Roughly speaking, what is the definition of an “adolescent ?”

10–21 years old

In the USA, what is the most common reason for 15–24-year-olds to visit a general outpatient clinic, if they are female?

Pregnancy !

Adolescents are frequent visitors to emergency departments. What are male adolescents usually seen for?

Injuries

(usually non-urgent)

What complaints most often bring adolescent girls to the emergency department?

 (3 categories)

Sore throat, abdominal pain, & pregnancy/sexual activity-related conditions

What is the leading cause of death for African-American adolescents?

Homicide

What is the leading cause of adolescent death & injury, for all adolescents together?

Car & motorcycle collisions

Risky behaviors during adolescence lead to this common cause of morbidity & mortality for Hispanic and African-American 24–44-year-olds. What is it?

HIV

What is the typical age for onset of puberty in African-American girls, and what is the range?

• 8 years

• Range is 6–10 years

How long does puberty usually last for girls?

4 years

How long does puberty usually last for boys?

3 years

What is the typical age for onset of puberty for Caucasian girls?

(average & range)

• About 10 years

• Range is 8–11 ½ years

When do boys typically begin puberty?

(average & range)

• 11 ½ years

• Range 9 ½–13 ½

In relation to Tanner stage, when do girls usually have their adolescent growth spurt?

Tanner stage 2 or 3

When do boys usually have their growth spurt, in relation to Tanner stage ?

Later –

Tanner 4

About what proportion of total skeletal height growth occurs during adolescence?

¼

(some sources indicate as much as ½)

What is the male pattern for lean body mass and fat percentage changes during adolescence?

•↑ lean body mass

•Small early ↑ in body fat (about 10 %)

Does respiratory rate increase or decrease during adolescence?

Decreases

(Remember, it’s heading toward the adult value)

Both boys & girls have a change in normal pulmonary function during adolescence. In particular, for the FEV₁/FVC ratio, what happens?

It decreases

(The ratio falls during childhood, then increases somewhat during the growth spurt of adolescence)

What impressive change occurs in the size of the heart in adolescent boys?

It doubles!!

What is the average age for menarche ?

12 ¾ years

(the average for African-American girls is somewhat younger)

What is usually the first sign of sexual maturation in a girl?

Thelarche

(development of breast buds)

In terms of sexual maturation, are boys more likely to have a negative self-image if they develop early or late?

Late

In terms of sexual maturation, are girls more likely to have a positive self-image if they develop early or late?

Late is more positive

(so it’s opposite in girls vs. boys)

In early adolescence (ages 10–13), most kids have difficulty with what type of behavioral regulation?

Impulse control

(and they usually also lack insight/ability to think about impulse control)

On the boards, if a health issue needs to be discussed with a 10–13-year-old, what are the “buzzwords” for how you should do that?

(3)

• Simple, clear language

• Direct communication

• Visual & verbal “cues” should be used

Who has their adolescent growth spurt earlier – girls or boys?

Girls do!

(Don’t they always say that “girls develop earlier?”)

Middle adolescents (14–16 years) have completed or nearly completed puberty. What is the most important force in their lives for support and change?

Peers

At what point in adolescence do individual relationships become more important than the peer group, as a whole?

Late adolescence

(17–21 years)

What are the top three reasons adolescents are hospitalized, in general terms?

1. Pregnancy

2. Psychiatric disorders

3. Injuries

Although specific guidelines vary from state to state, emancipated minors are generally defined as . . .?

 (4 criteria)

1. In the military

2. Married

3. Has children

4. Living independently & financially self-supporting

If you are required to notify parents of a minor child’s treatment, what must you do first?

Inform the minor

Is parental consent required for emergency treatment of a minor?

No –

No consent is needed

What situations always require the physician to break confidentiality?

1. Child abuse/elder abuse

2. Danger to self or others

Should adolescents be seen alone or with the parent(s)?

Alone

(at least for part of the time)

What is the guiding principle in providing adolescent health care?

Autonomy –

Give them as much autonomy as they wish, unless legal or safety concerns prevent it

What special areas are important to ask about in adolescent exams?

 (4 about the individual & 2 about relationships)

1. Peer & family relationships

2. Depression

3. Sexual relationships/activity

4. Substance use

5. Eating disorders

6. Self-image and school

What psychiatric problems are especially big issues in adolescents?

Depression

  &

Eating disorders

If you are legally required to report treatment of a minor, when the minor does not wish you to inform his or her parents, what are you supposed to recommend?

Bring the parents into the discussion, with the pediatrician as “facilitator” for the discussion

What self-exam techniques should you instruct adolescents about?

Girls – breast self-awareness

(breast self-exam per se is no longer mandatory, but it is an acceptable option)

Boys – testicular exam

(no proven benefit, however)

What sensory screening exams are important for adolescents, and why?

