Selected Issues in Adolescent Health
Authors: Robert A. Murden, MD, Associate Professor of Clinical Internal Medicine and Director, Division of General Internal Medicine, The Ohio State University, Columbus, OH; Dee Ann Althouse, MD, Clinical Instructor in Medicine, The Ohio State University, Columbus, OH.
Peer Reviewers: Robert T. Brown, MD, Professor, Clinical Pediatrics, Director, Division of Adolescent Medicine, The Ohio State University College of Medicine and Public Health; Victor C. Strasburger, MD, Professor of Pediatrics, University of New Mexico School of Medicine, Albuquerque, NM.
Editor's Note-Adolescent health care is complex. Adolescents often do not receive regular and complete care, despite being in a difficult transition period in which they need counseling as they are first being exposed to the problems associated with sexuality, substance use and abuse, and adult relationships and emotional needs. Unfortunately, primary care providers are often poorly trained to assist in this transition.
Introduction
Many issues are crucial to good adolescent care. Those about which recent position papers have been published updating or revising guidelines, and those with the most potential to benefit adolescent patients are discussed in this manuscript. Confidentiality is the crucial beginning to all adolescent health care. Providers don't discuss confidentiality often enough with teen patients, and, when they do, they frequently offer unconditional confidentiality that is inappropriate in certain circumstances.
Screening should be emphasized when caring for adolescents. It provides an opportunity to address many issues that are just arising in people who lack maturity, judgment, and knowledge of the health care system. Current recommendations for evaluating and treating hypertension and hyperlipidemia are significantly different from those in adults and are emphasized.
Issues pertaining to sexual activity for adolescents include birth control, pregnancy and abortion, and sexually transmitted diseases. Long-acting contraception is particularly appropriate for adolescents whose compliance is poor. It is tolerated well, with menstrual irregularities and weight gain the principal side effects. In addition, emergency contraception information should be available to adolescents. In 1997, the FDA approved oral contraceptives for use as emergency contraception, and primary care providers should become familiar with the effective regimens.
Eating disorders usually start in adolescence and are among the most frequent and most deadly chronic diseases of teens. They often present with physical and emotional findings unrelated to weight changes, and a high index of suspicion and great vigilance in diagnosis is required. Teens suffering from eating disorders also have a high incidence of concomitant risky behaviors. Major depressive disorder may present in adolescents, and atypical presentations, often with altered school functioning, are common. Tricyclic antidepressants have not been proven to be effective in teens, and selective serotonin reuptake inhibitors are the medications of choice.
Attention deficit disorder is reviewed since adolescents who manifest attention deficit are at high risk for substance abuse, school and emotional problems, driving without seat belts, and sexual promiscuity. Gender differences in presentation are reviewed, and new evidence for genetic causes and relationship to persistently elevated CSF dopamine is emerging. The authors review the details of a careful diagnosis and discuss in detail treatment regimens that can be initiated by primary care physicians.
Adolescence is a unique period of life, and health care of adolescents requires special knowledge and approaches. Adolescents are in a transition phase from childhood to adulthood, and thus neither traditional pediatrics nor adult medicine is quite an appropriate model for adolescent health care. Issues such as sexuality, substance abuse, and eating disorders arise at surprisingly young ages before most adolescents have sufficient maturity or judgment to deal with them. At age 14, only 18% of adolescents who will ultimately engage in significantly risky behavior have begun doing so, but this figure jumps to 59% at the age of 15.1 Simultaneously, during this time of increasing need for health care counseling, there are many barriers to adolescents seeking care, including confidentiality issues and locating an appropriate and trained provider. As a result, adolescents are the only age group in the United States for which health status is not improving,2 despite their having the highest percentage of preventable deaths (72%) of any age group.1
The authors present an update on adolescent medicine, focusing on some of the more prevalent and important issues, and on the most recent advances and position papers. Other than issues of confidentiality and screening which are universal, the remaining areas may often be handled by primary care physicians, but may require referral if complex.
Interviewing and Confidentiality Issues
Interviewing adolescents can be a unique experience. Adolescents have a short future time perspective, are acutely self-conscious, and need to be treated like adults, while recognizing their limited judgment and knowledge of health care practices.3 Adolescents are unlikely to spontaneously offer their own perspective, so skilled probing becomes more important.3 Adolescent interviews may be in three forms: parent-adolescent cooperative, adolescent primary-parent secondary, and adolescent alone-parent optional,3 and the most appropriate form varies with the situation, the age and maturity of the adolescent, and the parent-adolescent relationship.
