Larry N. Scherzer
From a developmental perspective, adolescence is a time of dynamic changes, with tremendous physical, sexual, psychologic, and intellectual growth. This chapter describes the normal changes and the major problems associated with each of these four spheres of development, and delineates practical approaches to the office care of the adolescent patient.
Adolescent Mortality and Morbidity
Adolescence should be the healthiest period of life; morbidity and mortality rates are low as compared to other age groups, but the absolute number of adolescents who die or have chronic illnesses is considerable. Because the number of productive years at stake for a teenager with a significant illness is large, adolescent health is a special priority.
Mortality among adolescents ages 15 years to 19 years has improved from 97.9 deaths/100,000 in 1980 to 66.9 deaths/100,000 in 2001. Whereas the mortality rate among white and Hispanic teens has improved, the mortality rate among black teens has worsened. Most of the improvement in adolescent mortality is a result of a lower rate of deaths from motor vehicle accidents; most of the worsening of adolescent mortality is a result of a higher rate of deaths from firearms (1).
Accidents are by far the leading cause of death among adolescents and young adults. The victims of accidental death usually have bypassed preventive measures, and in many instances, behavioral problems underlie those deaths. For example, alcohol is implicated in >50% of automobile accidents, and there may be an element of suicidal intent in some of them.
The second and third leading causes of death in older adolescents (and an important problem in young adolescents) are homicide andsuicide, respectively, problems that are discussed later in this chapter.
The fourth leading cause of death among adolescents and young adults is neoplasia. The most common diagnoses are acute leukemia (both lymphocytic and myelogenous), lymphomas (including non-Hodgkin lymphoma and Hodgkin disease), central nervous system tumors (especially supratentorial and infratentorial gliomas), bone tumors (especially osteogenic sarcomas and Ewing sarcomas), and solid organ tumors (especially of genital organs).
As medical treatment improves, conditions that were previously fatal in childhood are frequently seen in adolescents and young adults. It is common for patients with cystic fibrosis, nephritis, congenital heart disease, and leukemia to survive into adolescence and young adulthood.
Most visits to a practitioner by adolescents are ostensibly for preventive care or minor problems (Table 11.1). However, a number of more severe medical problems are limited chiefly to the adolescent period or are problems of adulthood that begin during adolescence (Table 11.2). The data in Tables 11.1 and 11.2 do not depict the significant distress that many adolescent patients (and their physicians) experience. This distress is often related to the pressures unique to the several chronologic stages of adolescence.
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TABLE 11.1 Number of Office Visits Made by Adolescents and Percentage Distribution by the 15 Most Common Diagnoses (by ICD-9-CM Categories), According to Age: United States, 1985 |
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The young teen (11 to 15 years old), who typically has special concern over physical development, may have anxieties about mutilation and death. Hostility toward an illness may be expressed in a fantasy of invincibility, leading to an uncooperative noncompliant patient. Other young adolescents become greatly depressed by their illnesses and become annoying, complaining, whiny patients, often regressing to a childlike dependence on adult caretakers.
The middle adolescent (14 to 19 years old) who is seriously ill suffers from the loss of valued contact with friends and schools. Illness may interrupt important aspirations and shatter dreams. Body image is at a critical developmental stage in mid-adolescence, and the teen may be more worried about a cosmetic defect resulting from an illness than about the disease or its therapy. Such fears must be faced early and dealt with honestly.
The older adolescent (18 to 21 years old) shares many adult concerns. For example, the patient may express anxiety over the cost of an illness, the length of hospitalization, and the burdens these place on the family.
Physical Development
Normal Patterns and Concerns
Physical maturation is an important feature of the second decade of life. Although the rate and the timing of maturation may vary, they follow the hormonal changes of puberty in a given individual. A notable growth spurt occurs during the adolescent years, with a 20% to 25% increase in height over 2 to 3 years. This spurt usually occurs earlier in girls than in boys (as does sexual maturation). During puberty, there is an average twofold increase in both lean and
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nonlean body mass. The ratio of lean to nonlean body mass is greater in boys than in girls. Fat accumulation tends to be greatest when growth ceases and may extend into adulthood.
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TABLE 11.2 Selected Medical Problems Limited to Adolescence or Persisting into Adulthood |
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The musculoskeletal system has special characteristics during adolescence. To accommodate growth, the ligaments and tendons become lax and elastic, often giving the teen a slouched-over appearance. Similarly, there is an increase in skeletal growth, particularly in long bones, and metaphyseal–epiphyseal junctions remain soft. Thus, the actively growing teen, who may not have developed muscle mass to correspond to skeletal growth, may be prone to some special injuries, particularly joint dislocations and fractures along epiphyseal plates.
As with all areas of development, the adolescent may have particular concerns about growth and weight. The principal reason for this is that adolescents often base judgment of each other's adequacy and acceptability on size or (for boys) on athletic ability, and adult criteria of social status based on other standards (or prejudices) are less important.
Children called “squirt” or “runt” are given various types of parental advice, much of it unhelpful. Some children adapt by engaging in an activity in which height is unimportant (e.g., debating, chess, fencing, swimming, or bodybuilding). Occasionally, normal children with a familial basis for their short stature require psychological counseling to promote effective adaptation to their stature. Some teens who are very sensitive about height and strength limitations may try radical, potentially harmful solutions, such as self-injections of purported growth stimulants.
The concern of the adolescent about height may be generalized to many other aspects of appearance, including body habitus, beauty (or lack of beauty), and skin condition. It is important to recognize when concern about body image is the patient's primary concern and to provide reassurance that the patient is medically and biologically normal. The physician can promote such reassurance by suggesting books in which the adolescent can learn more about normal growth (see http://www.hopkinsbayview.org/PAMreferences).
Short Stature
Short stature is discussed under Short Stature and Delayed Sexual Maturation, below.
Obesity
A practical definition of obesity is a body mass index (BMI) at or above the 95th percentile of the 2000 Centers for Disease Control and Prevention BMI for Age Growth Charts (Fig. 11.1; additional information is available at http://www.cdc.gov/nccdphp/dnpa/bmi/bmi-for-age.htm). BMI is calculated as weight in kilograms divided by the square of height in meters. This ratio should be compared with the clinical appearance of the child because the fat distribution changes at puberty in boys, when extra weight may be transformed into musculature, and in girls, who normally increase their storage of fat. Adolescent obesity is usually caused by overeating. Most estimates place the prevalence of obesity between 10% and 20% of adolescents, with the highest frequency among lower socioeconomic groups. If teens ages 12 to 18 years are considered, the prevalence of obesity has risen from 4.7% in 1976–1980 to 16.2% in 1999–2002, with blacks estimated to have a prevalence of 23.2% (2). Obesity often begins in early childhood but becomes a concern in adolescence because of desires to conform to peer standards.