Vision – myopia sometimes occurs with the growth spurt

Hearing – due to the loud music

When should young women have their first pelvic exam ?

 (3 situations)

1. Vaginal discharge

2. Complaint of menstrual problems or pelvic pain

3. Reaches age 21

(Note: This is a change – previous recommendations were to institute pelvic exams between ages 11 & 21, depending on history/risk factors)

What two important cardiovascular risk factors should be screened for in adolescents?

Hypertension & dyslipidemia

(Note: Dyslipidemia screening is a recent addition! The dyslipidemia screen is recommended early, between ages 9 & 11 years)

What orthopedic issue should be screened for in adolescents?

Scoliosis

(>10 % curvature requires ortho referral)

How often should adolescents have routine exams, if they have no complaints?

Yearly

(for preventative care)

Should sexually active adolescents be routinely screened for STDs?

Yes – & risk assessment for STDs should be conducted each year

Should HIV screening be routinely conducted with adolescent patients?

Yes –

Between ages 16 & 18

Should the routine genital exam of an adolescent girl include a Pap smear ?

No –

Routine internal examination with or without a speculum is no longer recommended

Which psychiatric disorder should be routinely screened for in adolescent patients?

Depression –

screen yearly, due to risk of suicide in this group (along with other depression-related morbidity)

What immunizations are usually given in adolescence?

 (6 in total)

• Tdap booster (around age 11 years)

• Meningococcus & HPV (beginning around age 11 years)

• Annual influenza vaccinations

• MMR & Varicella (this is the second dose – they are given in early adolescence if the second dose was not given during early childhood)

If a child has chronic liver disease, what extra immunization should you give (in addition to the routine ones)?

Hepatitis A

What is the recommended standard of care for how often you should provide routine health guidance to an adolescent’s care giver(s)?

Yearly

At the yearly visit, what sorts of health guidance should you provide to an adolescent?

 (4 categories)

1. Injury prevention (especially seat belt & helmet use, weapons safety, violence avoidance, & importance of exercise)

2. Diet info

3. Sexual behavior info

4. Substance abuse info

Especially for sports-oriented adolescent boys, what substance abuse topic needs to be addressed?

Anabolic steroids

If a child engages in one type of risky behavior, is he or she more or less likely to engage in others?

MORE

Which gender is more likely to smoke – girls or boys?

Girls

Which gender is more likely to drink alcohol ?

Boys

(by a lot!)

How common is marijuana use in adolescents?

At least 50 %

What is the average of first use for marijuana ?

14 years

What are the biggest behavioral markers of kids who are at risk for substance abuse?

Poor impulse control/“unnecessary” aggressive outbursts

Which psychiatric disorders put adolescents at special risk for substance abuse?

Depression & anxiety disorders

What are the main factors in the child’s environment that put the adolescent at risk for substance abuse?

(2)

1. Peer group use

2. Household drug use (especially by parents)

What social changes in an adolescent’s life are warning signs for possible substance abuse?

• Increasing emotional/physical isolation

• New peer group members

What warning signs for possible substance abuse can be noted at school?

(3)

• Decrease in school performance

• Increased absences

• Decreased interest in sports or other school activities

If an adolescent is involved in a crime, should this make you worry that substance abuse could be an issue?

Yes

What learning difference greatly increases the probability that an adolescent will get involved in substance abuse?

ADD or ADHD

(Attention-deficit disorder or attention-deficit hyperactivity disorder)

What is the “ mature minor ” rule for provision of health care?

Low risk care that is clearly of benefit to the minor can be provided if the minor understands the risks & benefits

Is it all right to perform a urine drug screening without an adolescent’s permission?

Generally, no

Which fairly common psychedelic recreational drug is not identified by most urine toxicology screens?

LSD

Before puberty, depression is equally common in boys & girls. In adolescence, which group is more often clinically depressed?

Girls

(2–3× more)

What unusual presentation does depression in an adolescent sometimes have?

Boredom

The main manifestation of clinical depression is depressed mood or irritability with loss of interest in things. Adolescents are also likely to have what weight & appetite changes?

(3)

1. Weight loss or gain

2. Appetite decrease or increase

3. Failure of weight to increase appropriately to overall size

How long should symptoms of depression be present to allow a diagnosis of “ major depressive disorder ?”

More than 2 weeks (without an identifiable stressor)

What cognitive and specific emotional changes are markers of depression in adolescents?

(4)

1. Difficulty thinking/

concentrating

2. Recurrent thoughts of death

3. Guilt

4. Worthlessness

To make the diagnosis of major depressive disorder, the general requirement of depressed or irritable mood with diminished interest must be met, plus what else?

4 out of 9 associated symptoms

(weight issues, cognitive & specific emotional items, sleep, energy, & psychomotor changes)

The associated sleep disturbance accompanying depression in adolescents is _________?

