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PE6.1-12 | Adolescent Health — PBL Case

CLINICAL SETTING

Adolescent Friendly Health Clinic (AFHC), Government Medical College and Hospital, Tier-2 city in Maharashtra. A Thursday afternoon. The AFHC counsellor, trained under RKSK, has arranged the consultation room to be private and non-clinical in appearance. A 14-year-old girl, Priya, arrives alone — her mother waited outside at the counsellor's suggestion. Priya is dressed neatly but looks tired and avoids eye contact.

Trigger 1: Opening Presentation

Priya, 14 years, Class 9 student, presents to the AFHC at her school health coordinator's suggestion after she was found crying in the school bathroom twice in the past week. She reluctantly tells the counsellor: 'I don't eat much at school, but then I eat a lot at home at night — and then I feel terrible about it. I have been doing this for about 3–4 months.' She denies vomiting or laxative use. She weighs 38 kg; her height is 152 cm (BMI 16.4 kg/m²). She appears thin. Her periods started at 13 years and have been irregular — she has had only 2 cycles in the past 6 months. She says: 'I know I need to eat more, but I just can't. I'm scared of getting fat.'

DISCUSSION POINTS

  • What is Priya's BMI, and how should it be classified using IAP growth charts for her age and sex?
  • What are the key features in this history that suggest an eating disorder? How do you differentiate between Anorexia Nervosa and Bulimia Nervosa based on the DSM-5 criteria?
  • What is the significance of menstrual irregularity in the context of a low BMI in an adolescent girl?
  • Which domains of the HEEADSSS framework remain unexplored at this point, and what questions would you ask next?
Click to reveal Trigger 2: Physical Examination and Psychosocial Disclosure (discuss previous trigger first!)

Trigger 2: Physical Examination and Psychosocial Disclosure

Vital signs: BP 92/60 mmHg, HR 56/min, temperature 36.2°C. Physical examination: Tanner Stage 3 breasts, Tanner Stage 3 pubic hair; lanugo hair on forearms and back; cold extremities; no parotid swelling, no Russell's sign, no dental erosions. Laboratory: Hb 9.6 g/dL; serum potassium 3.2 mEq/L; serum albumin 3.0 g/dL; TSH normal; blood glucose 72 mg/dL (4.0 mmol/L). ECG shows sinus bradycardia with HR 54/min; QTc 448 ms. When the counsellor sensitively asks about feelings, Priya discloses: 'Sometimes I think everyone would be better off without me. I've thought about hurting myself but I've never done anything.' She then says: 'My uncle — my father's brother — he has been touching me inappropriately for the past year. I have never told anyone. Please don't tell my parents — they won't believe me, and it will destroy the family.'

DISCUSSION POINTS

  • How do you interpret the ECG findings (bradycardia, QTc 448 ms) and low serum potassium in the context of this clinical presentation? What is the immediate management priority?
  • How do you classify Priya's nutritional status using the WHO/IAP SAM criteria and which specific parameter is most relevant to her management plan?
  • Priya has expressed passive suicidal ideation. Using the Columbia Suicide Severity Rating Scale (C-SSRS) framework, how do you stratify her risk and what are the immediate management steps?
  • Priya has disclosed ongoing sexual abuse by a family member and explicitly requested confidentiality. How does the POCSO Act 2012 apply here? What are the physician's obligations, and how should this be communicated to Priya in a trauma-informed way?
Click to reveal Trigger 3: Family Meeting and Programme Referral (discuss previous trigger first!)

Trigger 3: Family Meeting and Programme Referral

After Priya gives assent, the paediatrician arranges a family meeting with her mother (father is not available). Priya's mother breaks down: 'She has been so withdrawn. I thought it was just teenage drama.' The paediatrician discloses the medical concern (low weight, anaemia, bradycardia, electrolyte abnormality) without initially revealing the abuse disclosure (police process is being activated simultaneously through the SJPU as per POCSO mandate). The mother asks: 'What about her eating? Is it serious?' The team discusses admitting Priya for medical stabilisation. The AFHC counsellor arranges a referral under the RKSK mental health component and contacts the Child Welfare Committee (CWC).

