Adolescent maturity and the brain: the promise and pitfalls of neuroscience research in adolescent health policy

Transition and transfer of the patient with paediatric-onset lupus: a practical approach for paediatric and adult rheumatology practices

The prevalence of paediatric-onset SLE (pSLE) is estimated at 1million people worldwide and accounts for a significant proportion of SLE morbidity, mortality and cost. Patients with pSLE are especially vulnerable during and immediately following transfer from paediatric to adult rheumatology care, when substantial delays in care and increased disease activity are common. Transition is the process through which adolescents and young adults (AYA) develop the skills needed to succeed in the adult healthcare environment, a process that typically takes several years and may span a patient's time in paediatric and adult clinics. Recommendations for improving transition and transfer for AYA with pSLE include setting expectations of the AYA patient and family concerning transition and transfer, developing AYA's self-management skills, preparing an individualised transition plan that identifies a date for transfer, transferring at a time of medical and social stability, coordinating communication between the paediatric and adult rheumatologists (inclusive of both a medical summary and key social factors), and identifying a transition coordinator as a point person for care transfer and to monitor the AYA's arrival and retention in adult rheumatology care. Of paramount importance is empowering the adult rheumatologist with skills that enhance rapport with AYA patients, engage AYA patients and families in adult care models, promote adherence and encourage ongoing development of self-management skills.

What I'd Tell My 16-Year-Old Self: Criminal Desistance, Young Adults, and Psychosocial Maturation

This study qualitatively explored how young adult men on probation or parole view the components of psychosocial maturation that contribute to criminal desistance. The authors conducted nine focus groups with 40 men on probation or parole, including seven groups with men aged 18 to 25 years. Two additional focus groups were conducted with older men (ages 29-60 years) to refine our evolving understanding. According to the participants, psychosocial maturation processes of personal growth, learning from mistakes, considering consequences before acting, developing and executing long-range plans, improving peer associations, and recognizing and responding to a motivating event all contributed to their desire to change their course of criminal offending. These components map well onto existing theories of psychosocial maturation and criminal desistance and lend further insight into how young adult men perceive the psychological, emotional, and cognitive factors that can support their desistance goals.

Evaluation of the minimum age for consent to mental health treatment with the minimum age of criminal responsibility in children and adolescents: a global comparison

BACKGROUND

In many countries, a young person who seeks medical care is not authorised to consent to their own assessment and treatment, yet the same child can be tried for a criminal offence. The absence of child and adolescent mental health legislation in most countries exacerbates the issues young people face in independently accessing mental healthcare. Countries with existing legislation rarely define a minimum age for mental health consent (MAMHC). In stark contrast, nearly all 196 nations studied maintain legislation defining a minimum age of criminal responsibility (MACR).

OBJECTIVE

This review highlights inconsistent developmental and legal perspectives in defined markers of competency across medical and judicial systems.

METHODS

A review of the MAMHC was performed and compared with MACR for the 52 countries for which policy data could be identified through publicly available sources.

FINDINGS

Only 18% of countries maintain identifiable mental health policies specific to children's mental health needs. Of those reviewed, only 11 nations maintained a defined MAMHC, with 7 of 11 having a MAMHC 2 years higher than the country's legislated MACR.

CONCLUSIONS

With increasing scientific understanding of the influences on child and adolescent decision making, some investment in the evidence-base and reconciliation of the very different approaches to child and adolescent consent is needed.

CLINICAL IMPLICATIONS

A more coherent approach to child and adolescent consent across disciplines could help improve the accessibility of services for young people and facilitate mental health professionals and services as well as criminal justice systems deliver optimal care.

Neural Mechanisms of Early-Life Social Stress as a Developmental Risk Factor for Severe Psychiatric Disorders

BACKGROUND

To explore the domain-general risk factor of early-life social stress in mental illness, rearing rodents in persistent postweaning social isolation has been established as a widely used animal model with translational relevance for neurodevelopmental psychiatric disorders such as schizophrenia. Although changes in resting-state brain connectivity are a transdiagnostic key finding in neurodevelopmental diseases, a characterization of imaging correlates elicited by early-life social stress is lacking.

METHODS

We performed resting-state functional magnetic resonance imaging of postweaning social isolation rats (N = 23) 9 weeks after isolation. Addressing well-established transdiagnostic connectivity changes of psychiatric disorders, we focused on altered frontal and posterior connectivity using a seed-based approach. Then, we examined changes in regional network architecture and global topology using graph theoretical analysis.

RESULTS

Seed-based analyses demonstrated reduced functional connectivity in frontal brain regions and increased functional connectivity in posterior brain regions of postweaning social isolation rats. Graph analyses revealed a shift of the regional architecture, characterized by loss of dominance of frontal regions and emergence of nonfrontal regions, correlating to our behavioral results, and a reduced modularity in isolation-reared rats.

CONCLUSIONS

Our result of functional connectivity alterations in the frontal brain supports previous investigations postulating social neural circuits, including prefrontal brain regions, as key pathways for risk for mental disorders arising through social stressors. We extend this knowledge by demonstrating more widespread changes of brain network organization elicited by early-life social stress, namely a shift of hubness and dysmodularity. Our results highly resemble core alterations in neurodevelopmental psychiatric disorders such as schizophrenia, autism, and attention-deficit/hyperactivity disorder in humans.

Magnetic resonance imaging of cerebrovascular reactivity in healthy adolescents

BACKGROUND

Cerebrovascular reactivity (CVR), an important measure of cerebrovascular health in adults, has not been examined in healthy adolescents. Beyond the direct importance of understanding CVR in healthy youth, studies on this topic can yield insights regarding brain disease. We set out to evaluate 3 different CVR modelling approaches.

NEW METHOD

Thirty-nine healthy adolescents (ages 13-19 years, 20 females) completed six blocks of 15-second breath-holds separated by 30-second blocks of free-breathing. CVR was measured using blood-oxygenation-level dependent functional magnetic resonance imaging at 3-Tesla; voxel-wise analyses were complemented by regional analyses in five major subdivisions of the brain. Hemodynamic response functions were modelled using: (1) an individualized delay term (double-gamma variate convolved with a boxcar function), (2) with a standard 9-second delay term, and (3) a sine-cosine regressor.

RESULTS

Individual-delay yielded superior model fit or larger cluster volumes. Regional analysis found differences in CVR and time-to-peak CVR. Males had higher brain-wide CVR in comparison to females (p = 0.025, η²_part = 0.345). BMI and blood pressure were not significantly associated with CVR (all p > 0.4).