Either insomnia or too much sleep

In terms of psychomotor activity level, what is expected with depression in adolescents?

Can either increase or decrease

For the associated depression symptom that has to do with fatigue/energy level, what is expected?

Low energy/increased fatigue

Do the boards like asking about depression in adolescents?

Yes!

If symptoms of depression are present, but an identifiable stressor has occurred in the past 3 months, what is the correct diagnosis?

Adjustment disorder with depressed mood

(Note: Adjustment disorders are considered to be “stress-response syndromes” in the new DSM V)

When depression or another major psychiatric disorder is suspected in an adolescent, what other types of problems should you consider?

(4)

1. Substance abuse

2. Chronic systemic illness (like SLE)

3. Thyroid disease

4. Nutritional issues

How does the age of onset for depression affect the expected course of the disorder?

Earlier onset = more severe disease & more recurrences

How long will major depression usually last if it is not treated?

About 8 months

When is it all right to hospitalize an adolescent for psychiatric reasons?

(4)

The usual –

1. Danger to self or others

2. Not responding to outpatient treatment

3. Mania

4. Treatment is complicated by active substance abuse

What are the typical meds used for bipolar disorder ?

1. Valproic acid (for mania) & lamotrigine (for depression)

2. Carbamazepine (for both)

3. Lithium (for both – tox issues are a problem with adolescents, especially)

(antipsychotic agents are also helpful in some patients)

How is bipolar disorder different from regular depression?

There is cycling in the mood (length of cycle varies), and many patients experience mania as well as depression

Mania is not absolutely necessary, though

What is the other name for a cycling mood disorder ?

Cyclothymic disorder

(cyclo = cycling)

(thymic = emotion)

What is dysthymic disorder?

(dys = bad)

(thymic = mood)

Chronic depressed mood for at least 1 year that doesn’t meet criteria for major depression

Are multiple psychiatric disorders often present in the same individual?

Yes

What is the preferred pharmaceutical treatment for depression in adolescents?

SSRIs

( serotonin reuptake inhibitors )

Why are SSRIs preferred to TCAs (tricyclic antidepressants) for medication-based treatment of depression?

1. More effective in this population

2. Much safer

Eating disorders are more common in which gender?

Girls

(10:1)

How common is anorexia nervosa among girls (in %)?

About 1 % of girls

(sources vary – lifetime prevalence 0.3–4 %)

What is the most common age of onset for anorexia nervosa?

13–18 years

(research suggests about 85 % have onset during this age range)

Is it common for anorexia to develop in very young adolescent girls, <13 years old?

It is less common than in the older teens, but still occurs regularly

(data on how common it is are quite mixed)

Girls who participate in what three athletic activities are notorious for having higher rates of eating disorders?

(very popular test item)

Gymnastics, ballet, figure skating

What personality traits are often present in the girls who later develop anorexia?

Perfectionism/overachievers

Do anorectics usually announce that they are going on a diet, when they first begin to manifest the disorder?

Yes

What is often occurring in the adolescent’s life, when anorexia first appears?

Transition or stressful events

(e.g., beginning at a new school level)

Data is quite mixed as to whether negative events are actually related to the onset of adolescent eating disorders or not

Anorexia has what effect on the sex hormones secreted by both boys & girls affected by the disorder?

Suppresses them

There were four diagnostic criteria for anorexia. Which one has been eliminated in DSM V?

No menstrual criteria

(Absence of three consecutive cycles was previously a criterion)

One of the criteria for anorexia has to do with an unusual fear. What is it?

Intense fear of becoming obese, which doesn’t decrease as weight loss occurs

What is strange about the body image of adolescents with anorexia?

They “see” themselves as fat, even if they are abnormally thin

(altered body image)

What is the behavioral criterion in the diagnostic criteria for anorexia nervosa?

Inability to maintain a minimally normal body weight

(the term “refusal” has been eliminated, because it implied a conscious intent not to maintain body weight, which is not necessarily the case)

In addition to calorie restriction & excessive exercise, what other behaviors do anorectics sometimes engage in, which are especially likely to cause serious problems?

(3)

1. Vomiting

2. Diuretic use

3. Laxative abuse

What electrolyte disturbances are especially common in anorexia?

Hypokalemia

  &

Hypochloremic metabolic alkalosis (due to vomiting)

Why might anorectics be anemic, aside from nutritional issues?

Anorexia tends to suppress the bone marrow – both RBCs and WBCs may be low

In general, anorexia nervosa is associated with a lowering of many body functions & secretions. What is elevated in anorectics?

Cortisol

 &

Endorphins

Due to the very low amount of body fat, anorectics are at especially high risk for what environmental problem?

Hypothermia

What is the most life-threatening aspect of anorexia nervosa?

