Growth and Development

Growth and Development

د.رائد كريم العكيلي
General Objective:
By the end of this lecture, the student will be able to discuss growth and development of children.
Specific Objectives:
By the end of these lectures, the student will be able to:
Identify the importance of growth and development.
Define growth and development.
Mention the principles of growth and development.
List factors affecting growth and development.
Mention types of growth and development.
Identify the stages of development.
Growth and development
growth : is the physical increase in body size and appearance caused by increasing size and numbers of cells (e.g. human being started from a single cell to 3.5 kg at birth).
Development : progressive increase in capacity to learn and think and gain various skills and functions it continue throughout life.
Maturation: completed growth and development.
Stages of development:-
Embryonic stage (prenatal period):- from conception to birth.
Infancy stage: - from birth to the end of the 1st year.
-Newborn period (from birth to 28 days of age).
- Infancy period (from 28 days to 1 year of age).
Early childhood: - from 1-6 years of age.
- Toddlers: - from 1-3 years of age.
- Preschool: - from 3-6 years of age.
Middle childhood (school age):- from 6-11 years of age.
Adolescent stage: - 11-20 years of age. - Early adolescent 11-14 years.
- Middle adolescent 14-17 years.
- Late adolescent 17-20 years.
Adulthood stage: - from 20-60 years of age.
Elderly stage: - > 60 years.


Factors affecting growth and development
Prenatal :
Maternal illness , infection , or malnutrition .
Maternal exposure to toxins, teratogens, alcohol , illicit drugs , anticonvulsants , antineoplastics , or anticoagulants .
Decreased fetal movements
Intrauterine growth retardation
Family history of deafness , blindness , or mental retardation
Chromosomal abnormalities .

Perinatal :

Asphyxia : Apgar scores of 0 3 at min .
Prematurely , low birthweight .
Abnormal presentation .
Postnatal :
Meningits , encephalitis
Seizure disorder
Hyperbilirubinemia : bilirubin > 25 mg / dL in full-term infant
Severe chronic illness
Child abuse and neglect
- Genetic
- Nutritional .


Principles of Growth & Development
Continuous process
Predictable Sequence
Don’t progress at the same rate (↑ periods of GR in early childhood and adolescents & ↓ periods of GR in middle childhood)
Not all body parts grow in the same rate at the same time.
Each child grows in his/her own unique way.
Each stage of G&D is affected by the preceding types of development.

Assessment of growth and development according to the age :

Infant : using measurement length , weight , head circumference .
Supplemented by : Observation of nutritional state dentition , size and patency of fontanelles .
Older child : Measurements are : height , weight .
Supplemented by :
Measuring the length of the body segments such as :
Extremities span sitting height
Adolescence :
( 11 20 years ) , in addition to height , weight there are :
Assessment of sex maturity rate ( SMR ) .
Height velocity .
Skin fold thickness .
Body fat content ( especially in female ) .
Arm and leg circumference may be useful in estimation of male Mass .
A growth chart with predictable pattern or growth curves is used to plot and monitor a childs growth through the years. These growth chart allow for comparison between children of the same age and sex, also allow for comparison of the childs current measurements with the child previous measurements.
There are different types of growth charts (e.g. weight for age, height for age, head circumference for age, skin fold measurement, and mid-arm circumference). Each chart composed of 7 percentile curves representing distribution of weight, height, and head circumference at each age.
The term Percentile indicates the percentage of children at a given age on X axis whose measured value fall below the corresponding value on Y axis. 50th percentile is the median of values and below which 50% of the observed values fall, also is termed standard value.
Standard growth charts are used to determine if the childs pattern is appropriate or if for some reasons the childs growth is above or below a standardized normal range.


New born
Weight : average about 3.5 kg.
Length : average about 50 cm . ( 45 55 cm ) .
Head circumference : average about 35 cm . ( 33 37 cm ) .