COMPARISON WITH EXISTING METHODS

This was the first study to compare these methods in youth. Regional differences were similar to adult studies.

CONCLUSIONS

These findings lend support to future breath-hold CVR studies in youth, and highlight the merit of applying individualized-delay estimates. Regional variability and sex-related differences in CVR suggest that these variables should be considered in future studies, particularly those that examine disease states with predilection for specific brain regions or those diseases characterized by sex differences.

Child abuse and neglect experts' determination of when a child being left home alone constitutes child neglect

Background

Only 14 states have laws or guidelines regarding the minimum age a child may be left home alone. These ages range from 6 to 14 years. Our objective was to identify factors that influence child neglect determination by experts with regards to parents leaving children home alone.

Methods

American Academy of Pediatrics Section on Child Abuse and Neglect members (N = 523) were surveyed from July–August, 2015. Respondents were asked whether scenarios involving a child of varying age knowingly left home alone for 4 h were neglect in the presence or absence of injury to the child and the legality of the situation. Comparisons were performed using the chi-square test.

Results

One hundred ninety-three members responded (36.9%). In the scenario where there were no relevant laws and the child was uninjured, nearly 100% of the child experts determined this as being child neglect when the child was 6 years old. For 8, 10, 12, and 14 year olds, this was 88, 48, 4, and 1%, respectively. However, a significantly higher percentage of experts considered it child neglect for most ages when there was a law making the scenario illegal as compared when there was no law, and when the child was injured versus when they were not. The only demographic variable that showed a difference in child neglect determination was that females were more likely to consider higher aged children as having been neglected when there were no laws but the child was injured. The vast majority of experts (85%) stated that leaving a child home alone for 4 h should be illegal if the child is < 9 years old, and nearly one-half (44%) said it should be illegal for children < 11 years old.

Conclusions

A number of factors affect how experts view children being left home alone as potential child neglect. Our data suggests that such cases may be evaluated differently due to variations in state laws, even though the risk to the child is the same. These results call for child safety law reform to provide greater uniformity in the evaluation of potential child neglect cases and better protect the safety of children.

Adolescents, neurosciences et prise de décisions médicales : devrions-nous revoir certaines dispositions du Code civil du Québec?

Au Québec, le mineur de 14 ans et plus peut consentir seul aux soins médicaux requis par son état de santé, sauf exception. Or, les données provenant des neurosciences indiquent que : 1) l’acquisition de la « maturité cérébrale » est un processus continu, pouvant durer jusqu’à la mi-vingtaine, et que 2) certaines habiletés décisionnelles de l’adolescent, comme l’évaluation des risques et bénéfices à court et à long terme, seraient différentes de celles des adultes, surtout dans les situations émotivement chargées. Nous soumettons que, dans une perspective de protection de l’intérêt supérieur de l’enfant, la réalité neurophysiologique de l’adolescent devrait être prise en compte en contexte de soins de santé. Ainsi, nous questionnons le caractère adéquat de la présomption de capacité d’exercer un jugement de façon autonome dès l’âge de 14 ans et soulignons l’aspect paradoxal de la possibilité d’une intervention judiciaire en cas de refus de traitement. Nous questionnons également la pertinence de considérations d’âge dans le cadre de la relation entre le médecin et son patient, dès lors que la détermination de la capacité décisionnelle est une composante essentielle de l’obtention d’un consentement libre et éclairé. Enfin, nous questionnons l’exclusion des parents du processus décisionnel, à la fois en regard de leur responsabilité parentale et des bénéfices que peuvent représenter leurs conseils pour l’adolescent. Par conséquent, nous soumettons qu’une évaluation du bien-fondé de l’octroi d’un pouvoir décisionnel à l’adolescent de 14 ans et plus serait souhaitable et qu’un régime uniformisé tout au long de la minorité, avec de possibles exceptions, reflèterait mieux les connaissances scientifiques actuelles.

Younger Adults Initiating Hemodialysis: Antidepressant Use for Depression Associated With Higher Health Care Utilization

OBJECTIVE

To examine associations between antidepressant use and health care utilization in young adults beginning maintenance hemodialysis (HD) therapy.

PATIENTS AND METHODS

Antidepressant use, hospitalizations, and emergency department (ED) visits were examined in young adults (N=130; age, 18-44 years) initiating HD (from January 1, 2001, through December 31, 2013) at a midwestern US institution. Primary outcomes included hospitalizations and ED visits during the first year.

RESULTS

Depression diagnosis was common (47; 36.2%) at HD initiation, yet only 28 patients (21.5%) in the cohort were receiving antidepressant therapy. The antidepressant use group was more likely to have diabetes mellitus (18 [64.3%] vs 33 [32.4%]), coronary artery disease (8 [28.6%] vs 12 [11.8%]), and heart failure (9 [32.1%] vs 15 [14.7%]) (P<.05 for all) than the untreated group. Overall, 68 (52.3%) had 1 or more hospitalizations and 33 (25.4%) had 1 or more ED visits in the first year. The risk of hospitalization during the first year was higher in the antidepressant use group (hazard ratio, 2.35; 95% CI, 1.39-3.96; P=.001), which persisted after adjustment for diabetes, coronary artery disease, and heart failure (hazard ratio, 1.94; 95% CI, 1.22-3.10; P=.006). Emergency department visit rates were similar between the groups.

CONCLUSION

Depression and antidepressant use for mood indication are common in young adult incident patients initiating HD and and are associated with higher hospitalization rates during the first year. Further research should determine whether antidepressants are a marker for other comorbidities or whether treated depression affects the increased health care use in these individuals.

Binge Alcohol Exposure Causes Neurobehavioral Deficits and GSK3β Activation in the Hippocampus of Adolescent Rats

Heavy alcohol exposure causes profound damage to the adolescent brain, particularly the hippocampus, which underlie some behavioral deficits. However, the underlying molecular mechanisms remain inconclusive. The current study sought to determine whether binge alcohol exposure affects the hippocampus-related behaviors and key signaling proteins that may mediate alcohol neurotoxicity in adolescent rats. Alcohol exposure reduced the number of both NeuN-positive and doublecortin-positive cells in the hippocampus. Alcohol also induced neurodegeneration which was confirmed by ultrastructural analysis by electronic microscopy and was accompanied with the activation of microglia. Binge alcohol exposure impaired spatial learning and memory which was evaluated by the Morris water maze. However, alcohol did not alter the spontaneous locomotor activity which was determined by the open field test. GSK3β is a multi-function serine/threonine protein kinase regulating both neuronal survival and neurogenesis and plays an important role in various neurodegenerative disorders. We have previously shown that GSK3β is a key mediator of alcohol-induced neuron apoptosis in the developing brain. We showed here binge alcohol exposure caused GSK3β activation by inducing dephosphorylation at Ser9 without affecting the phosphorylation of Tyr216 in the hippocampus. Thus, GSK3β may be involved in binge alcohol exposure-induced neuronal damage to the adolescent hippocampus.

