan orang tuanya tentang
kerahasiaan yang akan dijaga
Waktu adekuat
Yakinkan bahwa dokter tidak akan
mencampuri kehidupan pribadi remaja,
tetapi merupakan hal penting untuk
kesehatannya

What are The importan Aspects of
an Adolescent History ?

HEADSSS untuk melacak informasi
psikososial yang penting dari pasien remaja.
H : Home/health
E : Education/Employment/Eating
A : Activities?Aspiration/Affiliation
D : Drugs
S : Sex
S : Sleep/Suicide
S : Shoplifting
How to Talk to Teens
about Puberty


Be open and honest
Treat the teen with respect
Talk directly to the teen
Begin conversation with least
threatening topics
Provide confidentiality

Wawancara
Wawancara terpimpin
Penilaian tugas-tugas psikoperkembangan
Pemeriksaan sistemik meliputi :
1. Nutrisi
2. Tidur
3. Perawatan diri, pengetahuan ttg
pemeriksaan sendiri
4. Olah raga
5. Hubungan keluarga dan sahabat
6. Teman sebaya

Wawancara
7. Sekolah
8. Minat pendidikan dan pekerjaan
9. Tembakau
10. Penyalahgunaan zat
11. Seksualitas
12. Kesehatan mental

Usahakan pasien mendapat kesan,
tertarik dan seperti mempunyai
dokternya sendiri
LAMPIRAN


PHYSIOLOGY OF PUBERTY
Physical Changes of Puberty
(Tanner)

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

- Pubic hair development is determined chiefly by
adrenal and ovarian androgen secretion.


Stages of breast development (Marshall and Tanner).

- Stage B1: Preadolescent; elevation of papilla only.
- Stage B2: Breast bud stage; elevation of breast and
papilla as a small mound, and enlargement of areolar
diameter.
- Stage B3: Further enlargement of breast and areola,
with no separation of their contours.
- Stage B4: Projection of areola and papilla to form a
secondary mound above the level of the breast.
- Stage B5: Mature stage; projection of papilla only, owing
to recession of the areola to the general contour of the
breast.




Stages of female pubic hair dev. (Marshall and Tanner).

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

B. Male Changes:
- The first sign of normal puberty in boys is usually
increase in the size of the testes to over 2.5 cm in the
longest diameter

- Pubic hair development is caused by adrenal and
testicular androgens

- The appearance of spermatozoa in early morning urinary
specimens (spermarche) occurs at a mean chronologic
age of 13.4 years; this usually occurs at gonadal stage
3-4 and pubic hair stage 2-4.
Stages of male genital and pubic hair development
( Marshall and Tanner)

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

Pubic hair:
- Stage P1: Preadolescent. The vellus is no further developed
than that over the abdominal wall, ie, no pubic hair.

- Stage P2: Sparse growth of long, slightly pigmented, downy
hair, straight or only slightly curled, appearing chiefly at the
base of the penis. This is subtle.

- Stage P3: Hair is considerably darker, coarser, and curlier and
spreads sparsely.

- Stage P4: Hair is now adult in type, but the area it covers is still
considerably smaller than in most adults. There is no spread to
the medial surface of the thighs.

- Stage P5: Hair is adult in quantity and type, distributed as an
inverse triangle. Spread is to the medial surface of the thighs
but not up the linea alba. Most men will have further spread of
pubic hair.

DELAYED PUBERTY OR ABSENT PUBERTY
(Sexual Infantilism)

- Any girl of 13 or boy of 14 years of age with no signs of
pubertal development falls more than 2.5 SD below the
mean and is considered to have delayed puberty

- By this definition, 0.6% of the healthy population are
classified as having constitutional delay in growth and
adolescence.
CASE
This is a 15 year old boy who is seen by his
primary care physician for short stature and
delayed sexual development. His past medical
history is unremarkable except for asthma
during early childhood, which has been well
controlled. He is currently on no medications.
He is an average student currently in the 9th
grade and is the smallest in his class. He has
been harassed by older classmates because of
his size. His parents are concerned because
Jim is becoming withdrawn and a "loner".
Females initially show a deposition of
adipose tissue and widening of the pelvis
and changes in the contour of the hips.
The first clinical sign is thelarche (the
appearance of breast buds) and
adrenarche (the appearance of dark
straight pubic hair over the mons veneris,
also called the mons pubis).
These changes identify a SMR stage (or Tanner stage) II
(see tables 1 and 2). Breast development over the next
4 years will proceed from breast stage II (secondary
mound of breast tissue to adult breast stage V).
Development of pubic hair starts about 1 year after
breast budding and may take place over a 1.5 to 3.5
year period.
During SMR stage 3, girls experience a very rapid
increase in their height. The peak of their height growth
(PHV=peak height velocity) should take place before the
onset of menarche in most girls. Menarche occurs six
months after the PHV and just prior to stage IV of breast
development. Most western girls achieve their
menarche around 12.4 to 12.8 years of age. African-
American girls are maturing earlier.
Puberty in boys also follows a regular sequence
of events, but lacks the clear cut landmarks such
as breast development and menarche. In the
male, the pubertal growth spurt is a late event
starting about two years later than in females.
The onset of pubertal changes however, are
only about 6 months later than in females (see
tables 2 and 3). Enlargement of the testes
indicates the transition from genital stage I to
Stage II, beginning at an average age of 11.5
years.
Penile growth occurs about one year later. This
is usually preceded by the appearance of pubic
hair at the base of the phallus progressing
through pubic hair stages II to V. Pubic hair
stage III is followed by the appearance of axillary
and facial hair growth. Testicular growth is
completed anytime between 13.5 and 17 years
of age. Growth of the penis reaches a SMR
(Tanner) stage V between 12.5 and 16.5 years
of age. Nocturnal emissions (wet dreams) may
first appear during SMR stage III.
There is a common misconception that the
difference between the onset of puberty in
males and females is 2 years. This
applies only to the growth spurt and not to
pubertal (SMR) changes.