Obese teens should be screened for other cardiovascular risk factors, such as positive family history, high blood pressure, elevated serum cholesterol or triglycerides, and smoking. Grossly overweight teens should be screened for diabetes mellitus type II and hyperinsulinemia with a 2-hour glucose tolerance test with insulin levels. Young women who are obese and have significant acne and/or hirsutism may have polycystic ovary syndrome. A menstrual history, along with testosterone and dehydroepiandrosterone sulfate (DHEAS) blood tests, should be obtained (see Chapter 101). If multiple risk factors are present, the patient should be monitored more frequently and risk modification should be encouraged.
Obesity in adolescence will generally continue into adulthood and will be a risk factor for cardiovascular disease, type II diabetes mellitus, and earlier mortality. To treat adolescent obesity successfully, the teen must be motivated to accept the physician's assessments and recommendations. Often, the patient has attempted to cope with
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the problem by him- or herself. Certain fad diets, such as fasting and water diets, may yield rapid weight loss but will deplete the strength of the child. Generally, because no modification of long-term eating habits is attempted, the weight is regained on cessation of the diet. Occasionally, serious biologic complications are associated with prolonged adherence to highly restrictive diets. Macrobiotic diets are associated with symptoms of protein and vitamin deficiencies, and liquid protein diets have cardiotoxic effects that have resulted in deaths (see details in Chapter 83). Severely calorie-restricted diets lead to a cessation of linear growth and may cause menstrual irregularities.
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FIGURE 11.1. A: Physical growth in girls. B: Physical growth in boys. Plot height and weight against age at each encounter. The curve so obtained should parallel percentile lines within the clear area (growth patterns of 90% of children/adolescents). If the curve deviates from percentile lines, an abnormal growth pattern is likely. The upper series of curves represents the normal range of height at various ages and the lower series of curves, the normal range of weight at various ages. If obesity suggested, check BMI and graph against age on appropriate curve. (From National Center for Health Statistics. NCHS growth charts, 1976. Monthly vital statistics report. Vol. 25, no. 3, suppl. [HRA] 76-1120. Rockville, MD: Health Resources Administration, June 1976.) |
Medications are of no value in weight control. In particular, amphetamines and methamphetamines are contraindicated because of their potential for abuse. Surgical treatment (e.g., jejunoileal bypass or gastric stapling) of obesity is rarely indicated, particularly in the adolescent years.
One is left with methods of dietary control by modification of eating habits (smaller portions, food choices with lower fats and carbohydrates) and by increasing exercise, together with moderate calorie restriction. These methods, although successful for some, are not successful for all. Often, the teen who wants to diet is well motivated, if for personal and emotional reasons rather than for reasons of health. A group meeting of obese teens provides a nucleus of peer support, with an opportunity for mutual discussions of problems of dieting and appetite control that may not be aired in a brief office visit. Such a group may also help alleviate home pressures. Parental coercion and control of diet in the context of a normally antagonistic parent–teen relationship may result in an angry rebellious youngster who is gaining rather than losing weight.
For overweight young to mid-adolescents, a reasonable goal is to maintain their current body weight because excess caloric restriction may result in a loss of lean body weight. For the late adolescent, the goal may be weight
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loss. For all obese patients, one wishes to achieve a change in long-term eating patterns.
Some adolescents overeat because of unresolved psychological difficulties. If there are expressions of problems in peer, school, or parental relationships, these should be explored further. However, obesity alone is not an indication of psychopathology.
Anorexia Nervosa and Bulimia
Anorexia nervosa is serious disorder of growth in adolescents and adults. It is marked by voluntary suppression of appetite and loss of weight (at least 15% of the baseline weight) that is not attributable to a medical or psychiatric illness ordinarily associated with weight loss (i.e., inflammatory bowel disease or a major affective disorder). Patients characteristically exhibit an intense fear of becoming obese even when very thin and have a distorted body image, so they still consider themselves overweight (Table 11.3).
Anorexia nervosa is most commonly a disease of young adolescent girls (approximately 90% of cases), but it affects boys and older girls as well. Most often, the problem develops in children of upper-middle-class families. Before their illness, the patients typically are considered model children who do well in school and are obedient to their parents.
It would be wrong to consider anorexia and bulimia purely adolescent problems. These conditions extend into adulthood, and, indeed, anorexia is touted by some as a socially acceptable and fashionable lifestyle. Adults in professions where thinness is a professional requirement, such as athletes, actors, dancers, models, and TV personalities, are at special risk for eating disorders.
The cause of the disease is unknown. Although many theories have been proposed to explain it, none is entirely satisfactory. Often, there has been some stress in the family (divorce, death, change of location) before the onset of the illness.
No simple treatment can be recommended for patients with anorexia nervosa. Help should be sought from a psychiatrist who has experience with eating disorders. The best results seem to be achieved by involving the patient and the patient's family in an intensive program in which counseling and behavior modification are used to restructure the patient's eating habits and attitude toward food. Very ill patients should be hospitalized so that a proper program of nutrition can be instituted.
Complete remission of anorexia nervosa is unusual, but approximately 75% of patients achieve an acceptable
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improvement in both their physical and emotional states. The rest remain chronically undernourished and maladapted. With current treatment, mortality has been reduced to between 2% and 8% (3). Cause of death is equally attributable to overt suicide and medical complications of starvation. Poor prognosis is associated with long duration of illness, disturbed parent–child relationships, concomitant personality disorder, and the presence of vomiting (more common in bulimia). The degree of weight loss generally is unrelated to prognosis (4). The more persistent the behavior and the later in life these conditions are diagnosed and treated, the poorer the outcome in terms of maintaining a healthy weight. Adults who are grossly underweight have a mortality risk that is three times normal (3). Anorexic patients may have electrolyte deficiencies that can predispose to cardiac arrhythmia. With their obsession with excessive exercise, these patients dehydrate quickly.
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TABLE 11.3 DSM-IV Criteria for Diagnosing Eating Disorders |
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Bulimia is a second eating disorder seen in adolescents and young adults. Most bulimic patients are female; bulimic symptoms have been reported by up to 10% of young women interviewed in community surveys (5). Characteristically, patients with bulimia periodically gorge themselves, only to follow this by self-induced vomiting and by further self-reprisals through abstinence from food (Table 11.3). As the disease progresses, patients may become withdrawn and depressed, leading to further appetite suppression. Amenorrhea is common in these patients, and it may be the presenting complaint. Some patients have a history of both anorexia and bulimia. Treatment of a patient with severe bulimia requires the help of a professional skilled in the management of eating disorders. Self-help groups such as Overeaters Anonymous may play an important role in the patient's long-term handling of bulimia.
Sexual Development
Normal Patterns and Concerns
A major difference between the child and the adolescent is the development of the teen into a sexual being. The onset of puberty is associated with an intensification of sexual feelings and desires that lead to sexual exploration. With the liberalization of sexual mores in recent years, the problems of adolescent pregnancy and venereal diseases have grown to epidemic proportions.
The staging of physical sexual development of adolescents established by Tanner is a widely accepted method of following the physical changes of puberty (Tables 11.4 and 11.5 and Fig. 11.2). As the adolescent enters puberty, he or she also assumes a role as a sexual being who must
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begin to meet expectations of society, family, and peer group and who is pushed into sexual propriety and conformity. These expectations are transmitted to the teen by multiple messages that are often conveyed poorly, and many teens remain ignorant and insecure about sexual issues.
