Adolescents with learning disorders are at significantly increased risk for negative outcomes in regard to their emotional, behavioral, and academic functioning. Primary care physicians should be alert to the effect of neurodevelopmental dysfunctions that might be taking their toll as academic demands increase or as new manifestations of previously identified problems emerge. The physician should review emotional, family, and environmental factors and rule out underlying or associated medical causes and can participate in the assessment process. He or she can advise and assist parents with obtaining necessary evaluations through the school or by referral to independent clinicians and should assist with the interpretation of the findings, ensuring appropriate understanding of the challenges by the adolescent and parents and coordinating care if other medical specialists are involved. The physician can direct students and their families to appropriate resources in the community and advocate for appropriate educational services at school. Brief office-based counseling can help in dealing with the stresses associated with learning challenges and ensuring that students are afforded regular opportunities to pursue their affinities and build on their strengths.
Adolescent males who self-identify as gay or bisexual come from all walks of life all socioeconomic backgrounds all religious denominations and all racial and ethnic groups. They live in urban centers suburban communities and small rural towns. Providing health care to this subpopulation of youth can be challenging to health care providers because of a pervasive societal stigma surrounding same gender sexual activity and sexual minority youth. Although gay and bisexual male youth share many of the same adolescent struggles as their heterosexual peers growing up in a society that often rejects and disapproves of them creates unique challenges to healthy physical and psychological development. Here we discuss the role of sexual identity formation in the lives of gay and bisexual male adolescents review some of the greatest challenges to their overall health and well-being and provide guidance for clinicians wishing to improve the delivery of health care services to this vulnerable population of youth. (excerpt)
The female athlete triad is a syndrome consisting of disordered eating, amenorrhea, and osteoporosis. The syndrome is increasing in prevalence as more women are participating in sports at a competitive level. Behaviors such as intense exercise or disordered eating patterns can lead to dysregulation of the hypothalamic-pituitarian-ovarian (HPO) axis, resulting in amenorrhea. Hypothalamic amenorrhea can lead to osteoporosis and increased fracture risk. Adolescents may particularly be at risk because it is during this crucial time that females attain their peak bone mass. Prevention of the female athlete triad through education and identification of athletes at risk may decrease the incidence of long-term deleterious consequences. Treatment of the female athlete triad is initially aimed at increasing caloric intake and decreasing physical activity until there is resumption of normal menses. Treatment of decreased bone mineral density and osteoporosis in the adolescent population, however, is controversial, with new treatment modalities currently being investigated in order to aid in the management of this disorder.
Many of the behavioral interventions designed to promote dietary change in individuals include medical assessment, initial assessment of diet history, assessing readiness, establishing dietary goals, self-monitoring, stimulus control training, training in problem solving, relapse prevention training, enlisting social support, nutrition education, dietary therapy, and ongoing contact to maintain progress. The comprehensive nature of a cognitive-behavioral weight management program is of value in modifying behaviors that are linked to adverse health effects and psychological distresses, without necessarily causing a drastic weight loss in obese individuals. The behavioral treatments for overweight and obesity directly modify behaviors that bear on health and illness, such as improving dietary choices, decreasing sedentary behaviors, and increasing habitual physical activity and exercises. Cognitive-behavioral treatment can be used to help overweight adolescents become more assertive in coping with the adverse social stigma of being overweight, enhance their self-esteem, and reduce their dissatisfaction with body image regardless of their weight loss. Cognitive-behavioral treatments seem to be more effective in children when delivered before puberty than they are for adults.
Starting in adolescence males use health care services less than females. Younger adolescent males who use existing services rely on access to their primary clinician: pediatricians adolescent medicine physicians family physicians internists or nurse practitioners. Older adolescent and young adult males obtain medical care from hospital emergency departments more often than primary care clinicians. Many adolescent males who do have contact with clinicians receive limited medical examinations whether for injuries or for sports physicals. There are few opportunities for preventive health messages or discussions with male adolescents; only one third report talking with a clinician about a reproductive health topic. Unfortunately utilization of health services decreases further as males leave high school and become increasingly disconnected from traditional venues that provide preventive health care services and education to young people. (excerpt)
The female athlete triad is a syndrome consisting of disordered eating, amenorrhea, and osteoporosis. The syndrome is increasing in prevalence as more women are participating in sports at a competitive level. Behaviors such as intense exercise or disordered eating patterns can lead to dysregulation of the hypothalamic-pituitarian-ovarian (HPO) axis, resulting in amenorrhea. Hypothalamic amenorrhea can lead to osteoporosis and increased fracture risk. Adolescents may particularly be at risk because it is during this crucial time that females attain their peak bone mass. Prevention of the female athlete triad through education and identification of athletes at risk may decrease the incidence of long-term deleterious consequences. Treatment of the female athlete triad is initially aimed at increasing caloric intake and decreasing physical activity until there is resumption of normal menses. Treatment of decreased bone mineral density and osteoporosis in the adolescent population, however, is controversial, with new treatment modalities currently being investigated in order to aid in the management of this disorder.
