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Turner syndrome TSalthough considered a rare disease, is the most common sex chromosome abnormality in women, with an incident of 1 in female births. TS is characterized by distinctive physical features such as short stature, ovarian dysgenesis, an increased risk for heart and renal defects as well as a specific cognitive and psychosocial phenotype.

Given the complexity of the condition, patients face manifold difficulties which increase over the lifespan. Furthermore, failures during the transitional phase to adult care result in moderate health outcomes and decreased quality of life. Guidelines on the optimal screening procedures and medical treatment are easy to find.

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However, recommendations for the Woman seeking hot sex Turner of the incriminating psychosocial aspects in TS are scarce. In this work, we first reviewed the literature on the cognitive and psychosocial development of girls with TS compared with normal development, from disclosure to young adulthood, and then introduce a psychosocial approach to counseling and treating patients with TS, including recommendations for age-appropriate psychological diagnostics. With this work, we aim to facilitate the integration of emphasized psychosocial care in state-of-the-art treatment for girls and women with TS.

Turner syndrome TS is caused by structural anomalies in or complete loss of the X-chromosome 45X. Although a rare disease with an incidence of 1 in female births, it is nevertheless the most common sex chromosome abnormality of human females.

TS is characterized by short stature and ovarian dysgenesis, together with a broad range of other phenotypic characteristics, including an increased risk for heart and renal defects 12. Clinicians treating girls with TS are challenged with many endocrine, genetic, cardiovascular, developmental, reproductive and psychosocial issues.

Medical care of girls with TS in child-centered healthcare systems is therefore highly specialized 3456. Reviews of medical care in TS that propose clinical guidelines and recommendations occasionally also mention psychosocial issues 3478but these are no more than footnotes compared with the medical discourse 9 Patients with TS have to cope with many difficulties; they not only need life-long medical surveillance but also psychological care and treatment for a good outcome 6. Symptoms emerge slowly. During the early infancy, affected girls show no psychological developmental differences from their unaffected counterparts.

As they grow older their phenotypical, psychosocial and intellectual development is seen to more clearly diverge from that of their normally developing peers.

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The typical TS-specific cognitive profile is characterized by strengths in verbal skills 11 and relatively weak performance in arithmetic, visuospatial processing and executive functioning In addition, girls with TS have frequently been found to have difficulty in encoding social cues and behaving appropriately in social situations Some cognitive and psychosocial TS phenotypes such as deficits in mathematical abilities 14 and impaired social interaction 13 persist throughout the adult life.

Early diagnosis and treatment of comorbidities is known to enhance the medical state of adult patients with TS Experienced clinicians have discussed inclusion of psychological testing and routinely screening of girls with TS for developmental progress, but evidence-based are rare Consequently, intervention guidelines for the psychosocial aspects of TS are scarce To our knowledge, no evaluated and documented standardized best practice model is available to provide psychological support for girls and women with TS. Transition, when adolescents move within the healthcare system from a pediatric protective and authoritative environment to an adult one that demands healthcare autonomy and a degree of independence and responsibility, is a difficult stage.

Individual readiness for the process varies and cannot be assumed to be naturally completed by the age of 18 years We have developed recommendations towards a psychological and psychosocial approach to improve the care for girls with TS.

Our recommendations importantly include supportive interventions encompassing the family system and caregivers. Our overall aim is to empower patients with TS to keep up with their peers at school and in their working life, and to improve their self-esteem and thus their quality of life QoL. Table 1 gives a summary of the relevant background information, recommendations and psychological tests.

Counseling and treating girls with TS is complicated because although the karyotype differences may affect the phenotype of TS, the karyotype is not a distinct predictor of the physical or psychological phenotypical outcome Consequently, in TS we must acknowledge normal and healthy development while being attuned to the possible impairments.

We thus compare the development in TS with the expected norms of development 2021 and describe areas of potential impairment as well as possible interventions including psychological screening and testing. Clinical abnormalities upon which a diagnoses of TS can be made arise from prenatal life until adulthood 4 These include suspicious findings of cystic Woman seeking hot sex Turner, increased nucheal translucency in fetal ultrasound, lymphedema on hands and feet and cardiac malformations at birth, short stature during childhood, delayed puberty combined with short stature at adolescence and even premature ovarian failure during adulthood.

The questions from advice-seeking parents and patients who will require explanation can cover a wide range, from life-deciding aspects of prenatal counseling to short stature and infertility. In all situations, merely explaining that the girl has a chromosomal disorder responsible for a complex combination of multisystem symptoms of unpredictable severity is insufficient to meet many questions raised when a decision is made to investigate the karyotype. Given the complexity of a Woman seeking hot sex Turner diagnosis and treatment, the diagnosis needs to be clearly communicated to the parents from the beginning, and to the child having regard to her age and developmental stage.

Furthermore, honesty about the condition within the family is essential.

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Pediatricians should offer assistance to overstrained parents in disclosing the condition to their daughters in an age-appropriate manner. Providing written Woman seeking hot sex Turner on the most important issues of TS to facilitate digesting the diagnosis over a period of time might be worthy of consideration The clinician charged with disclosing the diagnosis should be familiar with all aspects of TS.

Experienced pediatric endocrinologists specialized in growth disorders should be involved in order to inform about the option of growth hormone GH therapy. Accordingly, we advocate incorporating family counseling through a multidisciplinary care team immediately on disclosure of the diagnosis 7 At transition, starting at the age of 11—13 years, the clinician should repeat information about medical and health issues that were disclosed to the parents directly to the girl.

Standardized documentation sheets are available for this purpose The parents might also need counseling support to counteract both the feeling of guilt, which has been reported in well-educated mothers of girls with TS 28and the risk of poorer adjustment of parents reported in lower socio-economic classes Awareness of the psychological and psychosocial issues in TS is as important as the knowledge of treatment options. Importantly, information on the aspects of cognitive development should not instill fear of mental disability but stress the variability and strengths of cognitive development in TS see below.

