Recovery from osteopenia in adolescent girls with anorexia nervosa.

Osteopenia is a frequent complication of anorexia nervosa (AN). To determine whether the deficit in bone mineral changes during the course of this illness, we studied 15 adolescent patients prospectively for 12-16 months using dual photon absorptiometry of the spine and whole body. At follow-up, mean weight, height, and body mass index (BMI) had increased significantly, although 6 girls had further weight loss or minimal gain (less than 1.2 kg). Spontaneous menses occurred in 2 girls, and 3 others were given estrogen replacement. Bone mineral density of the lumbar spine did not change significantly (mean +/- SD, 0.836 +/- 0.137 vs. 0.855 +/- 0.096 g/cm2), while whole body bone mineral density increased (0.710 +/- 0.118 vs. 0.773 +/- 0.105; P less than 0.05). Despite gains in bone mineral, 8 patients had osteopenia of the spine and/or whole body. Changes in weight, height, and BMI were significant predictors of change in bone mineral density. Increased bone mass occurred with weight gain before return of menses; conversely, weight loss was associated with further decreases in bone density. In 1 patient who failed to gain weight, estrogen therapy resulted in increased spinal, but not whole body, bone mineral. We also studied a second group of 9 women who had recovered from AN during adolescence. All 9 had normal whole body bone mineral for age, but 3 had osteopenia of the lumbar spine. We conclude that osteopenia in adolescents with AN reflects bone loss, perhaps combined with decreased bone accretion. Weight rehabilitation results in increased bone mineral before the return of menses. Estrogen may have an independent effect on bone mass. The persistence of osteopenia after recovery indicates that deficits in bone mineral acquired during adolescence may not be completely reversible.

Insulin-like growth factor-I as a reflection of body composition, nutrition, and puberty in sixth and seventh grade girls.

Large variations in nutritional intake have profound effects on the GH-insulin-like growth factor-I (IGF-I) axis in children and adults, but the effect of normal variations in nutrition on IGF-I concentrations is largely unstudied, particularly during puberty. We measured serum IGF-I concentrations in 325 sixth and seventh grade girls (12.4 +/- 0.7 yr) at the beginning of a multisite school-based health curriculum. The mean serum IGF-I level among the 243 girls with complete data was 573 +/- 244 micrograms/L. Pubertal stage was significantly associated with IGF-I (P less than 0.0001, by analysis of variance). Mean concentrations rose from 427 +/- 198 micrograms/L among those at the earliest pubertal stages to 639 +/- 219 micrograms/L among the mature girls. After adjusting for the association with the stage of pubertal development, serum IGF-I was not significantly associated with measures of body composition (body mass index, triceps skin fold thickness, waist/hip ratio, height, and weight). Additionally, IGF-I concentrations were not associated with nutritional intake (total calories, total protein, total fat, and total carbohydrate) or such measures of nutrition as serum iron, hemoglobin, red cell mean corpuscular volume, white cell count, and cholesterol. IGF-I concentrations, however, were significantly correlated with transferrin concentrations, another possible index of nutritional status (r = 0.29; P less than 0.0001). IGF-I is not a clinically useful index of nutritional status among normal pubertal girls.

Pubertal stage and panic attack history in sixth- and seventh-grade girls.

OBJECTIVE: Although the incidence of first panic attacks appears to peak during adolescence, little is known about which features of adolescence contribute to the risk of a first panic episode. The purpose of this study was to compare the relative importance of age and pubertal stage in explaining the occurrence of panic attacks in adolescents. METHOD: From a school-based sample of sixth- and seventh-grade girls, 754 subjects completed both a structured clinical interview determining history of one or more panic episodes and a self-assessment of Tanner stages of pubertal development. A multiple logistic regression analysis was performed with panic attack history as the dependent variable and pubertal stage, age, and their interaction as the independent variables. RESULTS: A history of one or more four-symptom panic attacks was found in 5.3% of the girls (N = 40). After age was controlled for, pubertal stage was significantly related to panic attack history. At each age, higher rates of panic attacks were found in the more physically mature girls. CONCLUSIONS: Pubertal stage, after adjustment for the effects of age, appears to predict panic attack occurrence in young adolescent girls. Understanding the link between puberty and panic may offer clues regarding the onset and etiology of panic attacks.

Know thyself--adolescents' self-assessment of compliance behavior.