This article provides a rationale for interventions aimed at the prevention of eating disorders and obesity, an overview of some of the questions and controversies currently facing the fields of eating disorder and obesity prevention, and a discussion of the potential for integrated prevention approaches that address the broad spectrum of weight-related disorders. A rationale for utilizing an integrated approach, the challenges inherent to developing such an approach, and suggestions for working toward integrated approaches aimed at preventing the broad spectrum of weight-related disorders are discussed.
Human papillomaviruses (HPVs) are members of the Papillomaviridae family of DNA viruses. More than 100 types have been identified; some HPV types cause nongenital cutaneous infection and other HPV types cause anogenital mucocutaneous infection. Based on their association with cervical cancer anogenital HPV types have been classified further: low-risk types (e.g. 6 11) are associated with anogenital warts and mild dysplasias and high-risk types (e.g. 16 18 31 45) are associated with anogenital cancers and high-grade dysplasias. In contrast to other sexually transmitted pathogens HPV cannot be cultured and no serologic test is available for clinical use. HPV infection is assessed clinically and by detection of HPV DNA. Anogenital HPV infections are estimated to be the most common sexually transmitted infection; an estimated 5.5 million adults are infected with HPV annually. In one study cumulative annual incidence in young women was 43%. It is unclear whether the high prevalence of genital HPV infection is because the virus is easily transmitted remains infectious on the genital mucosa for long periods or both. (excerpt)
Overlooked amid the advances made in womens health over the past decade strategies for improving the health status of men and the quality of health care that they receive are now emerging. The importance of this is made clear from national data indicating that at birth the life expectancy for men is an average 5.4 years less than that for women (5.2 years for non-Hispanic Caucasians and 6.7 for African Americans). The age adjusted death rates for leading causes of premature mortality such as heart disease malignant neoplasm and motor vehicle crashes are also substantially greater for men than for women (32% 32% and 56% greater respectively). Greater emphasis on the value of prevention is also emerging. In the medical model attention is directed traditionally toward early detection and treatment of conditions such as heart disease hypertension cancer and hyperlipidemia. Using the public health model of prevention attention is directed toward antecedent factors that contribute to disease. The need for this approach was made clear in a seminal study which concluded that personal behaviors such as tobacco diet and physical activity alcohol firearms sexual behavior motor vehicles and illicit use of drugs accounted for approximately 42% of the 2.148 millions deaths during 1990. (excerpt)
Pubertal changes generally commence in males between 9.8 and 14.2 years with a mean of 11.8 years. Although there are a number of diseases that can lead to delayed puberty in males the vast majority of boys who experience delayed puberty have no underlying clinical pathologic condition. In a large case series of patients with delayed puberty 63% of males were found to have a constitutional delay. Of the remaining males with delayed puberty 19% had functional hypogonadotropic hypogonadism (FHH) and went into spontaneous pubertal development albeit late. Conditions leading to FHH in males included growth hormone deficiency hypothyroidism Crohns disease celiac disease sickle cell anemia seizure disorders and severe asthma. Males are much less likely than females to have a clinical pathologic condition as a basis of delayed onset of puberty; in fact most boys who enter puberty late have a family history of delayed pubertal development. (excerpt)
In most aspects of life the adolescent is at an awkward transition between childhood and adult life. In medicine and especially urology this gray zone pertains often to the disadvantage of these individuals--too big to consider themselves children but clearly not adults. The genitourinary problems of adolescent males perhaps a unique species unto themselves span a wide range from undetected congenital anomalies to developmental and environmentally acquired problems. Most genitourinary anomalies are detected in infancy if not before by virtue of antenatal ultrasonography and careful newborn examination. Many children do not receive these examinations however and only later in childhood are the problems identified. (excerpt)
Lack of physical activity is a known determinant of obesity. Unfortunately, children become less and less active as they reach and progress through adolescence. This behavior leads to detrimental effects on body composition and other components of health-related physical fitness. Various types of exercise and activities have different effects on fitness, body composition, and metabolic state. For a physician to recommend activities or sports and exercise type, he or she should examine and discuss the patients fitness and physique goals to maintain their enthusiasm and promote lifelong physical activity benefits.
