Student Essay Prize

What impact can chronic illness have on adolescent development and how can adolescent development effect chronic illness?

Chronic illness is defined by the Centres for Disease Control and Prevention (CDC) as conditions that broadly last one year or longer, which significantly limits activities of daily living and often necessitates ongoing medical care. In this essay, the main focus will be on the most common adolescent chronic illnesses listed by NICE: type 1 diabetes mellitus (T1DM), asthma, cancer, epilepsy, and mental health disorders. However, it is acknowledged that this does not truly represent the entire spectrum of chronic illnesses experienced in adolescence.

Adolescent development, defined as the period of time in which a young person experiences puberty (Christie & Viner, 2005), can be broadly envisaged using the biopsychosocial model (Engel, 1981). In which, adolescent growth encompasses not just biological changes necessary for sexual maturity, but also changes in mental health, general wellbeing, and social interactions for the developing young person.

Biological effects

Biologically, literature suggests that the most common effect of chronic illness on adolescence is growth restriction and pubertal abnormalities (Suris et al., 2004). This is particularly seen in conditions that encourage chronic inflammation and/or significant periods of malnutrition such as inflammatory bowel disease (Ballinger et al., 2003) and chronic endocrine disorders, including type 1 diabetes mellitus (T1DM) (Codner et al., 2020). In T1DM, puberty can be either prolonged, delayed or have an earlier onset (Codner et al., 2020). These changes in the timing of puberty are associated with a plethora of different complications in adolescence, including but not limited to: smaller height gain (Rocha et al., 2014), delayed menarche and thelarche (Bizzarri et al., 2018). This paradoxical picture of observed early or delayed pubertal onset is attributed to the fluctuating levels of insulin in T1DM due to the disease itself and its management strategies. Insulin contributes to the secretion of gonadotrophin-releasing hormone (GnRH) via neuroregulation (Burcelin et al., 2003). Therefore, absolute insulin deficiency seen in T1DM creates an environment of hypoinsulinemia which suppresses androgenic hormones that facilitate puberty, causing a delay; whereas insulin injections that are used to rectify T1DM, promote hyperinsulinemia giving the reverse effect (Codner et al., 2020). Interestingly, increased growth hormone levels associated with adolescence may conversely contribute to insulin resistance (Moran et al., 2002), therefore in this case, adolescent development affects T1DM, the chronic illness.

Besides T1DM, asthma and cancer are interesting examples of how adolescence development can biologically modify the nature of chronic disease. Severe asthma can undergo resolution during adolescence for both males and females, due to the beneficial effect of increased androgen levels on the airway(Ross et al., 2020). For instance, there is evidence that the rise of dehydroepiandrosterone-sulfate(DHEA sulphate) in puberty can inhibit fibroblast proliferation(Mendoza-Milla et al., 2013) and inhibit smooth muscle contraction in the airways(Kouloumenta et al., 2006). Decreased airway inflammation is also associated with increased androgen levels in asthma models (Cephus et al., 2017). Nevertheless, this only occurs in a subset of asthmatic adolescents, particularly those who had peripheral eosinophilia, some adolescents’ asthma will remain unchanged or become worse through the adolescent period (Ross et al., 2020). Alternatively, the adolescent period may exacerbate some chronic conditions, for it is theorized that increased bone growth rate and therefore faster production of cells during puberty can predispose more cell dysregulation and predispose bone tumorigenesis in bone sarcomas, which is a common adolescent cancer (Meyers & Gorlick, 1997) (Grünewald et al., 2018).

As healthcare providers, acknowledging the unique challenges posed by long term illness and its management on the adolescent body; as well as how the adolescent body in turn affects the processes of chronic illness unlike in adult bodies is critical. Acknowledging these differences will allow for greater patient-centred care, and tailor clinical management that is appropriate for the adolescent patient. Furthermore, encouraging multi-disciplinary collaboration to support young people with chronic illness facilitates better understanding of their complex individual needs and allows for collaborative discussion to maximize professional-patient partnerships (Comacchio et al., 2018; Suris et al., 2004).

Psychological effects

Adolescents with chronic illnesses such as asthma report higher incidences of depression and anxiety, low self-esteem, and increased experience of somatic symptoms unlike their healthy peers (Forero et al., 2009). Chronic illness may also facilitate worse mental health outcomes in adolescents. Anorexia nervosa a mental health disorder which primarily affects adolescent and young women (Bordo, 2003), can be exacerbated by concurrently having T1DM. T1DM adolescents can skip their insulin injections to aid in weight loss and further enable their anorexia(Fairburn & Steel, 1980).

Moreover, mental health disorders are chronic illnesses. It is challenging to pinpoint why there is such a high incidence of these disorders observed in the adolescent cohort (Oldehinkel et al., 2011). Though, this most likely may be due to a complex interplay of both biological and environmental factors, including genetic predispositions, cognitive, behavioural, and hormonal changes as well as social pressures and changes (Suris et al., 2004). The occurrence of psychotic disorders and increased suicide risk may be amplified in adolescence due to greater impulsivity, and increased engagement of risk-taking behaviours such as smoking cannabis (Arseneault et al., 2004). Increased depressive symptoms, anxiety and low self-esteem may also be related to fluctuating neuroendocrine activity in puberty (Steiner et al., 2003). As depression is experienced more in female adolescents who have early menarche (Sisk & Zehr, 2005). Adherence to management regimes for chronic illness is also impacted by adolescent development. Gross remodelling of the brain occurs in adolescence (Sisk & Zehr, 2005); the development of abstract thinking, critical decision making, and future planning may in part be influenced by steroid hormone levels during puberty (Sisk & Zehr, 2005). Consequently, the cognitive maturation process of adolescents may influence adherence.