The midpoint of stature of the newborn infant is near the level of the umbilicus , whereas in the adult it is at the symphysis pubis .
The posture of the new born infant tends to be partial flexion .
The respiratory rate for adequate gas exchange , which is the priority at birth , ranges from 35 to 50 breaths / min . The normal heart rate ranges from 120 160 beats / min . Transient murmurs are common .
The first stool ( meconium ) are generally passed within 24 hr . on the 3rd 4th day when milk feedings are established , transitional greenish brown stools that may contain milk curds occur. The typical brown stool occurs after a further 3 4 day interval . Stools relate to the frequency and amount of feeding : usually there are 3 5 stools / day by the end of the 1st wk . On a particular day in the 1st wk , stools may range from 0 to 8 / day , particularly with breastfeeding.
The temperature of mother and infant are virtually the same at birth. The infant's temperature usually falls transiently and is restored by 18 hr . The caloric requirement for normal temperature and activity is about 55 kcal / kg / 24 hr . By the end of the 1st wk total caloric needs are 110 kcal / kg / 24 hr
The extra-cellular fluid compartment constitutes 35% of the newborn's body weight . During the first few days of life there is a loss of fluid that usually averages 6 10 % of body weight . Excessive loss and poor intake may lead to fever and dehydration .
Glomerular filtration rate ( GFR ) and urine output are low during the first days of life but increase rapidly in the first few weeks . During the 1st wk , proteinuria is common and the urine may contain urates , which may stain the diaper pink .
The newborn infant's hemoglobin ( Hb ) ranges from 17 to 19 g/dL ( 30 % is Hb A and the rest HbF ). Leukocytes are about 10.000 mm3 at birth and increase during the first 24hr , with a relative neutrophilia . WBC counts of 25.00 35.00 may occur. After the 1st wk, the total white blood cell count is usually below 14.000 and characterized by the relative lymphocytosis of infancy and early childhood . Establishment of normal hemostatic depends on acquisition of normal intestinal flora and production of vitamin K .
Maternal hormones transferred by the placenta may produce transient enlargement of the breasts and genital secretions .
The gamma globulin level (IgG ) of the newborn is similar to that of the mother and protects against many viral and some bacterial infections . Maternal immunoglobulins IgM , IgA , and IgE , however do not cross the placenta in significant amounts . IgM may be formed by the fetus in response to in utero infection .
Pattern of development
* Cephalic Caudal .
( reaching , grasping , transferring , manipulating ) .
* Proximal distal .
( use thumb to pork , explore objects )
Thumb opposition fine pincer grasp


Primitive reflexes

Present at birth , assess the functional integrity of the brain stem and basal ganglia .

Any asymmetry or absence of primitive reflexes may indicate a significant CNS abnormality and requires further evaluation .
Any delay in the expected disappearance of the reflexes may requires an evaluation of the CNS .

The 1st Year

Most full-term infants regain their birthweight by the age of 10 days . Infants regain or exceed birthweight by 2 wk of age and should grow at approximately 30g/day during the 1st mo. This is the period of fastest postnatal growth.
The full term infants generally doubles birthweight by 4-5 mo, and triples it by 1 year. The premature infant is likely to gain about 6-7 kg in the 1st yr, which is about the average gain for full-term infants.
There is an increase in subcutaneous tissue in the early months of life reaches its peak at about 9 mo .
The length of the normal infant increases during the 1st yr by 25 30 cm.
The anterior fontanel may increase in size after birth but generally diminishes after 6 mo and may become effectively closed between 9 and 18 mo .
The posterior fontanel is usually closed to palpation by 4 mo .

Formulas for Approximate Average Height and Weight of Normal Infants and Children :

WeightKilogramsAt birth
3 12 mo

1 – 6 yr

7 – 12 yr

3.25

age ( mo ) + 9
ـــــــــــــــــــــــــــــــــــ
2

age ( yr ) x 2 + 8

age ( yr ) x 7 – 5
ــــــــــــــــــــــــــــــــــــ
2

Height

Centimeters

At birth

At 1 yr
At 4 yr
At 2 – 12 yr
50
75
100cm
age ( yr ) x 6 + 77

Head circumference ( normally 34 35 cm at birth ) increases to approximately 44 cm by 6 mo and to 47 cm by 1 yr (2cm/mo. in 1st 3 mo. , 1cm/mo. in 2nd 3 mo. and 0.5cm/mo. in the next 6 mo.) . The head circumference is slightly larger than that of the chest at birth , but the two measurements become equal by the end of the first year .
The first deciduous teeth erupt in most children between 5 and 9 mo . The first to appear are the lower central incisors , followed by the upper central and then the upper lateral incisors . By the age of 1 yr most children have 6 8 teeth .
First 3 months of Life
By 12 wk there is some control of the head as the infant is drawn to a sitting position . When held in ventral suspension, the newborn infant will be in a posture of flexion of head and extremities around the supporting hand .
By 1 mo of age the infant will raise the head momentarily to the plane of the body , and by 2 mo he or she will start to sustain the head in that plane . By 3 mo the head will be raise above the plane of the body , and the legs will be extended as well .
In the first days of life infants visually fixate best on those objects that are placed close to or moved through their line of vision . They may maintain fixation with movement of the eyes and head to nearly 90 degrees to either side of the midline . By 2 mo of age a supine infant will be follow an object presented 90 degrees from the midline through an arc of 180 degrees . A fully developed social smile becomes manifest usually between 4-6 wk of age . The infant who does not have a social smile by the age of 8 12 wk should be regarded as possibly seriously .