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TABLE 11.4 Typical Progression of Female Adolescent Sexual Development (see also Fig. 11.2) |
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TABLE 11.5 Typical Progression of Male Adolescent Sexual Development |
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Early adolescence is characterized by a bisexual period, in which close friendships are formed with members of the same sex but heterosexual attitudes develop. Young teens often develop best-buddy relationships. These relationships may even be physically intimate, but they are not considered characteristic of adult homosexuality. However, the teen (particularly male) may fear being a homosexual, and the frequent name-calling of this period (in which people are called “gay” or “queer” with little provocation) may be taken too seriously. Boys who have developed noticeable gynecomastia may be particularly confused about their sexual identity. Such boys need to be reassured of the normality of these concerns. Masturbation tends to be a frequent practice in this period, and there may be associated guilt that increases as the sex drive stimulates the teen to continue the practice. Again, where appropriate, problems associated with masturbation should be met with reassurance of its normality.
In mid to late adolescence, dating and heterosexual activities begin in earnest. By age 15 years, one in four girls and one in three boys has had sexual intercourse (6). Often, teens rush into sexual activity before they fully understand their own feelings about it. It is often part of the dating relationship—a prerequisite to communication, rather than vice versa. It may be part of thrill-seeking behavior for some teens, and others use it to escape from loneliness and depression.
Short Stature and Delayed Sexual Maturation
A common problem that comes to the attention of physicians is the teenager with short stature or delayed puberty. These two symptoms are often interrelated, and the medical investigation is similar, so they are discussed together. However, the presence of one does not necessarily indicate a problem with the other.
Most of these patients simply are at one end of the spectrum of normal development (7). Many teenage boys may not appreciate the fact that some people fall into the 10th percentile of a normal curve, and they may not accept a cursory dismissal of their concerns about size. Some may be helped by looking at normal growth curves that indicate the predicted ultimate height for people in their percentile (Fig. 11.1). Patients may need detailed discussion to comprehend fully and to cope with normal findings.
Assessment of short stature and delayed puberty by the generalist consists of the following steps:
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FIGURE 11.2. Diagrammatic representation of Tanner stages I to V of human breast maturation. (Adapted from Marshall WA, Tanner JM. Variations in pattern of pubertal changes in girls. Arch Dis Child 1969;44:291 .) |
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A physical examination is essential, including an accurate height and weight and Tanner stage assessment (Tables 11.4 and 11.5). If the testes are softening and show enlargement or if breast budding is present, there usually will be a normal sexual development. Unusual facies or ears, unusual hand creases, clinodactyly (deviation or deflection of the fingers), obesity, or delayed intellectual development may suggest a recognizable hereditary syndrome.
The initial laboratory investigation should include urinalysis; measurement of serum urea nitrogen, creatinine, and electrolytes; and radiographs of the hands and wrists to assess skeletal growth. More specific laboratory investigations may be suggested by the history and physical examination. Examples are thyroid enlargement (testing for hypothyroidism); normal physical examination and appearance but markedly short stature that is falling away from growth lines (testing for growth hormone deficiency); girls with delayed puberty, heights under the third percentile, associated with a short webbed neck, a systolic murmur, or widely spaced nipples (buccal smears performed to rule out Turner syndrome, i.e., X-O chromosomes); and striking pubertal delay without a history of similar delay in other family members (testing for gonadal failure including measurement of serum follicle-stimulating and luteinizing hormones, estradiol or testosterone, and urinary 17-ketosteroids and 17-hydroxysteroids; vaginal smear for maturation index and buccal smear for sex chromatin analysis or blood chromosome analysis).
Definitive diagnosis and planning for adolescents with suspected endocrine, metabolic, genetic, or psychological reasons for maturation delay require referral to an appropriate specialist. Families whose children have genetic disorders that affect growth and fertility will benefit from genetic counseling. The availability of biosynthetic growth hormone has raised possibilities for the management of teens with familial short stature. It is unclear whether growth hormone will increase the final adult height of normal children, although for some the rate of growth increases. Weighed against its questionable efficacy, growth hormone treatment is very expensive (often costing $5,000 to $10,000 per year).
Sexually Transmitted Disease
Sexually transmitted diseases (STDs) are epidemic in 15- to 19-year-olds. For example, more than 500,000 adolescents in the United States contract gonorrhea each
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year (6). The high frequency of STDs is partially caused by more casual attitudes toward sex and frequent changes of sex partners. Sex education programs have had little impact on the problem. Fear of infection apparently does not deter some teens, who seem irresponsible, impulsive, and emotionally insecure and who appear to have little respect for others. Often, parents fail to provide basic information about sex and the risks of infection and pregnancy that accompany it.
In most states, adolescents have a legal right to receive treatment for STDs without the parents’ knowledge; it is important to be receptive to the teen seeking treatment. Visits for treatment should also be used to explain the mechanism of acquiring venereal infection and to explain and encourage the use of condoms to prevent reinfection. The diagnosis and treatment of various STDs are discussed elsewhere in this book (see Chapters 37 and 102).
The high rates of sexual intercourse and adolescent pregnancy in the 1980s and 1990s raised concerns about acquisition of infection with the human immunodeficiency virus (HIV) in this age group. Given the long incubation period of HIV infection, data showing that 21% of all acquired immunodeficiency syndrome cases occur in people 20 to 25 years of age suggest strongly that adolescence is an important period of acquisition of HIV infection (9). Other data suggest that a frequent route of spread of the virus in adolescence is by heterosexual transmission, rather than intravenous drug abuse, blood products, or homosexual contacts. Furthermore, many cases of HIV infection in infants may be linked to maternal acquisition of the virus during adolescence. It is imperative that teenagers, especially sexually active teens, be counseled about high-risk behaviors that may expose them to HIV infection and about safe sex practices. This information and details about the ambulatory care of HIV-infected patients are described in Chapter 39.
Pregnancy
Each year in the United States, almost 1 million teenage women—10% of all women age 15 to 19 years and 19% of those who have had sexual intercourse—become pregnant, accounting for 13% of all U.S. births. Seventy-eight percent of teen pregnancies are unplanned, accounting for about one-fourth of all accidental pregnancies annually (6). More than half (56%) of the 905,000 teenage pregnancies in 1996 ended in births, and nearly 4 in 10 teen pregnancies (excluding those ending in miscarriages) were terminated by abortion (8). Many of these pregnancies are associated with serious medical risks for the mother and the fetus. Mothers younger than age 14 years have particularly high risks of toxemia, anemia, prematurity, infants with low birth weight, prolonged labor, and postpartum complications. Many of these problems can be prevented by good obstetric care, so that the first goal in adolescent pregnancy should be early diagnosis and entry into a comprehensive treatment program.
There are multiple social and behavioral reasons for the high number of teenage pregnancies. For many adolescents, pregnancy may be part of a maladaptive attempt to solve psychological issues, such as independence from a clinging mother or manipulation of a boyfriend. Such patients may have previously engaged in other maladaptive activities, such as drug abuse or delinquency. They may also be ignorant about methods and availability of birth control (see Chapter 100), including emergency contraception (see below).