Psychologically, healthcare providers should offer early psychological and/or wellbeing support to adolescents. This could be in the form of providing appropriate hotlines and in-hospital services leaflets to increase accessibility and exposure of mental health services. In particular, cognitive behavioural therapy and motivational interviewing could be encouraged to increase adherence to medication and treatment regimens (Manber et al., 2011).

Social effects

Adolescents with epilepsy, especially those who had more frequent seizures that were of higher severity and neurotoxicity, reported poorer health-related quality of life outcomes in both social and academic domains (Devinsky et al., 1999; Riechmann et al., 2019). These results observed in adolescents with epilepsy, as well as in adolescents with other chronic illness (Wolman et al., 1994), are due in part to a number of social reasons. For instance, parents/guardians of these adolescents may report experiencing more incidences of stress and depression, which may lead to poorer family interactions (Chen et al., 2018). Secondly, peer relationships may also suffer, adolescents with chronic disease may experience greater isolation, exclusion from peer group interactions, and may have a harder time relating to their healthy peers because of the nature of their chronic diseases (Tolley et al., 2020). Frequent hospital visits and sick days may also reduce a young person’s ability to attend school, resulting in poorer academic performance and thus, less future vocational opportunities and financial independence. Chronic illness may additionally impact the development of self-image in adolescence, being very symptomatic or having a noticeable medical intervention resulting in scarring may increase the prevalence of lower self-esteem issues and body dysmorphia in this cohort (Wolman et al., 1994). Finally, provisions for adolescents with chronic illness are generally poor (Carlson & Elvins, 2021). In general, most healthcare services only cater for either children or adults, the adolescent period is unique and does not quite fit into either of these two categories. Therefore, adolescents often end up displaced in hospitals and are accessing services that they deem as either too childish or too mature (Carlson & Elvins, 2021). Nevertheless, these are broad generalizations of what social challenges adolescents with chronic illness may face. Some families may be more resilient and/or have better knowledge and support in assisting their adolescents’ needs (Suris et al., 2004). Similarly, adolescents with T1DM often report having excellent peer friendships, are well-adjusted in school and receive appropriate hospital care (Suris et al., 2004). For the most part, the majority of adolescents with chronic conditions will fall somewhere in the middle of these two social extremes.

Overall, every social domain may be affected by chronic illness in adolescents. Healthcare workers can support adolescents by providing more appropriate social services. For instance, hospitals can aim to provide more adolescent-only social spaces such as an in-hospital wellbeing room or common area specifically for adolescents (Eaton et al., 2015). Family therapy should be offered more regularly to parents/guardians of adolescents and peer support groups for both adolescents and their carers should be highly recommended and encouraged to avoid isolation (Law et al., 2019; Tolley et al., 2020). Greater access to appropriate services such as higher education, career, and employability counselling and advice services may prove helpful for adolescents as well (Carlson & Elvins, 2021). Finally, healthcare providers should utilize social media more often. This may reduce the spread of misinformation and may provide a more accessible platform for adolescents to communicate with their healthcare providers, especially in the age of covid where in-person communications may prove difficult (Rideout & Fox, 2018).

In conclusion, adolescent development and chronic conditions can affect young people in all biopsychosocial domains, consequently healthcare providers should take an inclusive approach and aim to address all of these domains as well. ^[1]

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Guidance and Regulations

1. Eligibility

1.1 The competition is open to all those currently enrolled at a UK Medical School at the time of submission.

1.1.1 Entrants must detail their medical school and course year in their submission email.

1.2 Entries are invited one of the following essay titles:

· What impact can chronic illness have on adolescent development and how can adolescent development effect chronic illness? (1500 words)

· Case study: the patient that changed my outlook on adolescent healthcare. (1500 words)

· What are the advantages and disadvantages of digital healthcare for adolescents? (1500 words)

2. Essay submission

2.1 Candidates must nominate themselves for entry by submitting a short essay on the specified topic to the judging panel.

2.2 Entries must be made to the following email address: yphsigstudent@gmail.com

2.3 Only essays that are submitted via email, in Word format to the published email address will be accepted.

2.4 Entries in PDF format will not be accepted

2.5 The deadline for submission is 23.59 GMT on Monday 31 January 2022. Submissions after this time will not be accepted.

2.6 Essays must be up to 1500 words. Entries over the word limit will not be accepted.

2.6.1 The word limit does not include the title or references.

2.6.2 References should be presented as footnotes and endnotes; references presented in alternative formats may be considered to be part of the limit.

3. Judges and judging criteria

3.1 Essays will marked by both senior members of YPHSIG and the YPHSIG student representatives.

3.2 The panel will mark essays against the following criteria:

Style of writing

Punctuation, spelling and grammar

Content/understanding

Originality

3.3 It is the entrant’s responsibility to ensure submission has been received by YPHSIG. The student representatives will email to confirm receipt of applications within 5 working days of submission.

3.4 The judge’s decision is final.

4. The Prize

4.1 The 1^st place winner will receive a prize of £100 and free entry to the Royal College of Paediatrics and Child Health (RCPCH) Annual Conference (28^th-30^th June 2022) in Liverpool. The winner will receive a certificate during the YPHSIG organised session at the conference. The winning essay will be published on the YPHSIG website.

4.1.1 The conference ticket itself is non-redeemable or exchangeable with no cash alternative. Individuals are expected to cover the cost of their own travel and accommodation during the conference.

4.2 The winners of 2^nd and 3^rd place will each receive a prize of £25 and a certificate by post.

Updated 23/11/21