Confidentiality is particularly important to adolescents, who are worried about parental notification of privately discussed issues. Surveys have shown that 25-50% of adolescents would not seek health care if not assured of confidentiality,4 and 83% of teens feel assured confidentiality probably or definitely would lead them to seek care.5 Despite this, in a large study, only 53% of primary care physicians offered confidentiality assurances to their adolescent patients.6
Confidentiality should be granted to adolescents, but certain circumstances mandate violation of confidentiality. (See Table 1.) When these issues arise, the adolescent should be informed of the reason to violate confidentiality and should be involved in revealing the problem. Additionally, some states have laws concerning confidentiality and emancipation for adolescents in specific circumstances. An important educational note for adolescents is that states that do require parental notification for certain procedures (e.g., abortion) must allow the minor the option of applying for court authorization to obtain the procedure without parental involvement. Physicians, unfortunately, are not well versed in confidentiality issues regarding adolescents. A survey of 786 California primary care physicians found that only 63% knew the legalities of a hypothetical case, and that 64% inappropriately offered unconditional confidentiality to all adolescents, regardless of the circumstances.6
Charting and billing may create special confidentiality problems for adolescents. Some have advocated providing subtle chart confidentiality through the use of individualized abbreviations (e.g., SU for sexually active-unprotected intercourse), which could be a solution for some physicians. Billing may be more problematic, however.
Preventive Services in Adolescents
Primary care traditionally has a strong emphasis on preventive care, and primary care physicians have a unique opportunity to have a major effect on the health and development of adolescents. Publications including the Guidelines for Adolescent Preventive Services (GAPS),7 and Bright Futures,8 offer guidelines for health supervision in adolescent patients. The most current recommendations from a position paper by the Society for Adolescent Medicine include annual visits to allow immunization, screening, and guidance and counseling in multiple areas.9 Areas to be addressed include anticipatory planning for teens (what to expect from the health care system) and parents (what to expect from their adolescent), diet and weight management, exercise, injury prevention including seat-belt use, sexual behavior, immunizations, behavioral and psychosocial problems, and screening for medical illness.10 Issues of sexuality, assessment for eating disorders, and depression will be addressed more extensively in other sections of this manuscript. Issues of concern to physicians with adolescent patients that will be addressed here include risky health behaviors (including substance abuse), blood pressure, cholesterol screening, and immunizations. Preventive care in adolescents involves screening for health-risk behavior. Risk-taking behavior typically occurs as part of a pattern for any individual, and identification of one type of risk-taking may be indicative of others. Spain et al, for example, identified several high risk behaviors in their study of adolescent trauma patients.11 Twenty-one percent of adolescents involved in trauma tested positive for blood alcohol on admission, and only 7% of those testing positive had used seat belts.11 Students using anabolic steroids have been found to have a clustering of other risky behaviors, with increased driving after drinking, increased numbers of sexual partners in life and within the past three months, and decreased use of seatbelts and condoms.12 Screening adolescents for patterns of risky behavior can allow intervention and education.
Table 1. Reasons for Violating Confidentiality with Adolescents
Suicidal or Homicidal Ideations
Physical or Sexual Abuse
Serious Eating Disorders
Serious Chemical Dependency
A prominent health risk in adolescents is substance use. Efforts to prevent or delay onset of alcohol and drug use must begin early in childhood, as younger adolescents are increasingly using alcohol and other drugs.13 The signs and symptoms of abuse are often more subtle in adolescents, as physical manifestations are less common. Changes in psychosocial functioning (e.g., school performance, peer relationships, family relationships) detected in a screening visit may raise suspicion for substance abuse. Screening questionnaires for alcohol abuse, such as the CAGE questions, may be more helpful when used in conjunction with the addition of questions about tobacco use and friends' drinking patterns. Direct questions about alcohol and other drug use, in an atmosphere of trust and confidentiality, is encouraged.14 Tobacco use represents a specific challenge, as 85% of current smokers began smoking by the age of 21. Physicians are encouraged to address tobacco use at every visit, encourage abstinence, and assist users in quitting.15 The potential for positive influence in this area inspires dedication to screening for adolescent substance abuse.