The teenager herself may be ambivalent about her pregnancy. Often, the manipulations that led to the pregnancy (e.g., the promise of a prolonged relationship) did not succeed and the patient feels abandoned. Furthermore, the pregnancy may result in hostility from the family when the teenager is in greatest need of help from her parents.
Clearly, the teenager about to make important decisions about herself and her pregnancy needs counseling. It can be provided by her primary physician or, commonly, by a staff member of a counseling agency such as Planned Parenthood. In either case, the patient's primary physician should be aware of programs in the community, including public schools that accommodate the needs of teenagers who choose to have their babies, and should be available for any problems that a pregnant teenager may wish to discuss. In many states, adolescents have the right to treatment for pregnancy-related events, including abortion, without parental consent or knowledge. If the teenager decides to continue with the pregnancy, she should be prepared to assume a parenting role. Furthermore, she should be educated about future pregnancies and given medical assistance for the pediatric care needed for her infant. If possible, daycare, vocational, and educational services should be available for the mother so that she may continue her education after the birth of her child. As an integral part of counseling, a stable caring person should be identified (a parent, if possible) who can assist the teen emotionally and financially and who can help her see the future for herself and her baby in a realistic manner.
Rape
Rape is a sexual act, usually intercourse, with a nonconsenting victim. The most common type of adolescent rape has been called acquaintance rape, and it is probable that most instances are never reported. Acquaintance rape occurs when the victim is sexually misused by a boyfriend during a date, or by a casual friend, or when a trusting teen accompanies her friends to a strange place where she is gang raped.
Teens, in exploring sexuality, may not have set limits to their petting, or if limits have been set unilaterally,
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they may afford little protection for the victim, especially when the assailant is an adolescent for whom limit setting has not been successful in other areas. Some teens may also, in their uncertainty, present themselves in provocative pseudomature ways (e.g., by wearing clothing that may be viewed as sexually inviting by male acquaintances).
There is a tendency in dealing with adolescent rape victims to imply that the victim may have invited the assault. This viewpoint inappropriately diverts attention from the fact that rape should always be treated as a very serious problem for the victim who reports it.
Initial care for the rape victim should be handled by a physician, with followup by a rape counseling service if one exists in the community. Often, a physician who is already acquainted with the patient can provide the best care.
The following are important considerations when caring for the rape victim:
Norgestrel or levonorgestrel plus ethinyl estradiol pills (oral contraception pills) within 72 hours of assault and again 12 hours later.
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Brand |
Color |
First Dose |
Second Dose |
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Ovral |
White |
2 pills |
2 pills |
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Lo/Ovral |
White |
4 pills |
4 pills |
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Levlen |
Light orange |
4 pills |
4 pills |
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Nordette |
Light orange |
4 pills |
4 pills |
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Tri-Levlen |
Yellow |
4 pills |
4 pills |
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Triphasil |
Yellow |
4 pills |
4 pills |
Psychosocial Development
Normal Patterns and Concerns
The major psychosocial developmental task for the adolescent as adulthood approaches is to increase independence from their parents and to establish a positive identity congruent with social norms. In early adolescence, the young teen is faced with the dilemma of seeking independence from parents while at the same time relying on them for emotional and physical support. The conflict over independence is evidenced by contradiction and ambivalence. For example, a teen may refuse to listen to parents’ suggestions about study habits but blame mediocre grades on the fact that the parents did not help with homework assignments.
As teens enter middle and late adolescence, they demonstrate a remarkable resourcefulness in coping with anxiety over separation and in learning more mature behavior. Much assistance comes through peer relationships. Teens support each other by experimenting with adult roles that mirror societal expectations of behavior; a sense of moral responsibility begins to take shape. In this period, individual identity tends to be blunted by the seeking of independence from the family. Peers tend to look alike, dress alike, date alike, and experiment with drugs and sex alike. Later, as teens address their concerns about careers, a greater differentiation of personalities takes shape and individual identities emerge.
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Normal development also requires the example of secure healthy parents in an environment in which the teen can feel secure. Thus, parents who are preoccupied with their own psychological problems at work, in their marriage, or with their own families may have difficulties helping and coping with the development of their adolescent offspring. Often such parents have not previously succeeded at their own adolescent tasks and so are unable to proceed with the task of adulthood—they have not developed the ability for intimacy, close personal feelings, the sharing of feelings and thoughts with others, and adhering to reasonable limits.
One clear fact about adolescent development is that its emotional course is variable, even among normal adolescents. The idea that adolescence is usually a time of crisis, in which persistent neurotic behavior is essential for development of a personal identity, has not been borne out by longitudinal research. On the other hand, it has been found that at least 20% of first-year college students have psychological problems, usually personality disorders of the compulsive, schizoid, or passive–aggressive type (see Chapter 23) expressed as difficulties in academic, social, and psychosexual functioning (10). Furthermore, adolescents are more likely than people in other age groups to be hospitalized for psychiatric conditions (11). A longitudinal study of teenage boys (12) points out that achievement of identity is a long-term process. Subjects were first studied in the first year of high school and were followed for 7 years. At the end of this interval, most subjects had yet to consolidate their identities to the point where they could develop an intimate relationship, one of the best indicators of progress to adulthood. Despite this, self-satisfaction and parental satisfaction were the norm. For many, adolescence is a crisis, but an internalized noiseless one.
Generally, the teen must succeed in the other spheres of development to meet tasks in the psychosocial sphere successfully. In children with retardation, physical disabilities, or chronic illness, the dependence–independence struggle may persist, impairing the development of self-esteem needed to develop a sense of identity.
Juvenile Delinquency
Juvenile delinquency is a legal term for youthful behavior that violates the law and would be adjudicated and punished if it had been committed by an adult. It is a major social problem and is sometimes brought to the attention of the practitioner, who is asked whether there is an underlying psychological cause for the delinquent behavior. To put delinquency in a statistical perspective, data from the Bureau of Justice Statistics National Crime Victimization Survey indicates that youths between ages 12 and 20 years were involved in more than 1 million arrests for serious crimes (assaults, threatened assaults, and robberies) in 2003 in the United States. If runaways, drug violations, curfew violations and other, less violent acts are included, there were more than 2.6 million juvenile arrests in the United States in 2003 (13).
Weiner (14) distinguishes between three broad categories of delinquency: sociologic delinquency, characterologic delinquency, and neurotic delinquency. Sociologic delinquency refers to illegal acts organized by a subcultural group (e.g., street gang). The delinquent acts are adaptive in that the teen receives the approval of his or her peers. The following four features of the clinical history suggest sociologic delinquency: first, the delinquent acts are performed with valued companions, rather than alone or with strangers; second, these teens see themselves as accepted and integral members of their peer group and rarely exhibit feelings of alienation or inadequacy; third, sociologic delinquents give little evidence of neurotic symptom formation or basic character flaws; and fourth, these delinquents often have had supportive family relationships during early childhood, although there may have been more recent problems that have led to their current activities. Often, involvement in other positive group activities changes the delinquent orientation of these teens.