Noncompliance with contraception is a major cause of adolescent pregnancy. Studies of compliance predictors have produced conflicting results. The possibility that female adolescents' assessment of their own past compliance with other medications may be useful in predicting their future contraceptive compliance is explored. Accordingly, patients beginning an oral contraceptive regimen described their past compliance on a four-point scale, and a subset, in addition described themselves on the basis of a five-point scale ranging from "forgetful" to "well-organized." At 6-month follow-up, 75% of the patients were found to have described themselves accurately in terms of potential compliance behavior. Of patients who proved compliant, 64% had initially rated themselves as "well-organized" whereas none of the noncompliant patients had done so. These findings demonstrate the potential importance of the teenagers' self-assessment in determining those at risk for contraceptive noncompliance. The findings also suggest that compliance behavior among female adolescents may be generalizable across clinical situations, rather than being disease or medication specific.

Medical complications of eating disorders in adolescents.

Anorexia nervosa and bulimia are occurring with increased frequency among adolescents and preadolescents. To determine the range and severity of medical complications encountered in younger anorectic and bulimic patients, we reviewed the medical records of 65 adolescents and preadolescents, aged 10 to 20 years, who were observed in the Eating Disorders Clinic of the Children's Hospital at Stanford. Significant medical instability was present in the majority of our patients. A total of 55% of anorectic patients and 22% of bulimic patients required hospitalization for medical reasons during the study period. Cardiovascular abnormalities were frequent, including bradycardia, prolonged corrected QT intervals, dysrhythmias, and marked orthostatic pulse and BP instability. Hypothermia, with temperatures less than 35.5 degrees C, was common. Renal abnormalities included pyuria, hematuria, and proteinuria. Electrolyte derangements occurred in patients who vomited or purged. Hypokalemia was most common, but hypocalcemia, hypomagnesemia, and hypophosphatemia were also noted. The majority of our pediatric patients with eating disorders had evidence of physiologic derangement requiring medical intervention. The need for adolescents and preadolescents with eating disorders to receive ongoing medical monitoring in concert with psychiatric treatment and the need for therapists and medical practitioners to become familiar with the potential medical sequelae of eating disorders are underscored by our data.

Mediastinal emphysema in an adolescent with anorexia nervosa and self-induced emesis.

A case of asymptomatic pneumomediastinum in a 14-year-old girl with anorexia nervosa and self-induced emesis is reported to emphasize the atypical aspects of this case and the importance of differentiating benign from potentially life-threatening sources of mediastinal air. Individuals who engage in purging behavior are not only at increased risk for both alveolar (primary pneumomediastinum) and esophageal perforation (Boerhaave syndrome) but may also obscure or delay the diagnosis by denying symptoms and/or previous emesis. Because esophageal perforation is serious, the presence of free mediastinal air in a patient with a known or suspected history of emesis should provoke prompt radiographic evaluation of the upper gastrointestinal tract.

Epidemiology of adolescent dysmenorrhea.

Dysmenorrhea is the leading cause of recurrent short-term school absenteeism among adolescent girls. Controversy surrounds the relative role of psychologic and biologic variables in the pathogenesis of dysmenorrhea. Therefore, data from 2,699 menarcheal adolescents, drawn from a national probability sample of 12 to 17-year-old girls (the National Health Examination Survey), were analyzed by bivariate and multivariate analytic techniques for biologic, psychologic, and demographic correlates of dysmenorrhea. Of 1,611 adolescents (59,7%) who report dysmenorrhea, 14% frequently miss school because of cramps. The greatest proportion of variation of independent variables in a stepwise multiple regression analysis in this study was predicted by gynecologic or postmenarcheal age. Preparation for menarche, a psychologic variable, did not predict either dysmenorrhea or subsequent school absence. Socioeconomic status was positively correlated with dysmenorrhea although race was not. However, black students (23.6%) miss more school because of dysmenorrhea than white students (12.3%) even when socioeconomic status is held constant. Data in this study suggest that biologic variables play a substantial role in the pathogenesis of dysmenorrhea.

Knowledge and concerns about acquired immunodeficiency syndrome and their relationship to behavior among adolescents with hemophilia.

The knowledge and concerns regarding acquired immunodeficiency syndrome (AIDS) and their relationship to certain behaviors among adolescents with hemophilia, a pediatric risk group with human immunodeficiency virus (HIV) antibody positivity rate as high as 70% to 90%, are described. Information was obtained from 26 patients, 13 to 19 years of age, through the use of a confidential self-administered questionnaire and a semistructured interview. In general, subjects demonstrated a high level of factual knowledge regarding the cause, natural history, transmission, and prevention of AIDS. Despite this, participants frequently behaved in ways that were potentially harmful to themselves and others. Specifically, although aware of the importance of using condoms, sexually active adolescents with hemophilia were not practicing safe sex. Restriction in the use of heat-treated clotting factor because of concerns about AIDS was also frequently reported. Professionals providing AIDS education and counseling for these individuals need to be cognizant of the concerns and social skills of this population; they should focus not only on factual information but also on the social and situational pressures confronting these teenagers, which may be more immediate determinants of their behavior and well-being. As AIDS continues to spread into the general population, these findings have relevance to AIDS education and health policy efforts aimed at all adolescents.