3 6 Months :
By the age of 3 mo an infant in the prone position on a firm surface is generally able to raise the head and chest with the arms extended . When the infant of 4 mo is pulled from a supine to a sitting position , the head is brought up without lag ; At 5 6 mo of age the infant begins to roll over , at first from the prone to the supine position and then in the reverse direction .
By 4 mo the infant becomes more adept at making contact with objects brought within reach and often brings them to the midline and to the mouth for visual and oral exploration . By 6 6 1/2 mo most infants can grasp a large object such as a rattle and transfer it from hand to hand . By 4 mo they begin to laugh aloud at pleasurable social contacts . By the end of the 6th mo normal infants have developed clear preferences for social contact with the persons giving them the most care . Total sleep requirements are approximately 14-16 hr/24 hr, with about 9-10 hr concentrated at night and 2 naps/day.

6 12 Months :

The ability to sit unsupported (6-7 mo), and by 8 9 mo they are able to assume a sitting position without help . By 9 10 mo most infants have learned to creep or to crawl. They are often able at 8-9 mo to stand steadily for a short time as long as their hands are held , and by 9 mo may be able to take some steps with both hands held .
Between 6 and 9 mo the radial palmar grasp becomes clearly . The index finger is used to poke at objects by 9 mo . And at this time the thumb and forefinger can be brought into sufficiently accurate apposition to permit a pellet to be picked up with a pincer motion . At 9 mo an infant may be able to release an object on request . At 9 mo the infant can wave bye-bye.
By 12 mo , the pincer will be executed without ulnar support . Between 6 and 12 mo the infant's behavior becomes more imitative . A major milestone is the achievement at about 9 mo of object permanence (constancy), the understanding that objects continue to exist, even when not seen. At 12 mo a child may enter into very simple games with a toy such as a ball
developmental milestones ( table below )

AgeGross motor Vision / fine motorHearing / speech Personality / social 6 wks Symmetrical limb movements .
Ventral-head in line with body briefly .
Supine-fencing posture.Fixed and follows to 90 .
Turns to light .
Grasp reflexes . Cries / Coos
Startles to noise . Smiles

3 months Moves limbs vigorously .

Head control.
Back-lumber curvature only .
Prone-lifts upper chest up . Fixes and follows to 180 .
Plays with own hands .
Holds rattles placed in hands .Quietens to mother's voice .
Turns to sound . Laughs and squeals . 6 months Sits with support .
Lifts chest up on extended arms .
Rolls frond to back .
Downward parachute .Palmar grasp .
Transfers objects .
Shakes rattle .
Mouths objects . Turns to quiet sound .
Says vowels and syllables . Laughs and screams .
Not shy . 9 months Tripod sits-rights self if pushed and can reach for toy steadily .
Rolls to standing .
Stands holding on .
Forward parachute . Reaches for small objects .
Rolls balls .
Points with index finger .
Early pincer grasp
Looks for fallen objects .
Releases toys .Distraction hearing test .
Says mama , dada (non-specifically) Chews biscuit .
Stranger anxiety .
Play peek-a-boo .
Understands no and bye-bye . 12 months .Cruises around furniture .
Walks if held , may take few steps unsupported . Neat pincer grip .
Casting objects .
Banges cubs together . Known name .
Understands simple commands .
Says few words . Drink from a cup .
Finger-feeds .
Waver bye-bye .
Find hidden objects . 15 months Broad-based gait .
Kneels .
Pushes wheeled toy . Sees small objects .
Tower of 2 bricks .
To and fro scribble . 2 6 words .
communicates wishes and obeys commands . uses cup and spoon . 18 months steady purposeful walk .
Runs , squats .
Walks carrying toy .
Pushes / pulls .
Creeps downstairs . Circular scribble points to pictures in book .
Turns pages of book .
Hand preference . 6 20 words Points to named body parts .
Feeds independently .
Domestic mimickry .
Symbolic plays alone .
Takes off socks and shoes 2 years Kicks balls .
Walks up and down stairs holding on . Tower of 6 bricks .
Copies vertical line . 2 3 word sentences .
Uses pivotal grammar .
Uses question words . Feeds with fork and spoon .
Begins toilet training .
Temper tantrums .3 years Walks up stairs 1 foot per step , down with 2 .
Walks on tip-toe .
Throws ball .
Pedals tricycle . Tower of 9 bricks .
Builds train and bridge with bricks .
Copies circle . Gives first and last name .
Knows sex .
Recognizes colours .
Pure tone audiometry . Washes hands and brushes teeth .
Eats with fork and spoon ( + / -knife ) .
Make believe play .
Likes hearing and telling stories . 4 years Walks up and down stairs 1 foot per step .
Hops .Builds steps of bricks .
Copies cross .
Draws man . Counts to 10 or more . Able to undress . 5 years Skips .
Catches ball .
Runs on toes . Copies triangle . Asks how and when .
Uses grammatical speech . Uses knife and fork .
Able to put on clothes and do large buttons . 


