Reading Time: 8 minutesIt’s often said that the older your child gets, the more they need your love and attention. Dr Sarah Borwein of Central Health explains how to care for the tween who is rapidly becoming a teenager.
It might feel like only yesterday that you were running between doctors’ appointments for vaccinations, developmental checks and those endless runny noses and coughs. Now that your child is a pre-teen, those visits are probably fewer and farther between. But, from the ages of nine to 12 years, it’s particularly important that your child has regular health checks and that their vaccinations are up to date. With the teenage years just around the corner, it’s also important that hormonal and emotional changes relating to puberty and issues around drugs and alcohol are discussed. This will help set the foundation for open communication between you and your child in the years ahead.
The last few years in Hong Kong have been challenging times for both parents and teens. Starting with the protests of 2019 and then the COVID-19 pandemic since early 2020, life as we know it has been turned upside down. While the virus itself poses lower risk to children and teens than adults, they are nonetheless greatly affected by the school closures, social distancing and travel restrictions. The stress, fear, isolation and uncertainty can exact a heavy toll on young people. As parents, we need to be aware of the signs of stress in our children and be prepared to support them and help build resilience through these difficult times. We can do this by recognising their feelings and answering their questions honestly, modelling how to manage emotions and encouraging healthy diet and lifestyle. This is often more easily said than done!
Signs of Stress in Older Children and Adolescents
- Mood changes, such as irritability, hopelessness, or rage
- Increased conflicts with family and friends
- Social withdrawal
- Loss of interest in activities previously enjoyed
- Insomnia OR wanting to sleep all the time
- Changes in appetite, including both loss of appetite and increased appetite
- Drop in academic effort
- Lack of personal hygiene
- Increased risk-taking behaviours
- Thoughts about suicide and death
If you are concerned about your child’s mood or behaviour changes, or your own responses, please make an appointment to discuss with your family doctor. Help is available.
Instil Healthy Habits
The best help you can give your child in setting them up for a happy life is to encourage them to live healthily from a young age. Encourage your child to participate in 60 minutes of physical activity every day. They don’t need to do the whole hour at once; it can be split throughout the day. Encourage a balanced diet with limited fat and sugar intake. Ideally, your child should eat five portions of fruits and vegetables a day. Try to limit your child’s salt intake – there is a lot of hidden salt in snacks, so check the labels. A normal, healthy diet should provide all the vitamins and minerals your child requires, but check with your doctor if you feel that your child needs vitamin supplements. It is particularly important to ensure that girls have enough iron in their diet, as their requirements will increase when their periods start.
• Red meat
• Dark, leafy greens
• Dried fruit (prunes, raisins)
• Iron-enriched cereals and grains (check the labels)
• Beans, lentils and chickpeas
Vitamin D is not found in high concentrations in dietary sources; instead, it’s produced by the body in response to UVB radiation in sunlight. Vitamin D is needed for calcium absorption, which is particularly relevant for pre-teens whose bones are growing rapidly. Children who spend most of their time indoors or wearing high SPF sunscreen may miss out. Just 15 to 20 minutes of sunlight on the bare face and arms on a clear day in Hong Kong will be sufficient. When that’s not possible, talk to your doctor about a supplement.
You may notice that as your child grows and enters puberty, their appetite grows with them. This is normal, but remember to watch that their diet remains balanced. Unfortunately this isn’t always easy, and many teenagers are now overweight. We know that this can lead to serious health problems such as Type II diabetes and heart disease later in life. At the other extreme, anorexia may be a worry for parents with pre-teen and teenage children. If you’re at all concerned about your child’s weight or eating habits, please make an appointment to discuss it with your doctor.
Possible Signs of Anorexia
- Weight loss
- Fear of gaining weight
- Refusal to eat
- Denial of hunger
- Constant exercising
- Sensitivity to cold temperatures
- Absent or irregular periods
- Loss of scalp hair
- Distorted body image
- Loss of interest in friends and hobbies
- Tiredness or fainting
Tackle Teen Issues Head-On
Many tween and teen health issues can be tackled with early and frank discussions between you and your child.
Drugs and alcohol
Alcohol can be a positive and enjoyable part of our lives, but drinking too young can lead to long-term health problems and can put young people in risky situations. Top medical experts recommend that children avoid drinking any alcohol at all before they are 15. It’s important for you to set a positive example, and to explain the risks associated with alcohol to your pre-teen, so that they can make decisions responsibly in a few years’ time.
Hong Kong is very safe compared with other cities around the world, but this can be deceptive for young teens who have little experience of dealing with the risks and dangers faced in other countries. Traffic, crime or simply getting lost in an unfamiliar place can all be alarming for children and frightening for parents. Prepare your pre-teen for their growing independence over the next few years by agreeing to expanding boundaries and allowing them to try new experiences one step at a time.
In recent years, an additional concern has been added. Parents may worry about their child’s involvement in political activities and how this may impact their current safety and their future. This is a difficult and highly personal subject. It is important to keep the lines of communication open and maintain a non-judgmental dialogue with your child about their feelings and your own concerns.
Puberty and Sex
One of the big issues on parents’ minds as their children reach the teenage years is how to talk about puberty and sex. Most experts agree that it’s best to start early and be open. You may find it useful to share a book with your child, which can form the basis for discussion. There are also many books available to prepare parents for questions their child may have, and you can shop around for an approach you feel comfortable with. Growing Up: It’s a Girl Thing by Mavis Jukes is a good book to buy for your daughter and then discuss with her afterwards. For boys, the same author has written The Guy Book: An Owner’s Manual. Or, you might try The Body Book for Boys by Rebecca Paley, Grace Norwich and Jonathan Mar.