Age-Related Differences in Socio-demographic and Behavioral Determinants of HIV Testing and Counseling in HPTN 043/NIMH Project Accept

Youth represent a large proportion of new HIV infections worldwide, yet their utilization of HIV testing and counseling (HTC) remains low. Using the post-intervention, cross-sectional, population-based household survey done in 2011 as part of HPTN 043/NIMH Project Accept, a cluster-randomized trial of community mobilization and mobile HTC in South Africa (Soweto and KwaZulu Natal), Zimbabwe, Tanzania and Thailand, we evaluated age-related differences among socio-demographic and behavioral determinants of HTC in study participants by study arm, site, and gender. A multivariate logistic regression model was developed using complete individual data from 13,755 participants with recent HIV testing (prior 12 months) as the outcome. Youth (18-24 years) was not predictive of recent HTC, except for high-risk youth with multiple concurrent partners, who were less likely (aOR 0.75; 95% CI 0.61-0.92) to have recently been tested than youth reporting a single partner. Importantly, the intervention was successful in reaching men with site specific success ranging from aOR 1.27 (95% CI 1.05-1.53) in South Africa to aOR 2.30 in Thailand (95% CI 1.85-2.84). Finally, across a diverse range of settings, higher education (aOR 1.67; 95% CI 1.42, 1.96), higher socio-economic status (aOR 1.21; 95% CI 1.08-1.36), and marriage (aOR 1.55; 95% CI 1.37-1.75) were all predictive of recent HTC, which did not significantly vary across study arm, site, gender or age category (18-24 vs. 25-32 years).

Altered Regional Brain Cortical Thickness in Pediatric Obstructive Sleep Apnea

Rationale

Obstructive sleep apnea (OSA) affects 2–5% of all children and is associated with cognitive and behavioral deficits, resulting in poor school performance. These psychological deficits may arise from brain injury, as seen in preliminary findings of lower gray matter volume among pediatric OSA patients. However, the psychological deficits in OSA are closely related to functions in the cortex, and such brain areas have not been specifically assessed. The objective was to determine whether cortical thickness, a marker of possible brain injury, is altered in children with OSA.

Methods

We examined regional brain cortical thicknesses using high-resolution T1-weighted magnetic resonance images in 16 pediatric OSA patients (8 males; mean age ± SD = 8.4 ± 1.2 years; mean apnea/hypopnea index ± SD = 11 ± 6 events/h) and 138 controls (8.3 ± 1.1 years; 62 male; 138 subjects from the NIH Pediatric MRI database) to identify cortical thickness differences in pediatric OSA subjects.

Results

Cortical thinning occurred in multiple regions including the superior frontal, ventral medial prefrontal, and superior parietal cortices. The left side showed greater thinning in the superior frontal cortex. Cortical thickening was observed in bilateral precentral gyrus, mid-to-posterior insular cortices, and left central gyrus, as well as right anterior insula cortex.

Conclusion

Changes in cortical thickness are present in children with OSA and likely indicate disruption to neural developmental processes, including maturational patterns of cortical volume increases and synaptic pruning. Regions with thicker cortices may reflect inflammation or astrocyte activation. Both the thinning and thickening associated with OSA in children may contribute to the cognitive and behavioral dysfunction frequently found in the condition.

Hot and Cool Executive Functions in Adolescence: Development and Contributions to Important Developmental Outcomes

Despite significant theoretical advancement in the area of child neuropsychology, limited attention has been paid to the developmental features of adolescence. The present study intends to address this issue in relation to executive function (EF). EF refers to the psychological processes that underlie goal-directed behavior; recent studies separate cool EF (psychological process involves pure logic and critical analysis) and hot EF (psychological process driven by emotion). Although neurological findings suggest that adolescence is a sensitive period for EF development, data on comparing the developmental progression in hot or cool EFs is highly missing. Moreover, while evidence has confirmed the relationships between EF and day-to-day functioning, whether and how hot and cool EFs contribute to core developmental outcomes in adolescence is still remained unknown. The current study aims to enhance our understanding of the development and impacts of hot and cool EFs in adolescence. A total of 136 typically developing adolescents from age 12 to 17 completed four cool EF tasks including Backward digit span, Contingency naming test, Stockings of Cambridge, and Stroop Color and Word test, and one hot task on Cambridge gambling task. Data on academic performance and psychological adjustment was also collected. Results showed that cool and hot EF exhibited different patterns of age-related growth in adolescence. Specifically, cool EF ascended with age while hot EF showed a bell-shaped development. Moreover, there were correlations among cool EF measures but no association between cool and hot EFs. Further, cool EF was a better predictor of academic performance, while hot EF uniquely related to emotional problems. The results provide evidence for the association among cool EF tests and the differentiation of hot and cool EFs. The bell-shaped development of hot EF might suggest a period of heightened risk-taking propensity in middle adolescence. Given the plastic nature of EF, especially over adolescence, the current findings may have practical implications for future EF identification and training.

The Relationship between Self-Reported Executive Functioning and Risk-Taking Behavior in Urban Homeless Youth

Introduction: Almost 2 million U.S. youth are estimated to live on the streets, in shelters, or in other types of temporary housing at some point each year. Both their age and living situations make them more likely to engage in high-risk behaviors, particularly during adolescence, a time of increased risk taking. Much of self-control appears related to the development of the prefrontal cortex, which is at a particularly crucial period of elaboration and refinement during adolescence and emerging adulthood. Executive processes like decision-making, inhibition, planning, and reasoning may be vulnerable to adversity experienced as a result of homelessness and related impoverishment during childhood and adolescence. No study to date, to our knowledge, has directly investigated differences in risk-taking by homeless youth as it relates to their developing executive control. Objective: Examine the relationship between the level of self-reported executive function (EF) and engagement in risk taking behaviors among a sample of shelter-living urban homeless youth. We predicted that homeless youth who have lower levels of self-reported EF would more readily engage in risky behaviors that could lead to negative outcomes. Participants: One hundred and forty-nine youths between 18 and 22 years of age were recruited from homeless agencies in Chicago. Of this study sample, 53% were female and 76% African American. Measures: All participants completed, as part of a broader neuropsychological assessment, the Behavior Rating Inventory of Executive Functioning-Adult Version (BRIEF-A), the National Youth Risk Behavior Survey (YRBS), and the Mini-International Neuropsychiatric Interview (MINI). Analyses: Groups were separated based on level of self-reported EF, with two groups identified: High self-reported EF fell >1 SD above the normative average, and low self-reported EF fell >1 SD below the normative average. All analyses utilized Chi-square and Mann-Whitney tests. Results and Conclusions: Analyses revealed a relationship between the level of self-reported EF and risk taking behaviors in this group of sheltered homeless urban youths. Those with lower self-reported executive functioning had higher rates of engagement in multiple substance-related risk taking behaviors. These findings are important because they are a first step towards identifying contributions to risk-taking behavior in urban homeless youths. Identifying potential factors like low self-reported EF better allows us to potentially intervene, thereby providing focused support to youths who are at higher risk for engaging in problematic behaviors.