The infants is able to make repetitive vowel sounds by 6 1/2 mo and by 8 mo is likely to produce repetitive consonant sounds , such as ba-ba , ma-ma , and da-da . Children of 8-9 mo become attentive to the sounds of their own names . Separation anxiety between the ages of 6 and 8 mo.





The 2nd Year

During the 2nd yr of life there is a further deceleration in the rate of growth: the average child gains about 2.5 kg and about 12 cm. After 10 mo of age there is often a decrease in appetite extending into the 2nd yr. The result is a loss of some of the subcutaneous tissue. With the upright posture the mild lordosis and protuberant abdomen appear that are characteristic of the 2nd and 3rd yr of life.
The growth of the brain continues its deceleration during the 2nd yr. Head circumference, which increased approximately 12 cm during the 1st yr, increases only 2 cm during the 2nd yr. During the 2nd yr more teeth erupt, making a total of 14 16. By 12 mo infants are generally able to walk a few steps alone. By 18 mo the infant is able to run stiffly. At 18 mo the infant can climb stairs of one hand is held; by 20 mo he or she is able to go downstairs, one hand held.
By 24 mo children normally enter the "runabout" age. They are able to move quickly from a safe environment into danger and need constant surveillance. At 15 mo generally be able to put the pellet into a small bottle by 18 mo is able dump it from the bottle.
By 15 mo the child is able to put a 1 in cube on top of another in response to a demonstration; by 18 mo be or she is able to make a tower of four cubes and by 24 mo a tower of seven cubes. Vertical lines at 18 mo; by 24-30 mo the child imitates circular strokes and can make a horizontal line.
During the 2nd yr the child develops a sense of self as separate from other person. The child normally has 10 words by 18 mo with the result that most normal children by their second birthday are able to put three words together. During the 2nd yr imitative behavior extends to person other than the mother, including siblings. By 18 24 mo most children are able to verbalize their toilet.
Preschool Years:
During the 3rd, 4th and 5th yr of life gains in weight and height are relatively steady at approximately 2.0 kg and about 6-8 cm / per y. Most children are lean in comparison with their earlier body configuration. The healthy preschooler is slender and agile, with an upright posture. The lordosis and protuberant abdomen of late infancy tend to disappear by the 4th yr. By 2 1/2 yr the deciduous teeth have usually erupted. Major development occurs in the area of fine motor coordination. The preschooler is an inquisitive learner and absorbs new concepts like a sponge absorbs water.
Myelinazation of the spinal cord allows for bowel and bladder control to be complete in most children by age of 3 years. The number of alveoli continues to increase, reaching the adult number at about 7 years of age.
Alternation of feet in ascending stairs by 3 yr and alternation in descending stairs by 4 yr. By 3 yr most children can stand for a short period on one foot; by 5 yr they are generally able to hop on foot and soon to skip. They can kick ball forward.
 18 mo 20 mo 2.5 y 3 y 4 y 5 y 6 y
 |
By the age 3 yr the child can respond to the request to draw a person. The first figures consist of a circular head with arms and legs attached as sticks. During the next years the child adds the trunk. Draw persons with 2-4 parts in 4 years, and at least 6 parts in 5 years.
The child in intuitive phase can count 10 or more objects, correctly name at least four colors, and better understand the concept of time, and he knows about things that used in everyday life, such as money, appliance, and foods.
During the 3rd yr the child puts short sentences together to sustain a brief conversation. Vocabulary at 3 years comprises about 900 words. The preschool child may acquire as many as 10-20 new words/ day and at age 5 usually has 2,100 words. They start to develops fluency.
By 3 yr most children can state their ages and whether they are boys or girls. During the 3rd yr of life children more increasingly into play activities in which other are involved, at first in parallel play (doing the same thing) rather than in reciprocating actions or exchanges.
Early school years:
The early school years are a period of relatively steady growth ending in a preadolescent growth spurt by about the age of 10 yr in girls and about 12 yr in boys. In early school-age years, girls and boys are similar in height and weight and appear thinner and more graceful than previous years. In later school-age years, most girls begin to surpass boys in both height and weight (2-years difference).
The average gain in weight during these years is about 3 3.5 kg / yr, and in height about 6 cm / yr. The head circumference increasing from about 51 cm to 53 54 cm between the ages of 5 and 12 yr. At the end of this period the brain has reached adult size.
All 20 primary deciduous teeth are lost, replaced by 28 of 32 permanent teeth, with exception of the third molars. The 1st permanent teeth, the 1st molars, most often erupt during the 7th yr of life. The shedding of deciduous teeth begins; it follows the same sequence as occurred in their acquisition. The 2nd permanent molars commonly erupt by the 14th yr; the 3rd molar mayn't appear until early 20 s.
Girls generally have a greater bladder capacity than boys. The typical school-age child has 20/20 visual acuity. The school years are a time of vigorous physical activity.
Lymphatic tissues are at the peak of their development during these years. Respiratory infections are common during these years, the usual number of respiratory infections during the school years is high, as many as six to seven illnesses / yr.