Characterologic delinquents reflect a basically antisocial attitude toward life. Their acts do not evoke in them any guilt or remorse. Such teens are often loners who have not established a strong relationship of basic trust in their life. Their history suggests a series of problems, with a flurry of destructive acts such as fighting, fire setting, and cruelty to animals preceding their more destructive delinquent activity. Such children often require long-term psychiatric treatment. Chapter 23 provides additional details about the course and management of patients with an antisocial personality.
The neurotic delinquent commits destructive acts as an atypical (for him or her) behavior pattern to illustrate and emphasize certain needs. These acts may reflect feelings of being ignored by family or peers or indicate that the teen is suffering from some form of psychological distress, most often depression. The acts are committed in such a way that the teen is caught in the process or gives himself or herself away soon after; generally, if concealment of illegal acts is repetitive and successful, a neurotic basis of the delinquency is unlikely. There is rarely a history of early behavioral problems, and typically the delinquent has enjoyed a loving relationship with parents and family members. Occasionally, however, some recent family stress may trigger the delinquent act. In general, neurotic delinquency may be treated through short-term counseling (see Chapter 20).
Violence and Violence Prevention
Recent shootings in schools in the United States by children and adolescents have brought to the forefront the
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issue of youth aggression and violence. Professionals who work with youth must work to define their roles and develop skills to address the risk factors and warning signs of violent behavior.
Violence (homicide and suicide) is the major cause of death and morbidity, outside of accidents, for teens and young adults. Deaths caused by firearms among adolescents ages 15 years to 19 years in the United States in 2001 was 12.4 per 100,000, of which 7.5 per 100,000 were a consequence of firearm homicide. However, deaths caused by firearms among black teens ages 15 years to 19 years in the United States in 2001 was 60.5 per 100,000, of which 52.0 per 100,000 were a consequence of firearm homicide (15). Youths have continuing exposure to violence, sex, and drug use through television, movies, and music videos; one estimate suggests that young people may view 10,000 acts of violence a year (16). Research suggests that a cause-and-effect relationship exists between media violence and aggression (17). Of deeper concern is the exposure of young teens to actual violence and aggression. One large cross-sectional study stated that almost 30% of 6th to 10th graders reported that they had participated in bullying, been bullied, or both (18). This study went on to suggest that bullies and those who are bullied both have a range of concurrent conduct, and school, emotional, and physical problems. As adults, bullies are likely to exhibit criminal behavior, and those who have been bullied have higher rates of depression and poor self-esteem. It is disturbing that the perpetrators of the violence in Littleton, Colorado, Pearl, Mississippi, and Santee, California may have been bullying victims.
The American Academy of Pediatrics Task Force on Violence has suggested a number of age-appropriate interventions (19), including promoting appropriate parenting skills by querying and counseling about discipline at home, substance abuse, violence and abuse exposure—physical, sexual, and verbal—at school and home, dating and dating behavior, and how conflicts are resolved at home. Most importantly, practitioners should have knowledge of community- and school-based resources where at-risk youth may be referred. Practitioners who are very interested in violence prevention may work with communities to help design curricula, advocate for increased services, promote preventive activities, and foster community attitudes that affect the risk and incidence of violence. These may include promoting gun safety and reducing child access to guns, working with child abuse teams, and designing school curricula that include violence prevention. Practitioners can also work through advocacy groups to affect laws and regulations that are pertinent to violence prevention, such as gun safety requirements, prohibition of corporal punishment in schools, visitation programs for isolated families and new parents, and after-school programs for children and teens.
Substance Abuse
Although substance abuse, including tobacco use, is a major problem of adult life, it often begins during the adolescent years. By age 11 years, 1 in 5 adolescents has smoked cigarettes and approximately 1 in 11 adolescents has had his or her first drink of alcohol; by the age of 15 years, 1 in 7 adolescents smokes on a daily basis and more than 1 in 3 adolescents has drunk excessively at least once (6). Experimenting with substances of abuse may be viewed as a rite of passage bridging the gap between childhood and adulthood or as a condition for belonging to peer groups or organizations. Advertising or exposure to images that appear to link the use of cigarettes and alcohol to life successes, popularity, and sex can be important inducements for adolescents to try alcohol or tobacco. A major concern is to identify the adolescent abuser—one whose life is being disrupted by aberrant activities. This teenager is most likely to continue to abuse alcohol or drugs in adult life.
The routine evaluation of a teen should include questioning about the use of alcohol and of drugs. Substance use should be explored using nonthreatening questions such as those listed in Table 11.6. The presence of drug abuse and its impact on a teenager can also be uncovered by asking the parents questions such as those in Table 11.7. If the use of a substance is excessive and hazardous, factors that might have led to abuse should be explored. Drugs and alcohol are often abused as a response to some psychosocial problem, and it is only by identifying the problem that the abuse may be stopped. Lecturing on the dangers of alcohol, drugs, or tobacco seems to have little impact on adolescents. Unfortunately, teens who drive and use alcohol and drugs may endanger others, so it still behooves
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practitioners to discuss substance abuse with teens who deny personal drug use.
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TABLE 11.6 Sample Questions Concerning Drug Use for Adolescents |
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TABLE 11.7 Questions for Interviewing the Parents of the Adolescent Suspected of or Known to Be Abusing Drugs or Alcohol |
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Occasionally, the serious abuser of hazardous substances develops physiologic symptoms that are dramatic enough to come to the physician's attention. Hospitalization for observation is almost always indicated for the teenager presenting with drug intoxication, even if emergency room evaluation indicates no immediate medical risks. The possibility of attempted suicide may be real and must be explored. Even if this is not a factor, there is still concern about the teen's ability to control his or her own drug abuse behavior.
How to intervene in teenage drug abuse behavior is a difficult question. Practical approaches to patients with substance abuse are contained in Chapters 27, 28, and 29.
Depression and Suicide
A behavioral hallmark of adolescents is mood shifts, from the peaks of elation to the depths of despair. Depressive symptoms are normal parts of psychosocial development. The quest for identity is balanced by a sense of loss once independence is achieved. Similarly, rejections by peers (e.g., first loves) may be felt very deeply. It is not unusual, as part of these depressions, for the adolescent to contemplate suicide. More than 1 in 4 adolescents in grades 9 through 12 has thought seriously about suicide, and 1 in 12 adolescents has actually attempted suicide (6).
Mattsson (20) describes five depressive states of adolescence:
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neurosis. Such teens withdraw from their normal functioning, are chronically sad, and begin to entertain suicidal ideation. This is a fairly severe level of depression and demands professional intervention.