Effects of traumatic experiences on obsessive-compulsive and internalizing symptoms: The role of avoidance and mindfulness

BACKGROUND

Trauma exposure is associated with adverse psychological outcomes including anxiety, depression, and obsessive-compulsive (OC) symptoms. Adolescence is increasingly recognized as a period of vulnerability for the onset of these types of psychological symptoms. The current study explored the mediating roles of experiential avoidance and mindfulness processes in the association between retrospective reports of childhood trauma and current internalizing and OC symptoms in adolescents.

METHOD

A group of at-risk adolescents (N = 51) and a group of college students (N = 400) reported on childhood trauma, experiential avoidance, mindfulness, anxiety, depressive, and OC symptoms. Mediation analyses were performed to examine the mechanistic roles of avoidance and mindfulness in the association between trauma and internalizing and OC-specific symptoms.

RESULTS

In the group of at-risk adolescents, experiential avoidance and mindfulness both significantly mediated the association between childhood trauma and OC symptoms. In the college student sample, experiential avoidance mediated the association between trauma and OC symptoms. Experiential avoidance, as well as the observe, act with awareness, and nonjudgmental facets of mindfulness all significantly mediated the association between trauma and internalizing symptoms.

LIMITATIONS

The group of at-risk adolescents was small, and the college student group was demographically homogeneous. All data was self-report and cross-sectional.

CONCLUSION

The current study demonstrated that experiential avoidance and mindfulness processes may be the mechanisms through which the association between trauma and obsessive-compulsive and trauma and internalizing symptoms exist in adolescents. These findings provide potential targets for clinical intervention to improve outcomes for adolescents who have experienced trauma.

Repetitive transcranial magnetic stimulation for the treatment of drug-resistant epilepsy: A systematic review and individual participant data meta-analysis of real-world evidence

Objective

To perform a systematic review and meta‐analysis of real‐world evidence for the use of low‐frequency repetitive transcranial magnetic stimulation (rTMS) in the treatment of drug‐resistant epilepsy.

Methods

We systematically searched PubMed, Scopus, Medline, and clinicaltrials.gov for all relevant articles. Relevant patient and stimulation predictors as well as seizure outcomes were assessed. For studies with and without individual participant data (IPD), the primary outcomes were the rate of “favorable response” (reduction in seizure frequency ≥50%) and pooled event rate of mean reduction in seizure frequency, respectively. Outcomes were assessed with comparative statistics and random‐effects meta‐analysis models.

Results

Of 3,477 identified articles, 12 met eligibility and were included in this review. We were able to obtain IPD for 5 articles constituting 34 participants. Univariate analysis on IPD identified greater favorable response event rates between participants with temporal seizure focus versus extratemporal (50% vs. 14%, p = 0.045) and between participants who were stimulated with a figure‐8 coil versus other types (47% vs. 0%, p = 0.01). We also performed study‐level meta‐analysis on the remaining 7 studies without IPD, which included 212 participants. The pooled mean event rate of 50% seizure reduction using low‐frequency rTMS was 30% (95% confidence interval [CI] 12–57%). Sensitivity analysis revealed that studies with a mean age ≤21 years and studies using targeted stimulation had the highest seizure reduction rates compared to studies with a mean age >21 years (69% vs. 18%) and not using a targeted stimulation (47% vs. 14–20%). Moreover, we identified high interstudy heterogeneity, moderate study bias, and high publication bias.

Significance

Real‐world evidence suggests that low‐frequency rTMS using a figure‐8 coil may be an effective therapy for the treatment of drug‐resistant epilepsy in pediatric patients. This meta‐analysis can inform the design and expedite recruitment of a subsequent randomized clinical trial.

Adolescence effortful control as a mediator between family ecology and problematic substance use in early adulthood: A 16-year prospective study

This study examined the mediated effect of early adolescence familial context on early adulthood problematic substance use through effortful control in late adolescence. The sample consisted of a community sample of 311 adolescents and their families comprising the control group within a randomized trial intervention. Parental monitoring and parent-child relationship quality (P-C RQ) were measured annually from ages 11 to 13. Effortful control was measured by self-reports and parent and teacher reports at ages 16 to 17. Self-reports of problematic tobacco, alcohol, and marijuana use were measured at ages 18 to 19, 21 to 22, 23 to 24, and 26 to 27. Structural equation modeling was employed to test hypothesized models. Only P-C RQ was found to be significantly associated with adolescent effortful control. As expected, higher levels of adolescent effortful control were associated with lower problematic substance use through early adulthood, controlling for previous substance use levels. Mediation analyses showed that effortful control significantly mediated the relationship between P-C RQ and problematic substance use. Higher relationship quality between youth and parents in early adolescence is associated with higher effortful control, which in turn relates to a lower level of problematic substance use in early adulthood.

Clinical indicators for nursing diagnosis Ineffective protection in adolescents with cancer

ABSTRACT Objective: To investigate scientific evidence related to the term protection and clinical indicators and etiologic factors for nursing diagnosis Ineffective protection in adolescents with cancer. Method: Integrative literature review in the databases of Scopus, Web of Science, National Library of Medicine and National Institutes of Health (PubMed) and Cochrane; by intersection of the descriptors protection and childhood cancer, which resulted in seven articles. These were insufficient for a comprehension of the term protection and aspects related to its impairment, therefore it was necessary to include a further three reference books. Results: Five clinical indicators and three etiologic factors associated to Ineffective protection were identified some of which were not cited in NANDA-International. Conclusions: There are clinical and etiologic factors important for the identification of ineffective protection in adolescents with cancer.