Role of self-esteem and autonomy in determining medication compliance among adolescents with juvenile rheumatoid arthritis.

This study was designed to improve understanding of adolescents' compliance with medical regimens. Compliance with salicylate therapy among adolescents with juvenile rheumatoid arthritis was examined in relationship to two of the most important issues of adolescent psychosocial development--self-image and autonomy. Standardized instruments that assessed these variables were administered to 38 adolescents with juvenile rheumatoid arthritis during the year in which compliance was determined, utilizing serum salicylate measurements. Patients and disease-related characteristics were also recorded, and interactions with personality variables were examined. The data show that adolescents with juvenile rheumatoid arthritis who comply with their medical regimen are those who have high self-esteem and are allowed more autonomy than the noncompliers. The longer the duration of the illness and the more symptoms present at onset, the poorer was self-concept, and hence compliance, at adolescence.

Adolescents' self-assessment of sexual maturation.

The variability in time on onset and progression of puberty warrants the use of stage of sexual maturation rather than chronologic age in assessing biological and behavioral measures during adolescence. The necessity to undress the teenage has seriously curtailed the application of stage of sexual maturation to behavioral and developmental research. This study demonstrated that adolescents can accurately assess their own developmental stage according to Tanner's standard photographs. Self-ratings by 43 females, aged 9 to 17, and 23 males, 11 to 18, were compared to those based on physical examination by one of the investigators. Agreement with the physician rating occurred for breast stage in 37/43, for female pubic hair stage in 40/43, and for male combined pubic hair and genital stage in 21/23 (kappa coefficients: 0.81, 0.91, 0.88). The excellent agreement between physician and adolescent's assessment compared favorably with the interrater agreement of professionals. This study suggests the value of utilizing adolescent self-staging in research. In addition, this exercise provides teenagers with an objective way to understand the wide range of normal pubertal development and to follow their own sexual maturation.

Decreased bone density in adolescent girls with anorexia nervosa.

Osteoporosis develops in women with chronic anorexia nervosa. To determine whether bone mass is reduced in younger patients as well, bone density was studied in a group of adolescent patients with anorexia nervosa. With single- and dual-photon absorptiometry, a comparison was made of bone mineral density of midradius, lumbar spine, and whole body in 18 girls (12 to 20 years of age) with anorexia nervosa and 25 healthy control subjects of comparable age. Patients had significantly lower lumbar vertebral bone density than did control subjects (0.830 +/- 0.140 vs 1.054 +/- 0.139 g/cm2) and significantly lower whole body bone mass (0.700 +/- 0.130 vs 0.955 +/- 0.130 g/cm2). Midradius bone density was not significantly reduced. Of 18 patients, 12 had bone density greater than 2 standard deviations less than normal values for age. The diagnosis of anorexia nervosa had been made less than 1 year earlier for half of these girls. Body mass index correlated significantly with bone mass in girls who were not anorexic (P less than .05, .005, and .0001 for lumbar, radius, and whole body, respectively). Bone mineral correlated significantly with body mass index in patients with anorexia nervosa as well. In addition, age at onset and duration of anorexia nervosa, but not calcium intake, activity level, or duration of amenorrhea correlated significantly with bone mineral density. It was concluded that important deficits of bone mass occur as a frequent and often early complication of anorexia nervosa in adolescence. Whole body is considerably more sensitive than midradius bone density as a measure of cortical bone loss in this illness.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of peer counselors on adolescent compliance in use of oral contraceptives.