Screening for hypertension in adolescents is important, often overlooked, and differs somewhat from adult populations. The diagnosis of hypertension in adolescents is made by repeated blood pressure (BP) measurements exceeding the 95th percentile based on age, gender, and height.16 Adolescents with BP measurements just greater than the 95th percentile are often overweight and have family histories of essential hypertension. In such cases, a thorough history and physical, urinalysis, and determination of blood urea nitrogen and creatinine levels are adequate to exclude other diagnoses. Adolescents with both diastolic and systolic BP well over the 95th percentile more frequently have a secondary cause, in which case consultation with a physician experienced in childhood hypertension is appropriate. In the setting of early onset, mild, essential hypertension, nonpharmacologic therapy, including weight reduction, exercise, and moderate sodium reduction, is the recommended focus. In practice, these methods are often ineffective, and clinicians do use anti-hypertensives, with beta blockers, diuretics, calcium channel blockers, and ACE inhibitors being preferred. Current published guidelines for adolescents, however, recommend that: 1) pharmacologic therapy should be reserved primarily for patients with secondary hypertension with the goal to reduce the BP to less than the 95th percentile, and 2) specific therapy should be directed at any identified underlying cause.16
The American Academy of Pediatrics has recently published guidelines for the evaluation of cholesterol in adolescents and children. Although no long-term studies have been conducted in children to evaluate the relationship between childhood cholesterol levels and coronary heart disease in later life, the Academy feels that some relationship may be inferred and recommends two approaches to lower cholesterol levels in children and adolescents. The first, or population approach, aims to lower the population's average cholesterol by recommending a low fat diet for all adolescents. The "individualized approach" aims to identify and treat adolescents at highest risk for high cholesterol levels as adults. Two cholesterol levels should be checked when indicated in adolescents. (See Table 2.) If total cholesterol is recommended and the value is high, a fasting profile is drawn. If averaged low density lipoprotein (LDL) cholesterol is less than 110 mg/dL, the patient should receive nutrition education and have the analysis repeated in five years. If the average is 110-120 mg/dL, the American Heart Association (AHA) Step I diet should be initiated and the analysis repeated in one year. If the average is above 130 mg/dL, the patient should be evaluated for secondary causes (thyroid, liver, and renal) and familial disorders, all family members should be screened, and the Step-One diet initiated, with repeat analysis in three months. If no improvement has occurred, the AHA Step-Two diet is initiated. All patients should receive counseling to avoid other cardiovascular risk factors. Drug therapy is recommended for children and adolescents only after an adequate trial of diet (6-12 months) and only in individuals whose LDL cholesterol level is 190 mg/dL or greater or 160 mg/dL or greater in the presence of family or other risk factors. The recommended drugs for adolescents are cholestyramine and colestipol; other agents are not recommended except in consultation with a lipid specialist.17
Immunizations should be integrated with other preventive services for adolescents. As part of a comprehensive strategy to eliminate transmission of hepatitis B virus (HBV), current recommendations call for immunization against HBV in all adolescents aged 11-12 years not vaccinated previously. Clearly, any adolescent at high risk for HBV exposure (e.g., more than 1 sex partner in 6 months, intravenous drug use, males who have sex with males, health care workers, etc.) should be immunized, as recommended by the American Academy of Pediatrics. This requires three doses, as in adults, and compliance may be improved by pre-scheduling subsequent visits. Some flexibility is acceptable, as intervals of up to one year between the first and third doses provide adequate antibody response.18 Studies of compliance with the three-injection regimen are variable, ranging from 14% in an inner city health clinic, to 87.6% in a Cincinnati adolescent clinic.19 Strategies to improve compliance include educational information on the importance of the vaccine, health care provider commitment to the program, and persistent attempts to reschedule missed appointments, along with a setting where at least annual visits take place.19
Varicella zoster virus (VZV) has increased morbidity and mortality in adolescents and adults, especially in pregnant women. Between 7% and 11% of young adults in the United States are seronegative to VZV.20 Varicella vaccine, therefore, should be administered to adolescents who have not been vaccinated previously and who have no reliable history of chicken pox. Patients 13 years of age and older should receive two doses (which increases effectiveness from 79% after 1 dose to 94%), separated by 4-8 weeks, and should not take salicylates for six weeks after the immunization.21 Pregnant women, immunodeficient individuals, and those recently receiving high-dose steroids should not receive the vaccine.18,21
Other immunizations recommended for all adolescents include a second dose of MMR (if the patient has not had 2 doses ³ 12 months of age) and a Td booster (if no dose in previous 5 years; subsequent routine doses required every 10 years).18 Establishing annual preventive health visits in adolescents may help ensure adequate immunization status.