Motivation and perceived competence for healthy eating and exercise among overweight/obese adolescents in comparison to normal weight adolescents

Background

The current literature on determinants of behavior change in weight management lacks sufficient studies on type of motivation among children/adolescents, on perceived competence, and in relation to healthy eating. This study aimed to investigate type of motivation and levels of perceived competence for healthy diet and exercise, as well as general self efficacy among adolescents. We hypothesized that overweight/obese adolescents would demonstrate lower autonomous motivation and perceived competence regarding diet and exercise, and lower self-efficacy in general, and that the scores would be influenced by socioeconomic factors.

Methods

Normal weight (n = 40, body mass index < 85% for age and gender) and overweight or obese adolescents (n = 60, body mass index ≥ 85% for age and gender) aged 13-18 years were recruited from pediatric ambulatory clinics. Information was collected about demographics, socioeconomic factors, and lifestyle behaviors. The study subjects completed a survey including the Treatment Self-Regulation Questionnaire (TSRQ) and the Perceived Competence Scale (PCS) for healthy eating and exercise, and the General Self-Efficacy Scale (GSES). Composite scores for the three scales were compared between the two groups using the using the two-sample t-test (for normal data) or the Mann-Whitney U test (for non-parametric data). Relationships between the composite scores and patient characteristics were determined using Pearson or Spearman’s correlations.

Results

The average age of the total cohort was 15.9 ± 1.9 years. 54% were female, and 82% identified as Latino/Hispanic. In comparison to normal weight subjects, overweight/obese adolescents exhibited higher scores for controlled motivation (mean ± standard deviation 28.3 ± 9.3 vs 18.1 ± 8.1) and higher perceived competence [median and 25-75% interquartile range 22.5 (19.0-26.0) vs 20.0 (15.5-25.0)] in relation to eating a healthy diet. These differences persisted after adjustment for age, sex, paternal education, and family income.

Conclusions

Overweight/obese adolescents did not lack autonomous motivation but demonstrated higher controlled motivation and perceived competence for healthy eating in comparison to normal weight adolescents, independent of socioeconomic factors. In the clinical practice of weight management, providers should carefully assess adolescents for type of motivation and perceived competence, while accounting for potential barriers to behavior change.

The relationship between salivary C-reactive protein and cognitive function in children aged 11-14years: Does psychopathology have a moderating effect?

Elevated C-reactive protein (CRP), a non-specific biomarker of systemic bodily inflammation, has been associated with more pronounced cognitive impairments in adults with psychiatric disorders, particularly in the domains of memory and executive function. Whether this association is present in early life (i.e., the time at which the cognitive impairments that characterise these disorders become evident), and is specific to those with emerging psychiatric disorders, has yet to be investigated. To this end, we examined the association between salivary CRP and cognitive function in children aged 11-14years and explored the moderating effect of psychopathology. The study utilised data from an established longitudinal investigation of children recruited from the community (N=107) that had purposively over-sampled individuals experiencing psychopathology (determined using questionnaires). CRP was measured in saliva samples and participants completed assessments of cognition (memory and executive function) and psychopathology (internalising and externalising symptoms and psychotic-like experiences). Linear regression models indicated that higher salivary CRP was associated with poorer letter fluency (β=-0.24, p=0.006) and scores on the inhibition (β=-0.28, p=0.004) and inhibition/switching (β=-0.36, p<0.001) subtests of the colour-word interference test, but not with performance on any of the memory tasks (working, visual, and verbal memory tasks). Results were largely unchanged after adjustment for psychopathology and no significant interactions between CRP and psychopathology were observed on any cognitive measure. Our findings provide preliminary evidence that elevated salivary CRP is associated with poorer cognitive function in early life, but that this association is not moderated by concurrent psychopathology. These findings have implications for early intervention strategies that attempt to ameliorate cognitive deficits associated with emerging psychiatric disorders. Further research is needed to determine whether salivary CRP levels can be used as a valid marker of peripheral inflammation among healthy adolescents.

Resting-state connectivity and executive functions after pediatric arterial ischemic stroke

Background

The aim of this study was to compare the relationship between core executive functions and frontoparietal network connections at rest between children who had suffered an arterial ischemic stroke and typically developing peers.

Methods

Children diagnosed with arterial ischemic stroke more than two years previously and typically developing controls were included. Executive function (EF) measures comprised inhibition (Go-NoGo task), fluency (category fluency task), processing speed (processing speed tasks), divided attention, working memory (letter-number sequencing), conceptual reasoning (matrices) and EF in everyday life (questionnaire). High-resolution T1-weighted magnetic resonance (MR) structural images and resting-state functional MR imaging were acquired. Independent component analysis was used to identify the frontoparietal network. Functional connections were obtained through correlation matrices; associations between cognitive measures and functional connections through Pearson's correlations.

Results

Twenty participants after stroke (7 females; mean age 16.0 years) and 22 controls (13 females; mean age 14.8 years) were examined. Patients and controls performed within the normal range in all executive tasks. Patients who had had a stroke performed significantly less well in tests of fluency, processing speed and conceptual reasoning than controls. Resting-state functional connectivity between the left and right inferior parietal lobe was significantly reduced in patients after pediatric stroke. Fluency, processing speed and perceptual reasoning correlated positively with the interhemispheric inferior parietal lobe connection in patients and controls.

Conclusion

Decreased interhemispheric connections after stroke in childhood may indicate a disruption of typical interhemispheric interactions relating to executive functions. The present results emphasize the relationship between functional organization of the brain at rest and cognitive processes.

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Interhemispheric frontoparietal connectivity is reduced after pediatric stroke.

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Interhemispheric frontoparietal connectivity relates to executive functions.

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Connectivity-function relation occurs in children, adolescents and young adults.

What is it going to take to move youth-related HIV programme policies into practice in Africa?

Introduction: HIV has been reported to be the leading cause of mortality amongst adolescents in Africa. This has brought attention to the changes in service provision and health management that many adolescents living with HIV experience when transferring from specialized paediatric- or adolescent-focused services to adult care. When transition is enacted poorly, adherence may be affected and the continuum of care disrupted. As the population of HIV-infected adolescents grows, effective and supported transition increases in significance as an operational imperative.

