In most developed countries, young people aged between 10 and 20 years account for 13% to15% of the population, with increased representation among the ethnic minorities (10). The latter is of particular relevance in the multicultural populations of these countries and of major relevance in the sociocultural context of adolescent health.
The epidemiology of adolescent rheumatology has not been widely reported: other chronic illnesses are more frequently discussed in generic adolescent literature. However, musculoskeletal symptomatology is the third most common presentation among teenagers in primary care in the United Kingdom (11), and adolescent arthritis or rheumatism (lasting six months or
Table 1 Definitions of Adolescence
World Health Organization 10-19 years (2)
World Health Organization (Youth) 15-24 years (2)
American Academy of Pediatrics 14-19 years (3) U.K. National Service Framework for Children, up to 19 years (4)
Young People, and Maternity Services
European Union (Youth) 15-25 years (5)
more) affects 7 per 1000 of adolescents (age 12-19 years), as reported in a nationally representative survey exploring the health status and behaviors of Canadians (12). In addition, 30 per 1000 adolescents unaffected by arthritis or rheumatism, reported chronic back problems (12). Furthermore, greater effects on measures of mental health, health services uses, school, work, and home activities of affected individuals (12- to 19-year-olds) compared with individuals without chronic disease or with other chronic disease have been reported (12). The burden of illness is not limited to adolescence either. Minden et al. reported considerable estimated 12-month costs into adulthood, although these differ among the various JIA subgroups (13).
The epidemiology of adolescent rheumatology cannot be considered in isolation. It is also important to reflect upon the predictors of adult disease identified during this developmental stage. In a study of 668 premenopausal women aged 18 to 35 years, menarche at age 15, physical inactivity as an adolescent, and low body weight were identified as independent predictors of low bone mass (14). Pain reports in childhood and early adolescence have been reported to be associated with the report of pain in early adulthood, supporting the need for effective pain management during adolescence (15). Of relevance to rheumatologists is the fact that the majority of childhood pain is musculoskeletal in origin (16). Of concern, a cost-of-illness to U.K. Society of Adolescent Chronic Pain discussed later in Chapter 9 has been estimated at approximately £3840 million in one year (17).
In addition to the reported associated morbidities of childhood-onset rheumatic disease into adulthood (18-27); (see also Chapters 6-12), health-risk behaviors adopted in adolescence track into adult life, with the antecedents of adult ill-health easily recognizable during adolescence (e.g., mental health, diet, exercise, cardiovascular risk, smoking, and injury). If such challenges are going to be effectively addressed, rheumatology professionals must learn to "think outside the health box," acknowledging that every health care encounter with an adolescent is a potential health-promotion opportunity, particularly in view of the pattern of health care utilization among adolescents (28). Adolescent behaviors have implications for health, many of which are directly relevant to the management of chronic rheumatic conditions, such as contraception for young people on teratogenic medication and alcohol use in young people on methotrexate (29).
Self-management patterns are also set down in adolescence, e.g., health care utilization, chronic disease self-management (see below), and therefore have potential implications for adult health. The importance of these adolescent antecedents to adult health and ill-health were echoed in a ground-breaking document about adolescent health from the professional colleges in the United Kingdom, which stated that "health services must pay greater attention to the special needs of young people if they wish to improve the emotional, psychological and physical health of the population" (6). There are no exemptions for rheumatology.
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