Cardiac arrhythmias due to electrolyte derangements

(not starvation – although that is also possible)

What is the best way to evaluate an anorectic for risk of serious cardiac arrhythmias?

Exercise stress testing –

Prolonged QT or ST depression during exercise stress testing = high risk

What is a common, but less life-threatening, cardiac rhythm problem often seen in anorectics?

Bradycardia

Severe anorectics are at risk for CHF (congestive heart failure) if what treatment is initiated too rapidly?

Hydration

When treatment for anorexia is initiated, is it all right for weight gain to occur as rapidly as possible?

Slow gain is best to decrease complications

(About 1/3 kg per day is the maximum)

Which is more common, bulimia or anorexia?

Bulimia

What is the typical weight for a bulimic patient – normal, overweight, or underweight?

Normal or slightly overweight

Is it possible to have both anorexia & bulimia?

Yes –

Or some patients alternate between the two

At what age does bulimia typically begin?

Mid-to-late adolescence

In addition to metabolic alkalosis & hypokalemia, what other lab value might be abnormal in a bulimic patient?

Amylase

(elevated)

Lots of people get sore throats. Why do bulimics have sore throats?

Vomiting

Are bulimics at risk for cardiac arrhythmia?

Yes –

It just depends how far out of whack they get their electrolytes

What special & rather unusual findings are you supposed to look for when bulimia is suspected (especially on the boards)?

(3)

(very popular test item)

1. Missing tooth enamel (on the inner surface – due to stomach acid with vomiting)

2. Bilaterally swollen parotid glands

3. Calluses on the dorsum of the fingers (from inducing vomiting)

What other psychiatric disorders are often coexistent with bulimia?

 (2 groups)

Affective disorders

Obsessive-compulsive disorder(s)

What characteristic eating pattern is seen in bulimia?

Binging & purging

What are the three easiest-to-remember criteria for bulimia?

1. Binge eating (multiple times – not just once)

2. Feeling “out of control”

3. Purging/dieting/exercising

In order to differentiate bulimics from folks eating Thanksgiving dinner, what other bingeing criteria was added?

Average of > 1 binge/week for at least 3 months

(the same frequency criterion is used for “binge eating disorder,” which features mainly the food binging behavior, without the other aspects of bulimia nervosa)

There are a total of five diagnostic criteria for bulimia. What are they?

1. Binge eating

2. Feeling out of control about bingeing

3. Inappropriate compensatory behavior (purging/dieting/exercise/laxatives)

4. Persistent binging (avg of > 1 time/week × 3 months)

5. Ongoing concern about body shape or weight

What medication group is often helpful in bulimia, and sometimes helpful in anorexia?

SSRIs

Is pharmacotherapy alone usually successful with either bulimia or anorexia nervosa?

No –

Therapy, behavior modification, & nutritional guidance are usually also needed

Is asymmetric breast growth in an adolescent reason for alarm?

No –

It is common & may be present even in adulthood

What is the most common breast mass in an adolescent?

A fibroadenoma

The initial breast development, the breast bud, is made up of what types of tissues?

(3)

1. Ductal tissue

2. Stromal tissue

3. Fat

Later breast development, after the breast bud, is mainly comprised of growth in what two histological parts of the breast?

1. Ductal

2. “Lobular-alveolar”

Fibrocystic changes are most often symptomatic in what part of the breast?

Upper outer quadrant

The hallmark of fibrocystic breast cysts is _______?

Cyclic changes with the menstrual cycle

How common is accessory breast tissue or more than the usual two nipples?

Common –

1–2 % of females

Where will polymastia (accessory breast tissue) and extra nipples be found?

Along the mammalian “breast line”

(running vertically down the chest, like on a cat or dog)

What is the special word for more than two nipples?

Polythelia

How is the discomfort of fibrocystic breast tissue managed?

 (3 strategies)

1. NSAIDs

2. Breast support (a good bra)

3. Oral contraceptives

Is mammography a good way to evaluate a breast mass in an adolescent?

No –

The tissue is too dense

When should an otherwise not concerning breast mass be evaluated further in an adolescent girl?

If it lasts more than 3 cycles

(at the same size or larger)

How should a breast mass be evaluated initially, after physical exam?

Needle aspiration

If needle aspiration of a breast mass does not provide a definitive answer about the type of mass, what should be done?

Excisional biopsy

Nonpregnant adolescents sometimes develop mastitis. How should you treat it in this group?

 (3 strategies)

1. Antibiotics (PO)

2. Pain management

3. Local heat application

Which organism is the most likely cause of mastitis in an adolescent?

Staph aureus

Mastitis is most common in what two groups?

Newborns

  &

Lactating women

A painless, rubbery, breast mass that does not change with hormonal variation is probably a _______?