DISCUSSION POINTS

  • What criteria for hospital admission apply in Anorexia Nervosa in adolescents? Does Priya meet any of these criteria?
  • How do you manage refeeding in a malnourished adolescent — what is the refeeding syndrome and how is it prevented?
  • What RKSK thematic areas and AFHC services are relevant to Priya's management? Who are the members of the multidisciplinary team involved in her care?
  • How should the team handle the intersection of the eating disorder treatment and the POCSO mandatory reporting process — particularly managing Priya's trust while fulfilling legal obligations?
Click to reveal Trigger 4: Six-Week Follow-Up (discuss previous trigger first!)

Trigger 4: Six-Week Follow-Up

Priya was admitted for 8 days for medical stabilisation, nasogastric feeding (with refeeding protocol), and electrolyte correction. She is now back at the AFHC for follow-up. Her weight has increased to 41 kg (BMI 17.7 kg/m²). HR is 68/min; QTc is normalised at 418 ms; potassium is 3.8 mEq/L. She has been seeing a child psychologist for cognitive-behavioural therapy (CBT). The SJPU has filed a case and Priya has given a recorded statement. She is visibly more engaged, though still quiet. She says: 'I have started having one proper meal at school. I feel a little better.' She asks the counsellor: 'Will this be on my school records?'

DISCUSSION POINTS

  • What are the evidence-based psychological therapies for Anorexia Nervosa in adolescents? How does Family-Based Treatment (Maudsley Approach) differ from individual CBT?
  • How do you address Priya's concern about confidentiality regarding her school records? What information (if any) is shared with the school, and under what conditions?
  • What are the markers of recovery in adolescent Anorexia Nervosa that you would monitor at follow-up visits? At what point would you consider discharge from specialist care?
  • Reflecting on this case, what systemic barriers at the school and community level contributed to a delay in Priya reaching appropriate care, and what advocacy steps could a paediatrician take?

Group Task Assignments

Group 1: Collaborative Task

Group 2: Collaborative Task

Group 3: Collaborative Task

Learning Issues

Research these questions and bring your findings to the discussion.

  1. [PE6.1] How is adolescence defined and staged (WHO stages, age boundaries, developmental characteristics of each stage)?
  2. [PE6.2] What are the Tanner/SMR stages for breast, pubic hair, and male genital development? What is the clinical significance of discordant staging?
  3. [PE6.5] What are the DSM-5 diagnostic criteria for Anorexia Nervosa (Restricting Type), Bulimia Nervosa, and Binge Eating Disorder? How do they differ in weight, compensation, and prognosis?
  4. [PE6.6] How do you screen for adolescent depression and suicidal ideation using the PHQ-A and C-SSRS? What are the risk factors for adolescent suicide, and how does the Mental Healthcare Act 2017 apply?
  5. [PE6.7] What are the ethical and legal limits of confidentiality in adolescent health care? Under what circumstances is breach of confidentiality mandatory (POCSO 2012)?
  6. [PE6.8] How is the HEEADSSS framework structured and applied in a clinical adolescent health assessment? What examination findings (Tanner staging, growth assessment, thyroid, breast exam) are part of the routine adolescent check-up?
  7. [PE6.9] What are the six thematic areas of RKSK (2014) and the functions of Adolescent Friendly Health Clinics (AFHC)? What are the referral criteria from an AFHC?
  8. [PE6.11] What is the burden of NCD risk (metabolic syndrome, T2DM, PCOS, cardiovascular disease) in Indian adolescents, and why does obesity in adolescence demand early clinical intervention?
  9. [PE6.12] What is the prevalence and impact of sexual abuse in adolescents and children in India? What are the POCSO Act 2012 provisions for mandatory reporting, and what are the clinical and legal steps after disclosure?