Discussion: Considerable gaps remain in moving policy to practice at global, national, and local levels. Policies that give clear definition to transition and provide standard operating procedures or tools to support this process are lacking. National guidelines tend to neglect transition. Beyond transition itself, there has been slow progress on the inclusion of adolescents in national policies and strategies. Guidance often overlooks the specific needs and rights of adolescents, in particular for those living with HIV. In some cases, prohibitive laws can impede adolescent access by applying age of consent restriction to HIV testing, counselling and treatment, as well as SRH services. Where adolescent-focused policies do exist, they have been slow to emerge as tangible operating procedures at health facility level. A key barrier is the nature of existing transition guidance, which tends to recommend an individualized, client-centred approach, driven by clinicians. In low- and middle-income settings, flexible responses are resource intensive and time consuming, and therefore challenging to implement amidst staff shortages and administrative challenges. First, national governments must adopt transition-specific policies to ensure that adolescents seamlessly receive appropriate and supportive care. Second, transition policies must form part of a broader adolescent-centred policy landscape and adolescent-friendly orientation and approach at health system level. Third, national actors must ensure that transition policies are supported at implementation level. Fourth, youth involvement and community mobilization are essential. Finally, further implementation research is urgently needed to better understand how to support young people and providers in achieving smooth transitions.

Conclusions: Only by moving from policy to practice through supportive policies and their implementation will we be closer to including adolescents in the 2030 goal of ending AIDS.

The Transition into Young Adulthood: a Critical Period for Weight Control

PURPOSE OF REVIEW

Emerging adulthood (age 18-25) represents a critical period for weight control: rate of weight gain is greatest during these years and the prevalence of overweight and obesity is estimated to be at least 40% among emerging adults. Unique behavioral, psychosocial, and cognitive risk factors among this population must be specifically addressed within weight management programs. We review extant treatment approaches, including lessons learned from the nascent literature specifically targeting this population. Lastly, we provide suggestions to inform future work in this area.

RECENT FINDINGS

The EARLY consortium comprises seven clinical trials targeting weight control in young adults age 18-35. Though these studies encompass a broader age range, two of the trials enrolled large numbers of 18-25-year-olds. Results from these trials and other recent pilot trials provide a foundation for next steps with respect to developing weight management interventions for emerging adults. The design of targeted weight control approaches for emerging and young adults has contributed to improved outcomes for this high-risk population. However, suboptimal engagement and variability in response pose challenges. Identifying and intervening on individual-level behavioral and psychological variables may enhance the effects of these adapted treatments.

Controversy About Dialysis for an Adolescent

For patients on dialysis, 1 frequent cause of death is their voluntary decision to discontinue dialysis. Such decisions raise complex questions when the patient is a competent adult. The decisions are even more complex when the patient is an adolescent. In this article, we present a case in which a 17-year-old adolescent decided that she no longer wished to undergo dialysis through her fistula. Her doctors thought that dialysis using any other technique would be too dangerous. Four experts in pediatric nephrology, bioethics, and palliative care discuss this decision and the different ways that the health care team might respond.

"At our age, we would like to do things the way we want: " a qualitative study of adolescent HIV testing services in Kenya

Supplemental Digital Content is available in the text

Objectives:

Adolescents in Africa have low HIV testing rates. Better understanding of adolescent, provider, and caregiver experiences in high-burden countries such as Kenya could improve adolescent HIV testing programs.

Design:

We conducted 16 qualitative interviews with HIV-positive and HIV-negative adolescents (13–18 years) and six focus group discussions with Healthcare workers (HCWs) and caregivers of adolescents in Nairobi, Kenya.

Methods:

Semi-structured interviews and focus groups were recorded and transcribed. Analysis employed a modified constant comparative approach to triangulate findings and identify themes influencing testing experiences and practices.

Results:

All groups identified that supportive interactions during testing were essential to the adolescent's positive testing experience. HCWs were a primary source of support during testing. HCWs who acted respectful and informed helped adolescents accept results, link to care, or return for repeat testing, whereas HCWs who acted dismissive or judgmental discouraged adolescent testing. Caregivers universally supported adolescent testing, including testing with the adolescent to demonstrate support. Caregivers relied on HCWs to inform and encourage adolescents. Although peers played less significant roles during testing, all groups agreed that school-based outreach could increase peer demand and counteract stigma. All groups recognized tensions around adolescent autonomy in the absence of clear consent guidelines. Adolescents valued support people during testing but wanted autonomy over testing and disclosure decisions. HCWs felt pressured to defer consent to caregivers. Caregivers wanted to know results regardless of adolescents’ wishes.

Conclusion:

Findings indicate that strengthening HCW, caregiver, and peer capacities to support adolescents while respecting their autonomy may facilitate attaining ‘90-90-90’ targets for adolescents.

Premier League academy soccer players' experiences of competing in a tournament bio-banded for biological maturation

Individual differences in the growth and maturation have been shown to impact player performance and development in youth soccer. This study investigated Premier League academy players' experiences of participating in a tournament bio-banded for biological maturation. Players (N = 66) from four professional soccer clubs aged 11 and 14 years and between 85-90% of adult stature participated in a tournament. Players competed in three 11 vs 11 games on a full size pitch with 25-min halves. Sixteen players participated in four 15-min focus groups and were asked to describe their experiences of participating in the bio-banded tournament in comparison to age group competition. All players described their experience as positive and recommended the Premier League integrate bio-banding into the existing games programme. In comparison to age-group competitions, early maturing players described the bio-banded games more physically challenging, and found that they had to adapt their style of play placing a greater emphasis on technique and tactics. Late maturing players considered the games to be less physically challenging, yet appreciated the having more opportunity to use, develop and demonstrate their technical, physical, and psychological competencies. Bio-banding strategies appear to contribute positively towards the holistic development of young soccer players.

Labeling and defining severe and enduring anorexia nervosa: A systematic review and critical analysis

OBJECTIVE

With anorexia nervosa (AN) having various presentations, attention has been directed towards particularly durable forms of the condition in both research and clinical contexts. A major hindrance in terms of advancing the field is the inconsistent labeling and defining of this subgroup. This has two implications; first, the inconsistent recruitment of participants when researching this sample, and second, the misdiagnosing of patients who may or may not have a durable course of the disease. The current research had the purpose of providing an overview of the current labels and criteria used for defining cases of severe and enduring AN, and critically analysing the implications of these findings.

METHOD

In accordance with PRISMA guidelines, a literature search was conducted using four electronic databases (PsycINFO, MEDLINE, Web of Science and Scopus) in order to identify 32 records that met the standards stipulated by the criteria. Data extraction included explicit labeling, the definition or criteria used to describe the subgroup, along with participant age and study design.

RESULTS

It was found that the terms chronic and severe and enduring were the most commonly used adjectives when referring to this subgroup. In terms of criteria, illness duration and the number of previously failed treatment attempts were the most common defining features within the literature.