Furthermore, information about self-help groups, support groups and specialist literature may be helpful. A divergence from normal psychosocial development is unobservable during infancy in girls with TS However, height and weight typically drops below that of age-matched normal developing girls 31often causing parental concern.

Furthermore, even where there is no obvious aberration parents are anxious to receive advice on how best to nurture the. TS-specific growth charts 36 are useful for monitoring expected growth and weight gain and relieve mothers of guilt feelings. Screening by using the Bayley scale 38 is strongly recommended as soon as delayed development is suspected.

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The difference in height compared with age-mates becomes obvious in early childhood. However, there is no evidence of any difference in development between girls with TS and their age mates regarding basic achievements such as controlling body functions, playing and operating with simple cognitive concepts. Albeit, reduced attention spans and a preference for playing with younger children have been observed in girls with TS, which might be due to the specific cognitive phenotype in TS described in detail in the paragraph childhood, age 6—12 years that is more obvious at a later age and includes attention deficits, hyperactivity and poorer social competence 1239 If short stature of a girl with TS is reported to become an issue within the family, both the psychosocial and auxological aspects should be considered.

The benefit of an early start of GH therapy for catch-up-growth aimed at the lower normal range or even normal range 16 should be weighed against the possible strain from daily injections. As there are no data about a benefit from an early start on final height, the authors are reluctant to start GH therapy before the age of 4 years in their clinic. Figures 1 and 2 give brief information on the psychological tests recommended. Citation: Endocrine Connections 6, 4; Occupational therapy 4748 may be helpful when delays or disorders in the psychosocial development of a girl become apparent at this early age.

Occupational therapists should give training to patients with TS to improve their sensory processing, promote functional and coping skills as well as advising and encouraging parents to adopt beneficial strategies. Physically, girls with TS grow slower and attain shorter height than their normally developing counterparts 47provoking comments from age mates and adults. Studies describe TS-related impairment of motor abilities including fine motor skills, endurance in physical activities and body balance Furthermore, deficits in visuospatial processing, visual memory and visual attention become obvious between the ages of 6 and 12 years 12135354 Girls with TS are also at a higher risk for Woman seeking hot sex Turner conditions such as attention-deficit hyperactivity disorder 5657 These setbacks lead to problems at school Psychosocial problems also become obvious at this age.

Poorer social skills have consistently been described as affecting all aspects of social behavior and functioning 1356 The girls tend to have fewer close friends, spend less time with peers and appear emotionally less mature than age-matched normally developing girls. Building up friendships and maintaining relationships are difficult for them and parents report that their daughters with TS as less socially competent than their peers This is the very latest point at which specialists in growth disorders should be involved to ensure parents receive state-of-the-art recommendations based on the latest findings in GH therapy also taking QoL outcomes into.

Considering possible motor deficits also in adult age 61we recommend encouraging girls with TS to undertake physical activities such as dancing, walking, swimming, hiking, biking, etc. Furthermore, the way a girl interacts with peers provides information about age-appropriate social development. Social skills intervention groups might help the patient if she has problems Woman seeking hot sex Turner along with peers or is socially isolated.

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Delayed puberty or the absence of pubertal development is the main medical and psychosocial issue during the phase of adolescent age and will lead to intensified medical care 34. Additionally, during adolescence girls with TS increasingly fall behind in normal cognitive development. Tasks such as abstract reasoning, clustering and the use of metacognition are likely to become a challenge.

Difficulties in mastering social cognitive tasks are especially evident when multiple cognitive domains are required These findings correlate with deficits reported in other areas of cognition where executive functioning is involved 4066 Limitations in working memory and slower response times indicate deficits in executive functioning that commonly result in weak planning, self-organization and self-regulation performances 121339405366 Verbal skills, however, are relatively strong in girls with TS, with normal to above average scores generally reported Recent studies indicate a possible specific TS profile in language use abilities with increased vocabulary, initial verbal memory, reading comprehension and understanding of rarely used words.

Sometimes reported slow responding and weak performances in verbal fluency tasks are less related to linguistic skills but rather reflect underlying deficits in executive functioning 6970 Adolescent girls with TS tend to have more difficulties than their age-matched peers to emancipate from their families, which might be due to increased anxiety, hyperactivity, impulsivity 72 or traits seen on the autism spectrum 557374 However, girls with TS differ in an important respect from patients with autism: they do desire social interaction Romantic love and sexual relationships Woman seeking hot sex Turner yet another sensitive topic emerging at this age 29 Young girls with TS experience primary amenorrhea and impaired psychosexual development despite their female gender identification.

Often, their first sexual experiences are delayed and subsequent experiences infrequent Moreover, limited sexual experience is associated with lower self-esteem 29 The need for estrogen substitution to promote feminization is the central topic in the pediatric-endocrine setting at the end of the childhood stage or at the latest during early adolescence. Full information about the biological background of ovarian insufficiency in TS should be given again to the parents and in an age-appropriate manner to the girl.

Intensive exploration of cognitive and psychosocial development is essential. Early intervention in school matters such as contacting and involving supportive teachers may be of great help.

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Equally important are questions concerning romantic feelings, sexuality and fertility. As parents often have difficulties broaching these sensitive topics, healthcare professionals need to address them and provide in-depth information.

Many difficulties and poor medical care of adult women with TS during the transition process have been reported 18 The chances for a successful transition are decreased in some chronic conditions, including TS, because it is difficult to find experts in adult care Young women with TS are furthermore seldom fully aware of their conditions 82 ,

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Care of girls and women with Turner syndrome: beyond growth and hormones