Adolescence growth and development

Adolescence spans the years of transition childhood to adulthood (11-20 years). There is some overlap between late school age and adolescence. Diet, exercise, and hereditary factors influence the height, weight, and body build of adolescent.
The secretion of estrogen in girls and testosterone in boys stimulate the development of breast tissue in girls, pubic hair in both sexes, and changes in male genitalia. These biological changes that occur during adolescence are known as puberty. Puberty is the result of triggers among environment, the CNS, the hypothalamus, the pituitary gland, the gonads, and the adrenal gland. Generally girls enter puberty earlier (9-10 years) than boys (10-11 years).
Neurons not increase in number, but growth of myelin sheath enables faster neural processing. The ossification of the skeletal system is incomplete until late adolescence in boys. Ossification is more advanced in girls and occurs at an earlier age.
The most important organizing process is the development of sexual maturity. It is reasonable to define early, middle and late adolescence in terms of stage of pubertal development; the stages are defined by the development of primary and secondary sex characteristics (pubic hair and breasts in females, genitalia and pubic hair in males).
The sex maturity ratings (SMRs, Tanner stages) are:
Classification of sex Maturity Stages in Girls:
SMR stagePublic hairBreasts1Preadolescent Preadolescent 2Sparse, lightly pigmented, straight, medial border of labia.Breast and papilla elevated as small mound; areolar diameter increased. 3Darker, beginning to curl, increased amount.Breast and areola enlarged no contour separation. 4Coarse, curly, abundant but amount less than in adult. Areola and papilla form secondary mound. 5Adult feminine triangle, spread to medial surface of thighs. Mature ; nipple projects , areola part of general breast contour 

Classification of Sex maturity Stages in Boy:

SMR StagePublic hairPenisTestes1None Preadolescent Preadolescent 2Scanty , long , slightly pigmented Slight enlargement Enlarged scrotum, pink texture altered.3Darker, starts to curl, small amount. Longer Larger. 4Resembles adult type, but less in quantity; coarse, curly. Larger, glans and breadth increase in size. Larger , scrotum dark 5Adult distribution , spread to medial surface of thighs Adult size Adult size 
Early adolescence
It is the first stage of puberty (SMR 2) which normally ranges in age of onset from 10.5 to 14 yr in boys and from 10 to 13 yr in girl and lasts from 0.5 to 2 yr in boys and from 0.2 to 1.2 yr in girls. The earliest stage of puberty (SMR2) is initiated by sleep-augmented pulsatile secretion of pituitary gonadotropins and growth hormone. During the early stages, gains in weight and height approximating 2.0 kg and 6 8 cm each year.
In females, an increase in body fat content. Males become more muscular, rather than fatter. In females breast development result from stimulation by ovarian estrogens that are secreted in response to follicle stimulating hormone (FSH). The predominant effect of FSH is to stimulate growth of the ovaries, beginning during late SMR 1, approximately 1 yr before the stage breast budding (SMR2). In males SMR2 consists of enlargement of the testes owing to an increase in the size of seminiferous tubules and in the number of Leydig and Sertoli cells; secretion of testosterone is responsible for enlargement of the epididymis seminal vesicles, and prostate.
Middle Adolescence
Middle adolescence refers to the period corresponding to SMR 3 and 4. There is at this acceleration in weight and linear growth as well as further development of secondary sex characteristics. The height velocity curve peaks, followed in approximately 6 mos by the peak of the weight velocity curve. During this phase the bulk of fat tissue is deposited in females and that of muscle mass in males.
Females average an increment in height of 8 cm / yr at a mean age of 12 yr; the later growth spurt of males (at a mean age of 14 yr) average 10 cm / yr. There is an orderly pattern of progression of skeletal growth from the distal to proximal parts of the body, beginning with growth of the feet. This is followed a proximately 6 mo later by growth of the calf and then the thigh. A similar pattern occurs in the upper extremity.
Elongation of the trunk and an increase in the anteroposterior diameter of the chest are the last manifestations of the pubertal growth. In middle adolescence development of secondary sex characteristics involves enlargement of the female breast and areola.
In the male enlargement of the penis begins shortly thereafter; it remains thinner in proportion to its length until later puberty, the penis elongates and widens, the testes enlarge, and the scrotum becomes more pigmented. Some breast development (gynecomastia) occurs also in 30 50% of males during the pubertal period.
In addition to secretion of testosterone in males, increased concentrations of adrenal androgens occur in both sexes and are responsible for initiation of growth of pubic and axillary hair. Ejaculation occurs approximately 1 yr following the onset of testicular growth at the time of appearance of pubic hair. Pubic hair darkens, coarsens, curls, and extends proximally and laterally to cover the mons (SMR 3 and 4).
Other effects of ovarian estrogen production include thickening of the vaginal mucosa, increased pigmentation, slight enlargement of the clitoris, as well as enlargement of the uterus. The most dramatic event of puberty for the female is menarche; it occurs at a mean age of 12.5 yr in the United States. It occurs at SMR 3 in 20% SMR 4 in 60%, and SMR 5 in 10% of girls. The timing of menarche is closely related to the peak of the weight velocity curve and is determined by a number of factors, the most important of which are genetic, other factors such as nutritional status, and any chronic illness. Height in girls increases after menarche and usually ceases 2-2.5 years after menarche.
Axillary and facial hair appears at about the time pubic hair reaches SMR 4. In males facial hair first appears at the corners of the upper lip and spreads medially. As an individual moves from SMR 3 to SMR 4, there is a decrease in sleep latency time and an increase in daytime sleepiness.
Late Adolescence
It is during this phase of development that the body approximates its young adult proportions and size. Little additional linear growth is achieved after the growth spurt of middle adolescence. Remaining epiphyses, such as those of the femur, humerus and sternoclavicular junction, become fused, sometimes as late the early 20s. Development of secondary sex characteristics is completed (SMR 5) with spread of public hair to the medial aspects of the thighs in both sexes.
In the male, facial hair spread to the chin, and chest hair appears as the last event in the progression of hair growth. The deepening of the voice is completed as testosterone stimulates growth of the thyroid and cricoid cartilages and of the laryngeal muscles.
The needs of adolescent:
Emancipation from his family and parents.
Integration of the personality.
A decision about the vocation as adult.
Creation of satisfactory relation with the opposite sex.
Acceptance of a new body image after the rapid physical changes in this period.
The problems:
Acne vulgaris.
Anemia and fatigue.
Psychological problems (depression, insomnia, anxiety).
Nutritional problems (obesity, anorexia).
Masturbation and nocturnal emission.
Menstruation problems (amenorrhea, dysmenorrheal).
Neurosis and psychosis.
Accident (cars, drowning, fire arms, and weapons).









PAGE 

PAGE 18