The patient described above is not only
short statured but is delayed in his
pubertal development. On the basis of the
physical findings described, he would fit a
presumptive diagnosis of constitutional
delay of growth and maturation
Boys with a constitutional delay of growth
and maturation, usually have a normal
birth weight and length, and progress
along their normal growth centile for the
first several years of life, following which,
they begin to deviate and grow at or below
the 3rd percentile throughout childhood.

At the time when normal puberty should
begin, there is often a marked fall off in
growth (pre-adolescent dip) due to a
diminished secretion of growth hormone.
This transient fall in growth hormone is
probably due to failure of sex hormone
production and stimulation.
Skeletal maturation is usually delayed.
When the bone age eventually reaches
the skeletal age when puberty is expected,
it is likely that early signs of sexual
maturation will also appear, which is the
stage of testicular enlargement (SMR
genital stage II).

Often a familial pattern of pubertal delay is
reported. The incidence of affected males is
about 10%. Patients with constitutional delay in
growth and maturation usually do not reach their
"mid parent" or predicted height. Catch up
growth is largely dependent upon the delay of
bone maturation at the time of diagnosis,
indicating that there may be a genetic or familial
component to their short stature.
In most males, a watch and wait approach is
indicated for six to twelve months. The patient
presented could have been prescribed a short
term course of testosterone or gonadotropins in
order to stimulate sexual maturation and growth
hormone production. In general, such treatment
has been reserved for teenagers with significant
behavior or psychological (self image) problems
due to their delayed puberty.
In most cases, the evaluation of a patient
suspected of delayed sexual maturity can be
conservative. A thorough family history, physical
examination, and assessment of sexual maturity
stage will often show signs of early pubertal
changes. The bone age is usually delayed and
reflects the physical delays and the height age of
the patient (the age corresponding to the 50%ile
of the patient's actual height).
Gonadotropins usually reflect the sexual
maturity status of the patient. A
chromosomal karyotype is indicated for all
short statured girls who are delayed (for
possible Turner syndrome) and for boys
who are tall with small soft testes with or
without delayed sexual maturity
(Klinefelter's syndrome).
Causes of Short Stature

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

Causes of Short Stature

IV. Chronic Disease
A. Heart Disease
B. Pulmonary
1. Cystic Fibrosis
2. Asthma
C. GI Disorders
D. Hepatic Disease
E. Renal
V. Iatrogenic
A. Corticosteroids, anabolic steroids
B. ADHD meds
Causes of Delayed Puberty
I. Constitutional Delay in Growth and Maturation
II. Hypogonadotropic hypogonadism
A. Central nervous system disorders
1. Tumors
a. Craniopharyngiomas
b. Gliomas
c. Germinomas
2. Radiation Therapy
3. Congenital Malformations

Causes of Delayed Puberty

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

Causes of Delayed Puberty

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

- The appearance of secondary sexual development before
the age of 7 years in Caucasian girls and 6 years in
African-American girls; 9 years in boys of either race
constitutes precocious sexual development.

- When the cause is premature activation of the
hypothalamic-pituitary axis, the diagnosis is complete
(true) precocious puberty;

- If ectopic gonadotropin secretion occurs in boys or
autonomous sex steroid secretion occurs in either sex,
the diagnosis is incomplete precocious puberty.

- In all forms of sexual precocity, there is an increase in
growth velocity, somatic development, and skeletal
maturation
Classification of precocious puberty.
- Central (complete or true) isosexual precocious puberty
- Constitutional
Idiopathic
Central nervous system disorders
Following androgen exposure
Incomplete isosexual precocious puberty
- Males
Gonadotropin-secreting tumors
Excessive androgen production
Premature Leydig and germinal cell maturation
- Females
ovarian cysts
Estrogen-secreting neoplasms
- Males and females
Severe hypothyroidism
McCune-Albright syndrome
Sexual precocity due to gonadotropin or sex steroid exposure
Variation in pubertal development
- Premature thelarche
- Premature menarche
- Premature pubarche
- Adolescent gynecomastia
Boy 25/12 years of age with idiopathic true precocious
134/12-year-old girl with constitutional delay in growth and puberty. History : normal
growth rate but short stature at all ages. Physical examination : height of 138 cm (-
4.5 SD) and a weight of 28.6 kg (-3 SD). The patient had early stage 2 breast
development. There was no pubic hair. Karyotype was 46,XX. Bone age was 10
years. After administration of GnRH, LH and FSH rose in a pubertal pattern.
Estradiol was 40 pg/mL. She has since spontaneously progressed through pubertal
development.