Primary care physicians are sometimes asked to evaluate depressed or suicidal adolescents. In taking the history, one should try to uncover recent events that may have precipitated the depressive disorder: any long-standing family, school, or peer problems; possibilities of organic brain disease or drug abuse that may mimic depressive symptoms; symptoms of cognitive or reality disturbances, suggesting a psychosis; and symptoms suggesting a masked depression. Openness in inquiry about depression usually puts the adolescent at ease and conveys that the physician truly understands what he or she may be feeling. A physical examination helps to rule out physical problems, and communication with the school may provide additional observations about the teen's current level of functioning. Considering the high prevalence of depressive symptoms and clinically significant depression during adolescence (estimated to be as high as 15% and 5%, respectively), there may be value to screening adolescents for depression. This is particularly important prior to transition periods, such as entry into high school or college, as social and academic stressors may lead depressed teens who may have been masking their symptoms to go into crisis. Such instruments as the Columbia Diagnostic Interview Schedule for Children (DISC) Depression Scale (21) or the Beck Depression Inventory (22) are relatively fast screening questionnaires that can be administered in an office setting and help clinicians identify depressed teens.
Adolescents with depressive symptoms need some counseling. If one believes medication is necessary and is unfamiliar with the use of psychoactive drugs in adolescents, conjoint treatment with a psychiatric consultant may prove helpful. Patients with long-standing depressive symptoms, which suggest thought disturbances, and possible suicide attempts should be referred for psychiatric intervention. Additional details about the office assessment and management of depression are found in Chapter 24.
Intellectual Development
Normal Patterns and Concerns
In adolescence, a major change occurs with respect to education and intellect. Schools differentiate students, placing them into vocational or academic tracks. The emphasis shifts from the learning of tasks (e.g., basic reading, writing, and arithmetic) to the accumulation of facts and the ability to think abstractly. As teens prepare for college, learning becomes a competitive task. For some teens and families with high aspirations, the competitive nature of academic rankings and the pressure to be admitted into very selective colleges may isolate the child and interfere with social development. Career choices become limited as an individual's abilities and talents become manifest. Upon entering college, a greater amount of independence and responsibility is expected. Symbolically, the university begins to resemble the workplace in terms of both potential rewards and potential pressures.
Scholastic Failure
Academic achievement is strongly related to parental aspirations, socioeconomic status, and intellectual ability. Occasionally, a child cannot meet parental expectations, and the resultant crisis may lead to a visit to the physician. Failure in school may also be a symptom of a physical impairment, mental retardation, substance abuse, specific learning disabilities, or emotional stress. By making an accurate diagnosis of the underlying problem, a caring practitioner can help such children.
First, a history is necessary to determine the nature of the school difficulties. When did they begin? Has educational achievement been a problem throughout a school career, as with a global intellectual deficit, or is it specific to certain subjects or tasks, as with learning disorders? Is there a family history of poor school performance, as is seen with familial dyslexics? How does the teen act with family and peers? Is there evidence of disturbed behavior outside school, as with emotional disorders? Is the family structure stable or has there been separation, divorce, or death of a parent or grandparent? Is there evidence of substance abuse or physical abuse on the part of the teen or a member of the family? Is there daytime hypersomnolence that suggests a sleep disorder? What has the family done to try to work through problems?
Second, a physical examination, including neurologic examination, is indicated, with emphasis on signs of minimal cerebral dysfunction, such as difficulty with right–left discrimination or spatial orientation, or overt signs of cerebral palsy (23). In such patients, there may be suggestions of a neurologic problem in the medical history, the birth may have been abnormal, or the patient may have shown hyperactivity or attention deficits as a child. Vision testing
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and office assessment for slight or moderate hearing loss (see Chapter 110) are also particularly important.
Third, some specific intelligence testing is indicated. Children with mental retardation tend to show low intelligence quotient scores, and achievement tests show a delay of several grades in math and reading levels. Children with dyslexia have a normal intelligence quotient but show a wide scatter of scores on subtests, indicating a nonglobal deficit. Achievement tests may also show a difference between abilities in reading and mathematics.
Some learning problems may appear late in a school career (23). The recent criticism of the ability of some college students to write well has given credence to the notion of expressive language disorders, which may not become manifest until adolescence. Some people with fine perceptual problems may not reveal difficulties until geometry or drafting is studied in high school.
In 1974, Congress passed federal law 94-142, ensuring a free, appropriate, educational placement for all children up to age 21 years. Thus, adolescents with specific learning problems, retardation, or emotional difficulties are entitled to be placed in a classroom setting where they will learn. The physician who suspects an unrecognized problem in one of these spheres may help by referring the teen and the teen's parents for evaluation, which is usually available through the school or the local education system. Unfortunately, problems remain unrecognized for many children and they may, out of frustration, drop out of school.
Attention Deficit Hyperactivity Disorder
Attention deficit hyperactivity disorder (ADHD) may be one of the most common disorders of childhood, with prevalence rates ranging from 3% to 6% of prepubertal children. Although data on prevalence and persistence in adolescents and adults are limited, long-term followup studies show that critical symptoms of ADHD—impairment of attention and regulation of activity and poor impulse control—often persist into adulthood, and many adults with ADHD remain distractible, impulsive, inattentive, and disruptive throughout life. On average, symptoms of ADHD diminish by approximately 50% every 5 years between the ages of 10 and 25 years. Adolescents with ADHD may have impaired school performance, a disorganized approach to tasks, limited participation in extracurricular activities, increased risk of delinquency, and harmful social relationships and family interactions. In adults, ADHD is often linked with psychiatric illness, incarceration, job failures, marital discord, and divorce (24).
Diagnosis
ADHD is diagnosed, usually at serial visits using information from multiple sources. Table 11.8 lists the criteria for the diagnosis. The diagnostic challenge in adolescents and adults is to detect the more subtle presentations of symptoms in these stages of life. For example, in teens and adults, symptoms of hyperactivity may be confined to fidgetiness or an inner feeling of jitteriness or restlessness. Current nomenclature differentiates ADHD into three types: predominantly inattentive, predominantly impulsive, and combined.
There has been increasing attention to ADHD in adult patients and more adults are seeking treatment for this disorder. There are screening instruments that are geared toward the diagnosis in adult patients, including the Copeland Symptom Checklist for Adult ADHD, the Wender Utah Rating Scale, and the Brown Adult Attention Deficit Disorder Scale (25). Wender developed a set of adult ADHD criteria, in addition to a history suggestive of childhood ADHD, that includes hyperactivity (restlessness, feeling on edge, difficulty relaxing) and poor concentration (forgetting appointments and social commitments) plus two of five additional symptoms: affective lability, hot temper, inability to complete tasks and disorganization (difficulty prioritizing tasks), stress intolerance, and impulsivity (such as blurting out rude or insulting remarks).
The physical examination usually is noncontributory in diagnosing ADHD but may be useful to rule out other conditions that are characterized by hyperactivity or short attention spans (see below). In teens, it is helpful to examine results of intellectual testing and academic achievement testing. A symptom checklist (Connor Scale, Child Behavior Checklist) that can be completed by teachers and parents is also helpful to identify and quantify symptoms that teens may be demonstrating in their classrooms and homes (25).