Osteopenia is a frequent and severe complication of anorexia nervosa. Once established, it is difficult to treat and is only partially reversible. Osteoporosis is a preventable disease, and intervention should begin during childhood and adolescence. Optimizing peak bone mass accrual during adolescence is essential, and an episode of anorexia nervosa during adolescence interferes with that process. In anorexia nervosa, results with hormone replacement therapy have been disappointing. Calcium and vitamin D supplementation should be prescribed where necessary. Excessive exercise should be avoided and moderate weight-bearing exercise encouraged. Ongoing research studying newer modalities such as IGF-1, DHEA, and bisphosphonates looks promising. Until more effective treatment regimens become available, the mainstay of treatment remains weight gain, nutritional rehabilitation, and spontaneous resumption of menses.
The relationship among eating disorders (EDs), psychosexual and identity development, and physical maturation (puberty) is reviewed. The developmental tasks of adolescence are summarized, and research from both community studies and clinical samples on the association between the development of an ED and putative risk factors that include pubertal development and psychosexual behaviors and attitudes for children and adolescents is reviewed. Specific issues explored include the role of child and adolescent abuse and EDs in males. Overall evidence suggests the following: there are inconsistent findings regarding early pubertal development as a risk factor; there is some support for differences between the ED subtypes in sexual attitudes, behaviors, and experiences; sexual abuse is not a specific risk factor; and gender identity issues may play more of a role for adolescent males than females. However, psychosexual issues are neither sufficient nor necessary for the development of an ED in a young person. It should be considered as only one factor in the multidimensional, multifactorial framework needed to clarify this complex and still poorly understood set of disorders.
The long-term goal of medical nutrition therapy for adolescents who are overweight or at risk for becoming overweight is to promote healthy lifestyle behaviors. These behaviors will, in turn, improve metabolic parameters and self-esteem while helping the adolescent achieve and maintain a desirable body weight. The identification of anthropometric, metabolic, nutritional, and environmental risk factors present in the child and family will help formulate the medical nutrition intervention. A well-balanced diet that supports growth and development, aerobic exercise, and cognitive behavioral strategies are essential components of an intervention program. Frequent and long-term monitoring by a registered dietitian and pediatrician will reinforce lifestyle changes and support the adolescent and family in achieving realistic goals of weight loss or weight maintenance. This article covers the assessment and interventions necessary for successful nutrition therapy for obese and superobese adolescents.
Anorexia nervosa (AN) commonly arises during adolescence and is associated with significant medical morbidity. Abnormalities in brain structure and function are among the most common, early, and concerning physical consequences. Advances in neuroimaging technology have played an important role in delineating the structural and functional changes found in patients with AN. Studies using computed tomography and magnetic resonance imaging have demonstrated changes in brain structure in the low-weight stages of AN. In addition, functional neuroimaging techniques have demonstrated altered brain metabolism. Debate continues as to whether these brain abnormalities are fully reversible with weight restoration. Neuropsychological research has demonstrated that cognitive dysfunction is also a common feature of AN. Multiple studies have indicated deficits in various neuropsychological domains. Whether the reported cognitive deficits are reversible with weight gain remains unknown. To date, some preliminary evidence suggests that reported cognitive deficits in patients with AN may be associated with structural brain abnormalities. This chapter reviews the current literature about neuroimaging studies and cognitive function in adolescents with AN, discusses the possible underlying mechanisms causing these changes, and explores the possible association between them.
This article addresses practical issues facing the primary care practitioner caring for an adolescent with an eating disorder. It is grounded in the four elements of successful treatment noted by Comerci: (1) recognizing the disorder and restoring physiologic stability early in its course, (2) establishing a trusting, therapeutic partnership with the adolescent, (3) involving the family in treatment, and (4) using an interdisciplinary team approach. Although primary care practitioners often have an established relationship with their patients, adolescents with eating disorders present special challenges. These adolescents tend to be bright, strong-willed, and wary of any recommendations to change their weight-control practices for fear that they will lose control. Their families are often distraught by the conflicts that arise as a result of the disordered eating behaviors and the fear that the condition is associated with significant morbidity and mortality. The article provides primary care clinicians with pragmatic ways to diagnose and initiate treatment and engage the patient and parents as active participants and members of the therapeutic team in the early phases of treatment. In addressing these principles, the authors combine the nurturant-authoritative approach described by Levenkron with the biopsychosocial model proposed by Engel.
Eating disorders in children and young adolescents are increasing in prevalence and occurring at ever-earlier ages. Eating disorders in this age group differ from the traditional eating disorders seen in older adolescents and young adults in that they frequently present atypically, they are suspected less often, they are more difficult to diagnose definitively, and there is less evidence to guide informed treatment decisions. Classification of eating disorders in this population also presents unique challenges. A high index of suspicion and aggressive screening will help to prevent delays in diagnosis. Treatment should include attention to nutritional, medical, and psychological issues. Family therapy has emerged as the treatment modality with the greatest evidence for its efficacy. Prognosis has been poorly studied, but good outcomes are common, particularly with early intervention.