Poor compliance with contraceptive regimens has been shown to be an important antecedent of adolescent pregnancy. The purpose of this study was to test prospectively the effect of a peer v nurse counseling program on adolescent compliance with the use of oral contraceptives. Fifty-seven females aged 14 to 19 years from a lower socioeconomic background were randomly assigned to a peer (n = 26) or nurse (n = 31) group. At the initial visit and at 1-, 2-, and 4-month follow-up visits, subjects received Ortho-Novum 1/35 combined with a tablet marker and were counseled by a nurse or peer. Noncompliance was measured using a Guttman scale consisting of: (1) avoidance of pregnancy, (2) appointment adherence, (3) pill count, and (4) urinary fluorescence for riboflavin. At the first and second follow-ups, the adolescents counseled by a peer had a significantly (P less than or equal to .038) lower noncompliance level than the nurse-counseled group. Adolescents with more frequent sexual activity (P less than or equal to .027), with one sexual partner (P less than .04), and who worried that they might become pregnant (P less than or equal to .01) had significantly lower levels of noncompliance when counseled by a peer than by a nurse. At the fourth month follow-up, adolescents who expressed feelings of hopelessness about the future had significantly (P less than or equal to .036) higher levels of noncompliance when counseled by a nurse than when counseled by a peer. These results suggest that incorporating a peer counselor into the health care team may be an effective method of increasing adolescent compliance.

Juvenile detention: another boundary issue for physicians.

It is estimated that there are 500,000 youngsters in detention in the United States per year. Detention facilities offer a unique environment in which adolescents at high risk for medical problems can be identified and treated. A health care program within the secure juvenile detention facility for New York is described in order to demonstrate how an academic medical center can effect improvement in the health status of underserved, incarcerated youth while meeting professional educational objectives for health trainees. Results of medical services are given for the past 11 years. Medical problems were diagnosed in 46% of the 47,288 adolescents examined. The conditions were grouped into those related to the legal status of the youngsters, socioeconomic background, and/or the institutional setting. The interrelationship of medical conditions with legal, ethical, and youth advocacy issues were demonstrated. The setting affords on opportunity to train primary care physicians with special emphasis on issues such as the nature of the doctor-patient relationship, confidentiality, and patient advocacy, while providing a necessary service to medically disadvantaged adolescents.

Caring for gravely ill children.

BACKGROUND: Much has been written about the care of the hopelessly ill adult, but there is little guidance for pediatric health care professionals in the management of children who are critically or terminally ill. METHODS: Through a 3-day meeting in Tarrytown, NY, attended by a group of pediatricians and others directly involved in these issues, a principled approach was developed for the treatment of, and health care decision-making for, children who are gravely ill. RESULTS: The group agreed that the needs and interests of the child must be the central focus of any treatment plan and that the child should be involved to as great extent possible, consistent with developmental maturity, in the decision-making process. Quality of future life should be viewed as being relevant in all decisions. Parents are believed to be the natural guardians of children and ought to have great latitude in making decisions for them. However, parental discretion is not absolute and professionals must maintain an independent obligation to protect the child's interests. CONCLUSIONS: Decision-making should be collaborative among patient, parents, and professionals. When conflict arises, consultation and ethics committees may assist in resolution. When cure or restoration of function is no longer possible, or reasonable, promotion of comfort becomes the primary goal of management. Optimal use of pain medication and compassionate concern for the physical, psychological, and spiritual well-being of the child and family should be the primary focus of the professionals caring for the dying child.

Pubertal changes in daytime sleepiness.

Nineteen children (8 girls, 11 boys) were evaluated in a total of 47 three-day sessions across three summers. Children were ranked according to Tanner's stages of secondary sexual characteristics. Nocturnal sleep was recorded from 2200 to 0800 hr each night. Multiple sleep latency tests were given at 2 hr intervals from 0930 each day. Nocturnal sleep time and REM sleep time remained constant across Tanner stages. Slow wave sleep time declined progressively across Tanner stages, with a 40% reduction from prepuberty to maturity. Daytime sleepiness was significantly greater in subjects at Tanner stages 3 and 4 than at Tanner stages 1 and 2. Subjects at Tanner stage 5 tended to be as sleepy as Tanner stage 3 and 4 subjects but did not differ significantly from the less mature subjects. No gender differences were found in daytime sleepiness for children at similar Tanner stages. More mature children were significantly sleepier at 1330 and 1530 than in the late afternoon and evening.

Psychiatric risk associated with early puberty in adolescent girls.

OBJECTIVE: This study prospectively evaluated the relationship between early puberty and the onset of internalizing symptoms and disorders in adolescent girls. METHOD: The sample was drawn from 1,463 sixth-, seventh-, and eighth-grade girls who participated in a longitudinal school-based study of growth and development. Pubertal stage was determined by self-assessment of Tanner stage. Psychiatric assessments included self-report instruments and structured diagnostic interviews. Survival methods were utilized for data analysis. RESULTS: Girls with onset of internalizing symptoms were on average 5 months earlier in pubertal development than those who were asymptomatic (p < .001). In addition, girls with earlier maturation (earliest quartile) were more likely to develop internalizing symptoms than were nonearly matures (hazard ratio = 1.8, confidence interval = 1.2, 2.7). In a subsample of girls followed into high school, early-maturing girls were at marginally higher risk (p < .10) for developing internalizing disorders by the study's end. The highest risk for internalizing disorders was for those girls with both early puberty and prior internalizing symptoms (odds ratio = 3.3). CONCLUSION: Early puberty increases the risk of internalizing symptoms and perhaps internalizing disorders in adolescent girls.