Comorbidity
Up to 65% of adolescents with ADHD have one or more comorbid conditions, such as learning disabilities, mood disorders (10% to 20%), substance abuse, and alcoholism, and may also be confused with other conditions that have hyperactivity as a feature, such as hyperthyroidism, Gilles de la Tourette syndrome, adjustment or oppositional disorders, affective disorders with manic features, social or personality difficulties, and medication-induced attention problems (e.g., substance abuse) (24). These patients have difficulty in the workplace, in school, and in social relations. They have more cognitive difficulties, poor performance in school, and significant difficulties with social skills and appropriate behavior. As a result, they tend to be underachievers with personalities that may be intrusive, immature, or negative.
Treatment
ADHD is treated best with a multimodal combination of medication and counseling. On the basis of placebo-controlled trials, it has been found that stimulant drugs
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greatly reduce the core symptoms of ADHD, hyperactivity, impulsivity, and inattentiveness (24). It is estimated that 70% to 80% of children and 60% of adults have improvement in academic and social behaviors and in cognition and a reduction of disruptive and negative behaviors. Long-term improvement in academic outcome has not been found, however. Most patients with ADHD are treated pharmacologically with psychostimulant medications, such as methylphenidate or dextroamphetamine, although a small number respond well to antidepressant agents, such as desipramine. Table 11.9 summarizes practical information regarding these medications. Medication should be titrated carefully and should be used on days when focus and attention may be needed (e.g., for long-distance drives, school or work days). Medication should be prescribed to cover learning and work-related needs, such as homework and examination preparation times. With short-acting stimulant medications such as methylphenidate, holiday periods off medication may be permitted. Counseling interventions include psychoeducational counseling, behavioral management, school-based interventions, family therapy, and social competence training. In many communities patients and their families have access to the Children and Adults with Attention
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Deficit/Hyperactivity Disorder (http://www.chadd.org) and to the ADHD Association (http://www.add.org) support groups.
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TABLE 11.8 Diagnostic Criteria for Attention Deficit Hyperactivity Disorder |
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TABLE 11.9 Medications for Attention Deficit Disorder with Hyperactivity (ADHD) in Adolescents and Adults |
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Approach to the Adolescent Patient in the Office Setting
When interviewing teens, it is helpful to keep in mind that the transitional nature of adolescence makes it a time of great experimentation and risk taking (see Sexual Development and Substance Abuse sections, above).
Each adolescent approaches the developmental pressures of this period of life with his or her particular skills and emotions. From a health perspective, adolescents can be responsible partners in maintaining their well-being and complying with medical care, or they can be infantile, dependent, uncommunicative, aggressive, or irresponsible. It is important to interview adolescents in private. Adolescents need to believe they are the patient and that their problems are being listened to and taken seriously. It is often useful to also talk to the parents separately.
Interviewing the Patient
Some adolescent patients are difficult to interview. An uncommunicative patient may have been sent to a physician involuntarily or may lack verbal skills needed for coherence. One must be verbally active with such patients and watch for any nonverbal cues to use as wedges in trying to get the patient to speak. Examples of nonverbal cues are a look of interest or initiation of eye contact when a subject is mentioned that the patient would like to discuss, a clenched fist when an anger-provoking subject is raised, and frequent position change and fidgeting when the patient is anxious about a specific subject or about the visit to the physician in general. Because adolescents are often reticent about their major concerns, open-minded invitations to share information (e.g., “Is there anything else you
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wanted to talk about?”) should be included in each office contact. The initial comprehensive interview may require several sessions. At the first visit, warmth and interest in the adolescent may open the way to better communication in future sessions.
Some adolescents respond more honestly to written questionnaires rather than to interviews. It may be a useful strategy to preface an interview with a form questionnaire for both the adolescent and the parent. As part of this questionnaire, ground rules can be outlined, such as assurances of confidentiality. In general, an adult-oriented questionnaire, with reviews of systems, is inappropriate for younger teens and should be reserved for teens age 18 years or older. The questionnaire should not take the place of the personal interview but can guide the interview to address issues of concern of the patient in greater detail.
Many adolescents continue to go to a pediatrician for medical care until they enter college, take a job, or marry. Because of this long-term association, their relationship may be almost like that of a parent and child: warm, intense, and comradely. These feelings cannot be transferred easily to a new physician, and it is unwise to attempt to transfer them.
Practitioners can most effectively surmount problems in communicating with adolescents by explaining their modus operandi in advance, emphasizing that they will be primarily the adolescent's physician rather than an agent of the patient's parents, as had been the case previously. The adolescent should also be encouraged to initiate patient–practitioner contacts. It is important to guard against paternalistic advice giving and to avoid showing disapproval or surprise when the adolescent attempts to impress one with tales of sexual exploits or the use of vulgar language. Sexuality is an important topic to address with teens, but one should not impose judgment on a teen's sexual activities, gender preferences, or other characteristics. Instead, one should address how a teen's sexuality may create health risk and focus screening and health education efforts on these risks.
It is wise to establish certain ground rules with adolescents. Patient–doctor confidentiality, for example, can be assured to adolescents only insofar as they do not reveal that they are contemplating harmful acts, such as running away or committing suicide. However, certain privileged communications should be kept confidential from parents. In particular, adolescent minors have the right to be seen for STDs or for sex offense-related examinations without the prior consent of a parent. The teen may also wish to keep some health-related or emotional problems, such as drug experimentation, from a parent's knowledge.
Interviewing the Parents
Whenever possible, parents should be involved with and concerned about the health of the teen. A separate interview with parents, immediately before or after the examination, may prove helpful and can emphasize particular concerns downplayed or denied by the patient. The parents of adolescent patients may be useful in providing emotional support and ensuring compliance with therapy; therefore, informing them about the adolescent's problems and needs is important.
Some parents ask physicians to take on the role of health educator or counselor for their adolescent child. Usually, these requests are for anticipatory guidance about birth control or drug usage. At times, the physician is asked to help the teen work through an upcoming family crisis, such as divorce, serious illness, or death. Often, adolescents welcome the opportunity to discuss these issues in private. Their knowledge in these areas is often found wanting, and a sensitive physician may help the adolescent grasp realities and make intelligent decisions. A number of books on these subjects are directed to an adolescent and young adult audience, and it may be useful to make these titles available (see http://www.hopkinsbayview.org/PAMreferences).
Parents often have questions about specific adolescent behavior. A particular episode or issue may come to the parents’ attention, and they may ask the physician whether they should exert control over it. In such instances, one should not offer specific advice but should try to discern any moral or behavioral conflicts between the parents and the adolescent. When the parents’ behavior is inconsistent with the parents’ own stated values, adolescents often act in opposition to those values. Miller (26) suggests that parents are not helped in this instance by being told how to behave. Advice either increases the parents’ uncertainty when faced with later difficulties or implies that the parents’ own opinions are inappropriate. Adolescents probably turn out mentally healthier when presented with models of adult behavior with which their parents are comfortable, whether consistent with societal norms or not. However, parents must be prepared to make allowances so that their children have freedom to make their own mistakes. Family counseling is a technique that a general physician can use when several members of a household are involved (see Chapter 20).