Sexual Behavior/Activity
Sexual behavior/activity is an extremely important area for adolescent health providers. By their senior year in high school, 67% of teens have become sexually active.10 Teen pregnancy rates in the United States are among the highest in the developed nations,22 and one-third of the 20 million cases of sexually transmitted diseases (STD) reported annually in the United States occur in adolescents.23 Adolescents are also at increased risk of having asymptomatic STDs, and girls are at increased risk of acquiring STDs due to immature biological cervical defenses.23
Effective prevention of STDs involves counseling for abstinence and for use of barrier methods, which should be included in routine adolescent health maintenance visits. The most effective methods of reducing teen pregnancy include counseling to delay the onset of sexual activity and providing birth control to adolescents who are already sexually active.22 Two topics that deserve particular mention in regard to adolescents are long-acting hormonal contraception and emergency contraception after intercourse.
Table 2. Recommendations for Cholesterol Screening Based on Risk Factors
Indications for Screening Initial laboratory test
Parent or grandparent with Fasting lipid profilecoronary atherosclerosis at age £ 55 years
Parent or grandparent with Fasting lipid profiledocumented myocardial infarction, angina, peripheral vascular disease, cerebro-vascular disease, or sudden death
Parent with blood cholesterol Total cholesterol level³ 240 mg/dL
Parental history unavailable, Total cholesterol levelespecially if other cardiovascular risk factors present
Adolescent with risk factors for Total cholesterol levelcoronary heart disease independent optionalof family history: cigarette smoking,hypertension, severe obesity,diabetes mellitus, physical inactivity
The two long-acting contraceptives currently available in the United States are Depo-Provera and Norplant. They are especially useful for adolescents who tend to be irregular in their use of birth control. Among sexually active teens now, 5.4% use one of these two methods.24 These are very well tolerated, as only 5-14% of Norplant users discontinue use within their first year, which compares with 45-60% discontinuation among oral contraceptive (OCP) users.22
Side effects of Depo-Provera and Norplant are primarily irregular menstrual bleeding (seen in 66% of adolescents who discontinue use of either method), weight gain (in 40% of those discontinuing), and headaches and mood changes (30%).25 These methods have few dropouts, and, even among the dropouts, up to 51% would consider re-starting their method, and up to 73% would recommend it to a friend.25 Irregular menstrual bleeding can be managed with estrogen to improve compliance, though most clinicians move to OCPs in this case. Abnormal Pap smears with atypia or squamous intraepithelial lesions are seen in 28-45% of adolescents on Norplant or Depo-Provera and are managed with more frequent exams. In one study, the Pap reverted to normal for most girls upon discontinuation of these contraceptive methods.25 After discontinuing either method, menstrual periods were re-established in 81% of prior Norplant users in the first month, as compared with 50% after Depo-Provera.25 Depo-Provera is given in a 150 mg dose by deep intramuscular injection every 12-13 weeks, with the first injection given during the first five days of a menstrual cycle, or after two negative pregnancy tests two weeks apart, with OCPs used in the interim.
Emergency contraception (EC) methods have been available for 25 years; however, in February 1997, the FDA officially approved the use of oral contraception pills for EC.26 Availability of EC leads to reduced rates of abortion and unintended pregnancy.27 Knowledge of EC has been shown to be high among adolescents, but use is low due to poor knowledge of proper timing and side effects and limited physician knowledge.27 It has been suggested that all teenagers, even when virginal, be offered information on EC at routine visits.26,27
The seven regimens that are approved and are currently available in the United States are shown in Table 3. The progestin only regimen (Ovrette) must be initiated within 48 hours of unprotected intercourse, with the others being effective if initiated within 72 hours. These regimens are 75% effective, which reduces the risk of pregnancy to 1-8% per episode, depending on the timing of intercourse within the cycle.26
These methods primarily work by creating an unstable uterine lining which prevents implantation, and, therefore, they do not function as abortifactants. They may be used after unprotected sex, after a failed contraceptive method, or if more than three consecutive days of OCPs were missed prior to intercourse. Contraindications are similar to those for OCPs, with the exceptions that thrombo-phlebitis and prior ectopic pregnancy are only relative contraindications, and diabetes and mild hypertension are not contraindications due to the brief duration of therapy. Minor side effects include dizziness, abdominal cramps, and headache. Nausea is seen in 50% and vomiting in 20% of those using EC, and most providers prescribe anti-emetics 30 minutes before ingesting the first pills. If vomiting occurs within three hours of a dose of EC, that dose should be re-taken. Initial visits for EC should include a pregnancy test, a review of all sexual activity, encouragement of abstinence for two weeks, and scheduled repeat pregnancy test in two weeks.26
A complete discussion of STDs is beyond the scope of this paper. Readers are referred to the report of the Committee on Adolescence of the American Academy of Pedicatrics.23 An important note on treatment is that ciprofloxicin, an accepted treatment for Neisseria gonorrhea and chlamydia, is relatively contraindicated in persons less than age 18, although if crucial they can be used in anyone with a Tanner development level of 4 or greater.