DISCUSSION

It is the aim of the authors to inspire further research into what is the most appropriate label and defining features for the subgroup in order to facilitate a better approach and outcome for the individuals affected.

Acceptance and commitment therapy universal prevention program for adolescents: a feasibility study

BACKGROUND

There is a need to prevent anxiety and depression in young people and mindfulness contains important emotion regulation strategies. Acceptance and commitment therapy (ACT), a mindfulness-based therapy, has yet to be evaluated as a prevention program, but has demonstrated an ability to reduce symptoms of anxiety and depression in adult and adolescent populations. This study examines the feasibility of using an ACT-based prevention program in a sample of year 10 (aged 14-16 years) high school students from Sydney, Australia.

METHODS

Participants were allocated to either their usual classes or to the ACT-based intervention. Participants were followed for a period of 5 months post-intervention and completed the Flourishing Scale, Depression Anxiety Stress Scale, and a program evaluation questionnaire. Analyses were completed using intention-to-treat mixed models for repeated measures.

RESULTS

The results indicated that the intervention was acceptable to students and feasible to administer in a school setting. There were no statistically significant differences between the conditions, likely due to the small sample size (N = 48). However, between-group effect sizes demonstrated small to large differences for baseline to post-intervention mean scores and medium to large differences for baseline to follow-up mean scores, all favouring the ACT-based condition.

CONCLUSION

The results suggest that an ACT-based school program has potential as a universal prevention program and merits further investigation in a larger trial. Trial registration Australian New Zealand Clinical Trials Registry. Trial ID: ACTRN12616001383459. Registered 06/10/2016. Retrospectively registered.

The puzzling question of inhibitory control in Tourette syndrome: A meta-analysis

Tourette syndrome (TS) is a neuropsychiatric disorder involving motor and phonic tics. Inhibitory control is a key issue in TS, and many disruptive or impulsive behaviors might arise from inhibitory deficits. However, conflicting findings regarding TS patients' inhibitory performance in neuropsychological tasks have been reported throughout the literature. Therefore, this meta-analysis aimed to evaluate inhibitory control through neuropsychological tasks, and to analyze the factors modulating inhibitory deficits. To this end, a literature search was performed through MEDLINE and PsycINFO, to retrieve studies including neuropsychological tasks that assessed inhibitory control in TS patients. Of the 4020 studies identified, 61 were included in the meta-analysis, for a total of 1717 TS patients. Our analyses revealed a small to medium effect in favor of inhibitory deficits in TS patients. This effect was larger in TS+ADHD patients, but pure TS patients also showed some inhibitory deficits. Therefore, deficits in inhibitory control seem to be an inherent component of TS, and are exacerbated when ADHD is concomitant.

Age at injury is associated with the long-term cognitive outcome of traumatic brain injuries

INTRODUCTION

The association between age at injury (AAI) and long-term cognitive outcome of traumatic brain injuries (TBI) is debatable.

METHODS

Eligible participants with a history of TBI from Alzheimer's Disease Neuroimaging Initiative were divided into a childhood TBI (cTBI) group (the AAI ≤ 21 years old) and an adult TBI (aTBI) group (the AAI > 21 years old).

RESULTS

The cTBI group has a higher Everyday Cognition total score than the aTBI group. All perceived cognitive functions are worse for the cTBI group than for the aTBI group except memory. By contrast, the cTBI group has higher assessment scores on either the Boston Naming Test or Rey Auditory Verbal Learning Test than the aTBI group.

DISCUSSION

The AAI is associated with the long-term cognitive outcomes in older adults with a history of TBI.

The adolescent brain at risk for substance use disorders: a review of functional MRI research on motor response inhibition

Youth with family history (FH+) of substance use disorders (SUDs) are at increased risk for developing SUDs. Similarly, childhood attention deficit hyperactivity disorder (ADHD) is considered to be a risk factor for developing SUDs. Recent research has suggested a close association between SUDs and impaired inhibitory control. As such, it is crucial to examine common and distinct neural alterations associated with inhibitory control in these at-risk groups, particularly prior to the initiation of heavy substance use. This paper reviews the functional magnetic resonance imaging (fMRI) literature of inhibitory control in these two at-risk youth populations (FH+ and ADHD), specifically considering studies that used motor response inhibition tasks (Go/No-Go or Stop Signal). Across the selected fMRI studies, we discovered no common alteration in the at-risk groups, but found neural alterations specific to each at-risk group. In FH+ youth and youth who transitioned into heavy substance use, blunted activation in the lateral part of the frontal pole (FP-lat) was most reliably observed. Importantly, longitudinal studies indicate that the blunted FP-lat activation may predict later SUDs, irrespective of the presence of FH+. In regards to ADHD, blunted activation was observed in the right dorsal anterior cingulate cortex (dACC) and left caudate. Of note, similar blunted dACC activation was also reported by one FH+ study, and thus, we cannot preclude a possibility that the right dACC activity may be a potential common alteration in both at-risk groups, particularly given a limited number of FH+ studies in the current review. Research challenges remain, and large-scale, longitudinal efforts will help determine the neurobiological markers predictive of SUDs among at-risk adolescents, including those with FH+, as well as those with ADHD and other psychiatric disorders.

Comparison of the behavioral effects of exercise and high fat diet on cognitive function in adolescent rats

Adolescence is a critical period for neurodevelopment, neuronal plasticity, and cognitive function. Experiences of adolescence can be exerted positive and negative effects on brain development. Physical exercise has a positive effect on brain function, which is characterized by improving memory function and increased neural plasticity. High fat diet (HFD)-induced obesity has a negative effect on brain function, which is characterized by insulin resistance and neuroinflammation and reduced microvessel constructure. Although the positive effect of exercise and negative effect of obesity on cognitive function have been documented, it has not been well whether comparison of the effects of exercise and obesity on cognitive function in adolescent rats. In the present study, we evaluated the behavioral changes related to cognitive function induced by exercise and obesity in adolescent rats. Male Wistar rats were randomly divided into three groups: the control group (CON), the exercise group (Ex), the high fat diet group (HFD). The HFD containing fat 60% was freely provided. The present results showed that spatial learning ability and short-term memory did not show significant effect exercise as compared to the control group. The present results showed that spatial learning ability and short-term memory was significantly decreased HFD-induced obesity group as compared to the control group. These results suggest that positive effect of physical exercise in adolescence rats may be exerted no significant effect on cognitive function. But, negative effect of HFD-induced obesity might induce cognitive impairment. HFD-induced obesity in adolescent rats may be used as an animal model of neurodevelopmental disorders.