Health Assessment and Preventive Care
The initial interview(s) should be comprehensive enough to ensure that the adolescent is meeting appropriate developmental tasks. Inquiries should be made into teenagers’ relationships and functioning with their families, at school, and with peers. It is important to determine whether teenagers are establishing positive personal identities (Do they have hobbies? Do they voice their own opinions? Can they choose their own friends or must friends be approved by the parents? Do they have plans for the
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future?); whether they are accepting their sexuality and adjusting to adult sexual roles (Do they date? Are they sexually active? Do they have a knowledge of contraception? Is contraception used?); whether they are establishing independence from the family (Do they drive? Do they earn money on their own? What sort of hours do they keep?); whether they are working toward a career (What are their plans after high school? What subjects in school do they like? What are their grades? Do they plan to go to college? Are their goals realistic and are they supported by the family?); whether they have established good health habits (What are their views about nutrition? Do they have an adequate source of calcium and iron in their diet [see Chapter 15]? Do they eat breakfast? Is eating done on the run, in isolation, or with friends and family? Have they experimented with alcohol, tobacco, or other recreational drugs? What drugs? Have they ever been drugged or high when driving or when attending school?); and whether affective swings are interfering with functioning (Do they often feel down? What makes them happy? Have sad feelings ever made them consider harming themselves?).
Adolescents visit physicians infrequently. When they do, few receive counseling on critical adolescent health issues. In an analysis of the National Ambulatory Medical Care Survey between 1995 and 1997, Merenstein and colleagues found that counseling about any of seven areas studied (diet and nutrition, exercise, weight reduction, cholesterol reduction, HIV transmission, injury prevention, and tobacco use) was documented in 15.8% of family physician visits and 21.6% of pediatrician visits (27). However, the Youth Risk Behavior Surveillance statistics published by the Centers for Disease Control and Prevention suggest that more than half of all teens self report behaviors that may seriously jeopardize future health, including not using a bike helmet or a seat belt; alcohol, tobacco, marijuana, and drug use; unsafe sex practices and sexuality concerns; lack of physical exercise and sport participation; too much time watching television or playing computer games; attempts to lose or gain weight through purging or fad diets; poor nutritional habits, including lack of calcium intake, unusual diets, and failure to eat sufficient fruits and vegetables; use of nutritional additives and steroids for rapid muscle development; violent behavior and victimization; and mood and emotional concerns.
As part of the review of systems before examination, a self-administered medical questionnaire may be useful and time saving. Such a questionnaire should be brief, with language simple enough to be understood by teens with poor reading skills. Positive answers must be explored further.
A physical examination should be performed in the absence of parents. Teenage girls examined by male physicians may be more comfortable with a female adult in the room with them. Some parts of the physical examination occasionally omitted by physicians but essential for adolescent patients include blood pressure measurement and examination of the entire integument, the spine (for scoliosis), and the external genitalia (for signs of venereal disease and for assessment of sexual development using Tanner staging [Tables 11.4 and 11.5]). All sexually active adolescent girls should have a pelvic examination, including gonorrheal cultures and a Papanicolaou (Pap) smear (seeChapter 104). If one is uncomfortable doing this examination, the teen should be referred to a gynecologist (preferably female) who is used to dealing with adolescents.
There are several important adjuncts to the physical examination of the healthy adolescent, including testing for myopia and hyperopia (using a Snellen chart) and screening for deafness (by pure tone audiometry). Adolescence is a period marked by noise pollution in the form of loud music that can cause permanent damage to the eighth nerve (see Chapter 110). Adolescents who have difficulty in school should be screened for learning disorders. Having a teenager read a newspaper paragraph aloud or do some simple arithmetic may reveal a previously undetected learning disability.
Laboratory screening tests for healthy adolescents are remarkably few. Screening for anemia with a hematocrit or hemoglobin determination may be limited to menstruating young women. Tuberculosis screening with purified protein derivative should be performed only if there are family or community risk factors. Screening for hyperlipidemia is controversial during adolescence. The chance of diagnosing a problem severe enough to require pharmacologic therapy is small, whereas the benefits of a diet low in total fat and cholesterol may be universal. The decision to screen adolescents may be influenced by family history of myocardial infarction or stroke in a person younger than age 55 years or by personal opinion about whether an abnormal lipid profile may influence a patient's dietary practices. One may wish to screen teens for thyroid disorders if there is a positive family history for thyroid disease, with thyroid-stimulating hormone (TSH), thyroxine (T4), and, if thyroiditis is suspected, antithyroid antibodies. Urinalysis, blood chemistry screens, chest radiographs, and electrocardiograms are not indicated in healthy adolescents.
Healthy adolescents may require tests, immunizations, and/or physical examinations for special needs, such as travel, sports, camp, and college entry. In addition, there may be optional vaccines or tests that will need to be coordinated with the routine health schedule, such as varicella vaccine for students entering college or chest radiographs for students who have had bacillus Calmette-Guérin (BCG) vaccine and a positive purified protein derivative test.
Recommended Preventive Services
Figure 11.3 summarizes the consensus American Medical Association Guidelines for Adolescent Preventive Services. Some offices find it useful to keep this table, as
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a prompt and for documenting completed actions, in the records of adolescent patients. Since publication of this report, there has been a recommendation for universal vaccination of adolescents with meningococcus conjugate vaccine, a single dose between ages 11 and 18 years. This replaces the optional meningococcus polysaccharide vaccine that had been suggested prior to college entry. In addition, the Tetanus-diphtheria (Td) vaccine is being replaced with a diphtheria, tetanus toxoids, and acellular pertussis (DTaP) vaccine between ages 12 and 14 years. (See Centers for Disease Control at http://www.hopkinsbayview.org/PAMreferences.)
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FIGURE 11.3. Preventive health services for adolescents by age and procedure. (From American Medical Association. AMA guidelines for adolescent preventive services [GAPS]. Updated April 2001 , with permission.) |
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TABLE 11.10 Sports Participation Health History |
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TABLE 11.11 Medical Conditions and Sports Participation |
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Examining the Adolescent Athlete
The examination of adolescent athletes requires an evaluation of their health and consideration of their functional ability, growth, and maturation. The purpose of the preparticipation health evaluation is to identify medical conditions that might preclude safe and effective athletic participation, including those that might become worse by participation in sports activities. It can also serve the purpose of facilitating and encouraging safe sports participation. Often, the sports exam is the only health encounter that a teen may have with a physician. A brief screening questionnaire (Table 11.10) along with information already known to the physician will identify most conditions that may disqualify an adolescent from participation in various types of sports (Table 11.11). However, there are lengthier forms that serve as a general health review, both to identify injury potential and to further good health and training practices for young athletes (see Matheson at http://www.hopkinsbayview.org/PAMreferences).
As athletes become more experienced, the most commonly encountered problems are residuals of previous sports injuries, most of them musculoskeletal problems. Common exercise-related musculoskeletal injuries that can be managed in the office are described in Section 10: Musculoskeletal Problems of this book.
Specific References*
For annotated General References and resources related to this chapter, visit http://www.hopkinsbayview.org/PAMreferences.