Table 3. Emergency Contraceptive Pill Regimens
Brand name Instructions Total estrogen and progesterone
Ovral 2 tablets orally, then 2 tablets in 12 hours 200 mcg ethinyl estradiol plus 2.0mg norgestrel
Lo-Ovral 4 tablets orally, then 4 tablets in 12 hours 240 mcg ethinyl estradiol plus 2.4 mg norgestrel
Nordette, or Levlen 4 tablets orally, then 4 tablets in 12 hours 240 mcg ethinyl estradiol plus 1.2 mg levonorgestrel
Triphasil, or Tri-Levlen 4 tablets orally, then 4_ tablets in 12 hours 240 mcg ethinyl estradiol plus 1.0 mg levonorgestrel
Ovrette* 20 tablets, then 20 tablets in 12 hours 3.0 mg levonorgestrel
* Must start within 48 hours of unprotected intercourse. _ Yellow tablets only.
Reprinted by permission of Thomson science.26
Eating Disorders
Eating disorders, specifically anorexia nervosa (AN) and bulimia nervosa (BN), affect adolescents at a time of critical growth and development, requiring meticulous attention to diagnosis and treatment. Most studies of eating disorders report prevalence of AN as 0.5-1%, with boys' rates consistently 10% that of girls'.28 The prevalence of BN was reported as 1-5% of adolescent girls throughout the 1980s, by strict DSM III-R criteria, but 10-50% of adolescent girls in studies reported occasional self-induced vomiting or binge eating.29 Approximately 50% of patients with eating disorders have had onset of their illness before age 18. The seeds for possible eating disorders are planted early, as 60% of 6- to 12-year-old girls in one study thought themselves too fat, and 35% reported attempting at least one diet.28 This trend persists, with one-half to two-thirds of adolescent girls seeing themselves as overweight, although only 10-15% truly are.28 This distorted self-perception leaves young girls vulnerable to development of a formal eating disorder.
Although eating disorders occur in both adolescents and adults, many issues are unique to adolescents. Both AN and BN have diagnostic criteria defined in the DSM-IV;30 however, in adolescents, some differences should be noted. Standard height-weight tables commonly used for adults should not be used for assessment of adolescents, but, instead, one should use curves of height, weight, and body composition changes developed specifically for adolescents.31 Although weight loss is one of the diagnostic criteria for AN in adults, this is not necessarily present in younger adolescents, who may instead have failure to gain appropriate weight.29 In older adolescents, a body mass index of less than 18 may be used as a diagnostic criterion.28 Also, the amennorrhea criterion defined as absence of three consecutive cycles, is less useful, as AN may develop in pre-menarchal girls, and may even delay menarche. Additionally, within the first two years of having cycles, healthy adolescents may have periods of amenorrhea lasting more than three months.29 For this reason, it has been proposed that in adolescents the combination of dieting associated with amennorrhea be considered a worrisome sign, warranting thorough assessment.
Although worried parents may bring an adolescent to a primary care physician for evaluation of weight loss, eating disorders may have different presentations. Patients with either type of disorder may present independently or at the request of parents for evaluation of menstrual irregularity, depression, fatigue, or weakness. Patients with AN may enter the health care system first following a sports injury or pathologic fracture. Patients with BN may complain of palpitations or request advice about dieting.28 Physical exam findings suggestive of an eating disorder are noted in Table 4.
The many medical complications of eating disorders and their treatment are beyond the scope of this paper. Adolescence is a unique time of physical, sexual, and emotional development. Development of an eating disorder in this period carries significant risk, including the potential for significant growth retardation, pubertal delay or interruption, and peak bone mass reduction.29 For this reason, the Society for Adolescent Medicine, in its position paper on eating disorders, recommends that the threshold for intervention in adolescents should be lower than in adults.32 In clinical practice, a diagnosis of an eating disorder should be considered in an adolescent who engages in potentially unhealthy weight-control behavior and/or demonstrates obsessive thinking about food, weight, shape, or exercise. Ongoing medical monitoring is recommended until the patient has returned to both medical and psychological health.32
In addition to direct complications of eating disorders themselves, adolescents with eating disorders (especially those with BN) also demonstrate other risky behaviors. One study of girls aged 12-17 with AN found 10% had attempted suicide, 11.9% self-reported stealing, and 11.9% were sexually active; of those with BN, 31% had attempted suicide, 32.8% reported stealing, and 63.8% were sexually active.33 Substance use was also more common in BN-67.2% had ever used alcohol, with 29.3% using at least weekly, and 29.3% had ever used cigarettes, 31% marijuana, 12.1% amphetamines, and 8.6% cocaine.33 These behaviors must be addressed throughout evaluation and treatment.