The teen years are a period of intense growth for your child, not only physically, but emotionally and intellectually, too. It’s understandable that these years can also be a time of confusion and upheaval for many families.
Reminding yourself of the physical changes your child will experience during puberty will help you navigate them through any anxieties they might have.
In girls, puberty can begin as early as six or seven years, but most often starts at around 11. In boys, puberty typically begins at around age 12, but may start as early as nine. As you might recall from your own adolescence, puberty is a process that goes on for several years. Most girls are physically mature by about age 14, whereas boys typically mature at about 15 or 16.
In girls, breasts will usually develop first. Then hair will start growing in the pubic area and the armpits. Some girls may experience acne as well. Menstruation (the period) usually happens last.
In boys, the testicles and penis usually get bigger first. Then hair will grow in the pubic area, armpits and face. The voice will become deeper, and they may experience acne.
COVID vaccination is recommended from age 12. By early 2022, it may become a recommendation for younger children as well. In Hong Kong, only the BioNTech vaccine is approved for this age group. There has been a great deal of misinformation circulating on social media, so be sure to consult reliable sources if you have questions. Millions of doses of COVID vaccine have been administered globally to teenagers and it is known to be both highly effective and very safe. It is also likely to be necessary for getting back to any semblance of a normal life. While it is important to understand and recognise potential side effects, such as inflammation of the heart, it is equally important to remember that these side effects are much rarer than side effects of COVID infection, even for healthy teens. In other words, the risk benefit assessment is heavily in favour of vaccination for most teens. Don’t hesitate to discuss with your doctor if you have concerns.
At around 11 to 12 years, your child will require a booster vaccination for diphtheria, tetanus, pertussis and polio, following on from the doses they had in infancy and early childhood. They may also need a hepatitis B booster. These are essential to give the immune system a “reminder” and ensure life-long protection. Without boosters, immunity to these diseases often wanes, leaving many people susceptible as they enter adolescence and young adulthood. This has been a particular problem with pertussis (whooping cough), which for this reason is now included with the adolescent tetanus booster.
Another vaccine that is strongly recommended for girls from nine years onwards is the human papilloma virus (HPV) vaccine, to protect against cervical cancer. This vaccine, known as Gardasil-9, is now included in the Hong Kong Childhood Immunisation Programme (HKCIP) and is offered to all girls in Primary Five and Primary Six (or equivalent grade). Boys can also be vaccinated against HPV and in many countries it is becoming routine to do so. While men are less likely than women to suffer adverse effects of HPV infection, it can lead to genital warts and certain kinds of cancer. Vaccinating boys also contributes to herd protection that may ultimately eradicate HPV-associated cancers. Australia, which vaccinates both boys and girls against HPV, is on track to eliminate cervical cancer in this way.
It is also worth considering the meningococcal vaccine. This is especially relevant if your child will be attending school or university outside Hong Kong, for example in Europe and North America, where meningococcal meningitis is relatively common. You should know that vaccines given elsewhere may not cover strains that are prevalent in China, and from which your child should also be protected. Australia and many European countries only vaccinate against meningitis C, whereas the A strain is also found in Asia. The best option may be the Menactra or Nimenrix vaccine, both of which provide long-lasting immunity against meningitis A, C W and Y strains. This vaccine is a requirement for attendance at most US universities. Meningitis A, C W and Y strains are responsible for two-thirds of outbreaks; the other one third are caused by Type B meningitis, for which there is now a separate vaccine (Bexsero or Trumemba). Type B Meningitis was responsible for some well-publicised outbreaks in US universities a few years ago, and as a result this vaccine is increasingly recommended.
If your child has not had chickenpox or a chickenpox vaccine by the age of ten, this vaccine is strongly recommended. While chickenpox is most often a mild disease in early childhood, it can be severe for teenagers and adults. Two doses, at least four weeks apart, are required.
You may also wish to talk to your doctor about recently introduced vaccines, which your child may have missed out on when they were younger, such as the pneumococcal vaccine to protect against bacteria that can cause pneumonia and meningitis.
Don’t forget additional travel vaccinations if your child is going away on a school trip. These may include rabies and Japanese encephalitis vaccines, which are essential for travel to much of Asia, and yellow fever vaccine for Africa and South America. Hepatitis A (if your child hasn’t already been vaccinated) and typhoid vaccines are again necessary for travel to most parts of Asia and for many other parts of the world. Requirements vary significantly, so remember to visit your paediatrician or family doctor for advice on vaccinations, anti-malarials and other preventative measures such as mosquito nets and first aid kits. If your child has any problems when they return, make your doctor aware of their recent travel as well as the symptoms they’re experiencing.
As your child grows older, they will become more independent in managing their own health problems. They may already carry their own asthma inhaler or epi-pen for allergies. Regular visits to the doctor will allow the parent, child and doctor to discuss any concerns or issues that may become increasingly important in adolescence. It might be helpful for your child to have some time to speak to the doctor in private, allowing them to build a relationship that will help them deal with sensitive issues in future years. If they have been seeing a paediatrician, you might also wish to discuss the best time to make the transition to a family doctor. It is also important to know, though sometimes difficult for parents to accept, that as a child matures through adolescence, they are entitled to a growing amount of confidentiality in their relationship with their doctor.
There are many helpful books and websites that address parents’ concerns and answer questions that pre-teens might have. Again, your doctor will be happy to point you in the right direction. Finally, don’t forget to enjoy sharing the new experiences that are around the corner as your child grows into a healthy and mature young adult!
Dr Sarah Borwein is a General Practitioner at Central Health Medical Practice.