Utilizing biopsychosocial and strengths-based approaches within the field of child health: what we know and where we can grow

We continue to increase our understanding of the experiences and settings that contribute to positive developmental outcomes in childhood, and those that confer greater risk. Although the mechanisms by which the risk and protective factors affect developmental outcomes need to be further elucidated through research, converging findings from the field of child health (spanning both physical and mental health) indicate that a biopsychosocial approach is useful. Here, we examine the evidence that early experiences confer both risk and protective processes on biopsychosocial development in childhood, and touch on some implications for the life course. Although this interdisciplinary field of research has already garnered substantial attention, here we aim to highlight the opportunity to use a strengths-based approach with the biopsychosocial model, with particular focus on children who experience prolonged stress. We close with consideration for future directions with an emphasis on policy and practice in clinical and educational settings to improve well-being in these early stages of the life course.

Improving Accident Statistics and Expanding the Role of Traffic Psychologists in Brazil

Abstract Due to the mandatory assessment of psychological fitness to drive of prospective drivers, Brazil has a relatively large amount of traffic psychologists. Since, in general, assessment only happens upon first licensing, the task of these psychologists is fairly limited (as is the scope of the assessment itself). Intention and method: this study aims to perform a critical analysis of possibilities to expand the role of psychologists working in the traffic system in Brazil. A systematic review study of databases and international documents was conducted and a scope of activity of psychologists in this area was built. First result statistical data is scattered over many agencies. First conclusion in order to better identify specific tendencies and risk groups in Brazil, statistical data related to accident involvement needs to be better, perhaps centrally, coordinated and consolidated. Second result international research related to three subgroups of drivers that constitute a significantly increased safety risk can inform future directions for traffic psychology in Brazil. Psychological processes that may underlie these risk increases are discussed. Second conclusion two subgroups (young drivers and aggressive drivers) could benefit from more than assessment, they could benefit from specific psychological interventions. The third subgroup (elderly drivers) is expected to increase significantly in the future, which asks for clearer policies, with a significant input form psychologists and psychological research.

Risk Factors for Graft Loss in Pediatric Renal Transplant Recipients After Transfer of Care

BACKGROUND

Improvements in transplantation have increased the survival of children after kidney transplantation. These patients have complex needs, and the current medical system is not prepared to effectively transfer the care of these individuals from pediatric to adult health-care systems. Too often, transfer occurs during moments of crisis and is associated with poor outcomes.

OBJECTIVE

The aim of this study was to use a national database, the Scientific Registry of Transplant Recipients, to test the hypothesis that the increased risk of graft loss after transfer of care (from pediatric to adult services) for young adult kidney transplant recipients over a 2- to 3-year posttransfer follow-up period was related to these posttransfer risk factors (medication noncompliance, acute rejection, insurance status).

DESIGN

A retrospective, longitudinal, correlational design using secondary data was used to evaluate the transfer of care of 250 kidney transplant recipients (ages 16-25).

RESULTS

Seventy-seven (30.8%) individuals lost their graft within 3 years after transfer of care. Medication noncompliance, acute rejection, and serum creatinine >2.0 mg/dL at transfer were significant predictors of graft loss after accounting for multiple other factors.

CONCLUSION

These individuals are at risk for graft loss after transfer of care and may benefit from increased personalized care during this risky period.

Linking Executive Function and Peer Problems from Early Childhood Through Middle Adolescence

Peer interactions and executive function play central roles in the development of healthy children, as peer problems have been indicative of lower cognitive competencies such as self-regulatory behavior and poor executive function has been indicative of problem behaviors and social dysfunction. However, few studies have focused on the relation between peer interactions and executive function and the underlying mechanisms that may create this link. Using a national sample (n = 1164, 48.6% female) from the Study of Early Child Care and Youth Development (SECCYD), we analyzed executive function and peer problems (including victimization and rejection) across three waves within each domain (executive function or peer problems), beginning in early childhood and ending in middle adolescence. Executive function was measured as a multi-method, multi-informant composite including reports from parents on the Children's Behavior Questionnaire and Child Behavior Checklist and child's performance on behavioral tasks including the Continuous Performance Task, Woodcock-Johnson, Tower of Hanoi, Operation Span Task, Stroop, and Tower of London. Peer problems were measured as a multi-informant composite including self, teacher, and afterschool caregiver reports on multiple peer-relationship scales. Using a cross-lagged design, our Structural Equation Modeling findings suggested that experiencing peer problems contributed to lower executive function later in childhood and better executive function reduced the likelihood of experiencing peer problems later in childhood and middle adolescence, although these relations weakened as a child moves into adolescence. The results highlight that peer relationships are involved in the development of strengths and deficits in executive function and vice versa.

Integrated oral, mental and sexual health management for adolescents: a call for professional collaboration

BACKGROUND

Globally, young people account for 15.5% of the total global disability-adjusted life-years burden for all age groups. They face mental health, nutritional problems, accidental and intentional injuries, sexual and reproductive health problems, and substance abuse. These health challenges have effects on their oral health. This paper discusses the oral health problems adolescents face and suggests approaches for providing integrated oral and general health care for adolescents.

DISCUSSION

Oral health issues linked with adolescent health concerns include: malocclusion and esthetic concerns linked with mental health status; oral and maxillofacial injuries linked with accidental and intentional injuries; oral manifestations of sexually transmitted infections; oral leukoplakia and oral cancers linked with alcohol, tobacco and psychoactive substance abuse; and oral manifestations of anemia resulting from nutritional problems. Training oral health care providers on adolescent health and care could promote prompt diagnosis, management and prevention of complications associated with major health challenges affecting adolescents.

CONCLUSION

Adolescent oral health care needs focused attention: as a possible route for early diagnosis and management of general health problems and for promoting adolescent oral health care. Oral health care should be integrated into adolescent friendly services and oral health care providers should learn how to handle adolescents' health needs.

Reforming the age of criminal responsibility

This article discusses the age at which criminal responsibility should begin and whether there is still a need for the rebuttable presumption of doli incapax. It clarifies the various meanings given to the concept of the age of criminal responsibility and considers its importance. Some common law countries have moved away from the traditional position of a minimum age level of 7 years and a rebuttable presumption of doli incapax from 7 years until 14 years. In doing so, there has been a tendency to raise the minimum age of criminal responsibility to 12 years and abolish the rebuttable presumption of doli incapax. After analysising these changes, the article argues that there is still a place for this presumption unless and until the minimum age of criminal responsibility is raised to the level preferred by the United Nations Committee on the Right of the Child.