Table 4. Physican Examination Findings Suggestive of an Eating Disorder
Dry skin Thinning hair
Bradycardia Hypotension
Stomatitis Parotid gland enlargement
Lanugo hair Dependent edema
Dental caries Hypothermia
Calloused knuckle(s) Carotene pigmentation
Any treatment plan for an eating disorder should include the same goals-normalization of weight and emotional and psychological adjustment. This may occur in a variety of settings, including in-patient, out-patient, and day treatment, depending on the medical and psychological status of the patient.29 For AN, nutritional rehabilitation is the key, along with family and individual therapy, in a setting familiar with adolescents and eating disorders. Additional medications are seldom helpful. In BN, however, anti-depressant medications (mainly serotonin specific re-uptake inhibitors), in combination with therapy and education, are believed to improve outcomes.28 Physicians working with adolescents have a unique opportunity to identify eating disorders and intervene early.
Depression
Major depressive disorder (MDD) may present during adolescence, with important implications for diagnosis and management.
The prevalence of MDD increases during adolescence, rising from childhood levels of 1% prepubertally to adult levels of 6-8% by the end of the teenage years.34 It affects twice as many girls as boys.35 The diagnostic criteria in adolescents parallel those in adults, except that in adolescents a persistently irritable mood may be substituted for a depressed mood in some cases.34 Clinical and epidemiologic studies have demonstrated that 40-70% of depressed adolescents have comorbid psychiatric disorders, most frequently anxiety disorder, but also dysthymic disorder, disruptive disorder, and substance abuse.36,37 Many adolescents present to physicians because of "excessive" or recurrent somatic complaints, either independently or due to parental concern. Adolescents may describe mood symptoms similar to adults but may also describe more atypical depressive symptoms, such as hypersomnia, hyperphagia, or excessive fatiguability.35 Assessment of psychosocial functioning (school performance, family interactions, and peer relationships), including recent changes, may point toward a diagnosis of depression.38
The diagnosis of depression can most often be made by a thorough history and physical. These should be used to rule out medical disorders, with special attention to signs and symptoms of thyroid disease and substance abuse, and to evaluate for iatrogenic causes (corticosteroids, phenobarbital, etc.).35 Routine laboratory screening is not indicated unless elements of the history or physical raise concern.
Depression in adolescents has considerable short-term and long-term morbidity, as well as increased mortality, often due to suicide.34,37 Mean duration of an episode of MDD in adolescents is approximately 7-9 months. A cumulative probability of recurrence of 40% by two years and 70% by five years exists.36 Depression presenting in adolescence may recur in adulthood. Rao et al report that 69.2% of adolescents in their study, diagnosed with MDD and followed into young adulthood (a mean of 7 years after diagnosis), had had recurrent episodes.37 Neither age of onset, severity of depression, suicidality, nor global functioning at diagnosis predicted recurrence.37 Suicide is a possibility in any adolescent with MDD, and assessment for suicidality should continue throughout diagnosis and treatment.34
Treatment available for adolescent MDD includes pharmacotherapy and psychotherapy. Selective serotonin re-uptake inhibitors (SSRIs) are considered the first line of pharmacotherapy.34,35 Tricyclic anti-depressants have little role in usual adolescent MDD, as they are fairly ineffective34,35,39 and can have adverse effects in adolescents. Adolescents may benefit from a gradual increase in SSRI dose, from a lower starting dose to published target doses. Treatment of 8-12 weeks at the target dose may be needed to see a full effect. If significant improvement has occurred at this time, therapy should be continued to complete six months, followed by gradual withdrawal of medication. If no or only partial improvement is achieved after 8-12 weeks, further strategies beyond the scope of this paper are appropriate.34 Individual, and sometimes family, psychotherapy is felt to be a necessary component of the treatment of adolescents with MDD.34,35
Attention Deficit Disorder
Attention Deficit Disorder (ADD) or Attention-Deficit Hyperactivity Disorder (ADHD) is a relatively common disorder affecting up to 5% of schoolage children.40 It is now understood that ADHD does not disappear as children age, but manifestations change and may lessen, and affected individuals may learn to cope. Thus, the identified prevalence of individuals displaying ADHD is lower in adolescents than in younger children and is even less in adults.41 However, some individuals may not be diagnosed until adolescence or adulthood, and the risk of serious morbidity from ADHD is highest in adolescents.42