Prospective study of risk factors for the initiation of cigarette smoking.

Risk factors for the initiation of cigarette smoking were examined in 2 consecutive cohorts of teenagers (N = 1,901). Students in Cohort 1 were followed over 4 years from 9th to 12th grade; those in Cohort 2 were followed over 3 years from 9th to 11th grade. Among girls with no history of smoking at baseline, those with more friends who smoked at baseline (p < .001) and those with higher sociability scores (p < .05) were significantly more likely to have tried smoking over the study interval. Among boys with no history of smoking at baseline, those with more friends who smoked at baseline (p < .05) and those with higher depression symptoms scores (p < .01) were significantly more likely to have tried smoking over the study interval. The data suggest that future research is needed to examine potential gender differences that may have implications for the next generation of smoking-prevention programs.

Ethnic differences in the association between pubertal status and symptoms of depression in adolescent girls.

PURPOSE: To examine the importance of chronologic age versus pubertal status in predicting adolescent girls' depressive symptoms in different ethnic groups. METHODS: A national probability sample was used to obtain a representative cohort of 3216 adolescents, 5th through 8th grades. Subjects completed a questionnaire, which included a modified version of the Children's Depression Inventory (CDI) and an assessment of timing of menarche. RESULTS: Among Caucasians, post-menarcheal adolescent girls had higher depression scores than did same-aged pre-menarcheal girls. Boys and pre-menarcheal girls had similar depression scores in most age groups. Among African-Americans and Hispanics, there were no menarche-associated differences in depressive symptoms. CONCLUSION: In early adolescence pubertal status is a better predictor of depressive symptoms than chronological age in Caucasian, but not African-American or Hispanic girls.

Ethnicity and body dissatisfaction: are Hispanic and Asian girls at increased risk for eating disorders?

PURPOSE: To compare prevalences and correlates of body dissatisfaction among white, Hispanic, and Asian girls. METHODS: A total of 939 6th and 7th grade girls (mean age 12.4 years) attending four middle schools in northern California completed self-administered assessments of age, ethnicity, desired body shape, parent education levels, mother's and father's body shapes, pubertal stage, and body dissatisfaction. Body dissatisfaction was assessed with the Body Dissatisfaction scale of the Eating Disorder Inventory. Height, weight, triceps skinfold thickness, and waist and hip circumferences were measured by trained examiners. RESULTS: Hispanic girls reported significantly greater body dissatisfaction than white girls, with Asian girls in-between. After adjustment for body mass index (weight/height), normal and overweight white, Hispanic, and Asian girls reported similar levels of body dissatisfaction. However, among the leanest 25% of girls, Hispanics and Asians reported significantly more body dissatisfaction than white girls. Body mass index was the strongest independent predictor of increased body dissatisfaction in all three ethnic groups. Shorter height among white girls and taller height among Asian girls also made significant independent contributions. Parent education level, a measure of socioeconomic status, was not significantly associated with body dissatisfaction. CONCLUSIONS: Body dissatisfaction is not limited to white girls in middle and upper socioeconomic strata. These findings suggest Hispanic and Asian girls may be at greater risk for adopting eating disorder behaviors than previously recognized.

Compliance with medical regimens during adolescence.

In summary, compliance behavior among adolescents is complex and imcompletely understood. Although the study of compliance is important for understanding the adolescent's stage of psychological development, relationships with authority figures, and the beginning of the youngster's career as a consumer of health care, its ultimate importance lies in the prospect of improving the likelihood that medication will be utilized appropriately. The first step in the process involves systematic monitoring of compliance rather than doing so only when noncompliance is clinically suspected. When compliance is found to be problematic for an adolescent, resorting to "scare" techniques or re-education is rarely effective. A more positive outcome may be achieved by determining the circumstances under which the youngster was successful in complying and attempting to tailor-make the regimen accordingly. Barriers to compliance, such as the presence of side effects, previous negative experience with the medicine, and lack of conviction about the diagnosis of appropriateness of therapy, should always be explored. Other potential intervention strategies for improving compliance have been discussed. In the final analysis, however, as Jonson has noted, all strategies aimed at improving compliance must provide the patient with insight into his own situation and himself, as well as his capability of doing something other than conforming when he judges it best.