Diagnosis. The diagnosis of ADHD requires rigorous history taking in two areas. First, classic historical data must be present. The individual should fulfill the DSM-IV30 criteria for ADHD (see Table 5) and should score in an abnormal range on one of several standardized ratings scales for ADHD. The most commonly used scale is the Conners parent and teacher rating scales, which include DSM-IV criteria questions and which can be obtained from the ADD Warehouse (954-792-8100). Secondly, other causes of the behaviors being addressed should be considered. This involves reviewing the child's birth and development; reviewing family, medical, psychosocial and scholastic history; and screening for visual, hearing, and neurobehavioral abnormalities.43 Confounding diagnoses such as hearing or visual loss, head trauma, seizures, insufficient nutrition or sleep, severe medical disorder, medications, drug abuse, and psychiatric diagnoses must be ruled out.44
Table 5. Diagnostic Criteria for Attention Deficit Hyperactivity Disorder
A. Either (1) or (2):
(1) Six (or more) of the following symptoms of inattention have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:
Inattention
a. Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities
b. Often has difficulty sustaining attention in tasks or play activities
c. Often does not seem to listen when spoken to directly
d. Often does not follow through on instructions and fails to finished schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions)
e. Often has difficulty organizing tasks and activities
f. Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework)
g. Often loses things necessary for tasks or activities (for example, toys, school assignments, pencils, books, or tools)
h. Is often easily distracted by extraneous stimuli
I. Is often forgetful in daily activities
(2) Six (or more) of the following symptoms of hyperactivity-impulsivity have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:
Hyperactivity
a.) Often fidgets with hands or feet or squirms in seat
b. Often leaves seat in classroom or in other situations in which remaining seated is expected.
c. Often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness)
d. Often has difficulty playing or engaging in leisure activities quietly
e. Is often "on the go" or often acts as if "driven by a motor"
f. Often talks excessively
Impulsivity
g. Often blurts out answers before questions have been completed
h. Often has difficulty awaiting turn
i. Often interrupts or intrudes on others (for example, butts into conversations or games)
B. Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before age 7 years
C. Some impairment from the symptoms is present in two or more settings (for example, at school [or work] and at home)
D. There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning
E. The symptoms do not occur exclusively during the course of a pervasive developmental disorder, schizophrenia, or other psychotic disorder and are not better accounted for by another mental disorder (for example, mood disorder, anxiety disorder, dissociative disorder, or a personality disorder)
Code based on type:
314.01 Attention-Deficit Hyperactivity Disorder, Combined Type: If both Criteria A1 and A2 are met for the past six months
314.00 Attention-Deficit Hyperactivity Disorder, Predominantly Inattentive Type: If Criterion A1 is met but Criterion A2 is not met for the past six months
314.01 Attention-Deficit Hyperactivity Disorder, Predominantly Hyperactive-Impulsive Type: If Criterion A2 is met but Criterion A1 is not met for the past six months
Permission granted from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Copyright 1994, American Psychiatric Association30
Pathophysiology and Epidemiology. The cause of ADHD is not well known; however, there is new information that has interesting promise in this regard. It has been shown that central spinal fluid (CSF) concentrations of homovanillic acid, the principal dopamine metabolite, correlate both with the degree of hyperactivity and with response to stimulant medication for ADHD.42 It is known that, in unaffected individuals, CSF dopamine metabolite concentrations peak at age 2 then decline. It is speculated that an abnormal lack of such decline may cause ADHD.42 Studies have also related maternal smoking during pregnancy to ADHD, and such smoking increases fetal brain nicotine receptors, leading to increased dopaminergic activity.45 Evidence for a genetic cause includes C4B null genes and certain alleles of DR4 histocompatibility genes being found in 40% of parents of ADHD children, 55% of the children, but only 7.7% of controls, and that 51% of twins of ADHD-affected individuals have ADHD.46
Some epidemiologic issues are of particular importance in caring for adolescents. ADHD is primarily a male disorder, as male to female prevalence varies from 3:1 to 9:1 in studies.47 Hyperactivity in affected individuals is seen less often in girls and may lead to under-diagnosis in girls. It has been shown that teachers under-recognize inattention in girls,47 so particular vigilance is needed to identify girls with the disorder. Affected girls tend to have more intellectual impairment and more difficulty with increasing peer rejection as they age than affected boys,47 and these issues need to be considered in counseling adolescent girls with ADHD.
Substance abuse and driving difficulties are rampant in adolescents with ADHD. Significant driving offenses are four times as likely and not wearing seatbelts five times as likely in adolescents with ADHD compared with unaffected individuals.48 ADHD doubles the risk of substance abuse, worsens its severity, and lowers the age of onset by three years compared with unaffected individuals.49 Figures have been reported that as many as 52% of adolescents actively manifesting ADHD have substance abuse or criminal behavior problems.42 Additionally, adolescents with ADHD, even more than affected younger children, have particular problems with poor self-esteem, poor peer relations, and non-compliance with treatment regimens.44
Treatment. Treatment of ADHD in adolescents as well as children consists of behavior and environmental modification and stimulant medication. Modifications that are helpful include proper classroom placement, provision of structure at home and school, counseling, and positive re-enforcement and promotion of self-esteem.43 For adolescents, prevention programs for substance abuse and particular vigilance for signs of substance abuse and reckless driving are crucial, as is promotion of self-esteem.
The primary medications for improving the inattention and/or hyperactivity of ADHD are stimulant medications. They should be initiated after an appropriate evaluation and only when there is evidence of significant disturbances in intellectual performance or social functioning. The following is a capsule summary of such medicines.43,50
Methylphenidate is most often used. It is started in a single 5 mg dose and should be advanced to be given in the morning and at noon and titrated upwards with a target of 0.3-0.8 mg/kg for each dose. The maximum suggested total daily dose is 60 mg.
Dextroamphetamine is often the second line choice. It is started in a 2.5-5 mg initial dose, may be given once or twice daily, and is titrated to a daily dose of 0.15-0.4 mg/kg, with a maximum of 40 mg recommended. If two daily doses are used, the second should be 5-10 mg less than the first. Benefits for dextroamphetamine and methylphenidate are seen almost immediately, and doses can be titrated every 3-7 days. The newest drug marketed for ADHD, Adderall, is a combination of dextroamphetamine and amphetamine salts. It is started at 5 mg daily and given once or twice daily, with a maximum dose of 40 mg daily. It does not have proven efficacy in long-term studies and is primarily reserved for children in whom other drugs have failed.50
Pemoline is the third drug of choice. It is started as a 37.5 mg dose daily and increased in 18.75 mg increments, with a maximum of 112.5 mg daily. It is given once a day and may take three weeks to begin showing a benefit, so it is titrated slowly.
The major side effects of these drugs are anorexia, stomachache, insomnia, and headaches. Tics may begin or increase on these medications, with Pemoline least likely to cause this. There is individual variation of side effects, so if one medicine isn't tolerated, another should be tried. Pemoline can cause hepatic abnormalities, and liver tests must be checked every six months. Dextroamphetamine may increase heart rate and blood pressure. Each of these medicines is about 70-80% effective in improving symptoms. No long-term growth retardation has been well confirmed, and, during drug holidays and after discontinuing medications, growth spurts have been noted.50 Recently, more long-term studies have been published,51 with no additional side effects reported. Drug holidays may be beneficial during vacations but only if the medications are being used solely to benefit schoolwork. Anti-depressants and clonidine have been used in individuals who cannot tolerate stimulants, but they have significant side effects and should be reserved for use by specialists.
Table 6. Current Resources in Adolescent Medicine
Emans SJ, Laufer MR, Goldstein DP. Pediatric and Adolescent Gynecology, 4th ed. Philadelphia: Lippincott-Raven; 1998.
Friedman SB, Fisher M, Schonberg SK, Alderman EM (eds). Comprehensive Adolescent Health Care, 2nd ed. St. Louis, MO: Mosby-Year Book; 1998.
Hofmann AD, Greydanus DE. Adolescent Medicine, 3rd ed. Stamford, CT: Appleton & Lange; 1997.
Neinstein LS. Adolescent Health Care: A Practical Guide, 3rd ed. Baltimore: Williams & Wilkins; 1996.
Strasburger VC, Brown RT. Adolescent Medicine: A Practical Guide, 2nd ed. Philadelphia: Lippincott-Raven; 1998.
Summary
Adolescence is a unique time, and health care of adolescents requires special knowledge and approaches. Adolescents are in a transition phase from childhood to adulthood, and thus neither traditional pediatrics nor adult medicine is quite an appropriate model for adolescent health care. Primary care physicians should remember to pay special attention to confidentiality when dealing with adolescents. A list of current resources in adolescent medicine is provided in Table 6.
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