What contributes to good outcomes? The perspective of young people on short-term psychoanalytic psychotherapy for depressed adolescents.

Depression is the fourth leading cause of adolescent illness and disability worldwide. A growing evidence base demonstrates that Short Term Psychoanalytic Psychotherapy [STPP] is an efficacious treatment for moderate to severe adolescent depression. However, with research in its infancy, key factors contributing to efficacy are unknown. Service users' lived experiences provide valuable insight in this area. This study aimed to elucidate what adolescents value in treatment by inductively exploring lived experiences of STPP. Five adolescents with the largest reduction in depressive symptoms scores between baseline and end of treatment, who had taken part in a large-scale randomized controlled trial, were sampled. In-depth interviews carried out soon after the end of therapy were analysed using Interpretative Phenomenological Analysis. Three superordinate themes were identified: "Therapy as a Transformational Process", "Explorative and Exposing: The Therapeutic Space" and "Being Heard and Working Together: The Therapeutic Relationship". Adolescents valued a process of collaborative exploration with the therapist which when it was achieved was felt to facilitate a deep-rooted transformation in self-perception. Additionally, they described how an adjustment was needed to the particular frame of a psychoanalytic therapy. However, not all participants with a good treatment outcome experienced therapy in this way, suggesting a potential gap between the quantitative assessment of outcomes, and the way young people experience and understand the change process. Clinical implications and directions for research are discussed.

Extrapolation of Efficacy and Dose Selection in Pediatrics: A Case Example of Atypical Antipsychotics in Adolescents With Schizophrenia and Bipolar I Disorder.

Pediatric labeling information for novel atypical antipsychotics can be significantly delayed as the result of time lag between initial drug approval in adults and the completion of pediatric clinical trials. This delay can lead health care providers to rely on limited evidence-based literature to make critical therapeutic decisions for pediatric patients. Effective and scientifically justified dosing recommendations are needed to improve treatment outcomes in pediatric patients with schizophrenia and bipolar I disorder. Extrapolation-based drug development strategies rely on leveraging prior data to reduce evidentiary requirements for newer data in establishing drug efficacy. On January 13, 2020, the US Food and Drug Administration (FDA) released a general advice letter to sponsors highlighting the acceptance of extrapolating efficacy of atypical antipsychotics to pediatric patients. This review provides insight into the FDA's justification for extrapolating efficacy from adult to pediatric patients and provides a rationale for dose selection in pediatric patients with schizophrenia and bipolar I disorder.

Polycystic ovary Syndrome in Adolescents: Pitfalls in Diagnosis and Management.

PURPOSE OF REVIEW: Polycystic ovary syndrome (PCOS) is the commonest endocrine disorder during a woman's reproductive lifespan, with well-documented diagnostic criteria and therapeutic strategies in adults; the same is not necessarily true for adolescents. The purpose of this review was to identify frequent pitfalls in PCOS diagnosis and management during adolescence. RECENT FINDINGS: Although there is no global consensus on the definition, most experts converge to the presence of both oligo/amenorrhea and (clinical and/or biochemical) hyperandrogenism, as a prerequisite for diagnosis in adolescents. The former criterion includes: (a) consecutive menstrual intervals > 90 days even in the first year after menarche; (b) menstrual intervals persistently < 21 or > 45 days for ≥ 2 years after menarche; or (c) lack of menses by the age of 15 or 2-3 years after pubarche. However, these menstrual irregularity patterns may overlap with other common entities in adolescents, such as frequent or infrequent uterine bleeding or anovulation due to immaturity of the hypothalamic-pituitary-ovarian axis. Clinical signs of hyperandrogenism are obscure, without well-validated criteria. Finally, the criterion of polycystic morphology cannot be safely used in adolescents, mostly due to technical limitations of the transabdominal ultrasound. Except for the efficacy of lifestyle intervention in overweight and obese adolescents with PCOS, limited and low-quality data exist regarding the available medications, such as oral contraceptives, metformin, and anti-androgens. Individualized management, guided by clinical experience and research data and close monitoring appear the most effective approach in this PCOS population for optimal control of its reproductive and metabolic outcomes. Research focusing on PCOS genetic and molecular mechanisms may elucidate what diagnostic and therapeutic strategies will be most appropriate in adolescents with PCOS in the future.

Identifying Missed Opportunities for Human Immunodeficiency Virus Pre-exposure Prophylaxis During Preventive Care and Reproductive Visits in Adolescents in the Deep South.

BACKGROUND: Pre-exposure prophylaxis (PrEP) for individuals at significant risk for Human Immunodeficiency Virus acquisition is approved for individuals weighing at least 35 kg by the Food and Drug Administration. This cross-sectional study analyzed indications for PrEP in a clinical setting. METHODS: There were 429 charts reviewed from adolescents between 15 and 21 years old seen for preventive care visits at an adolescent primary care center in the Deep South during a 1-year timeframe. Univariate and multivariable regression analyses were completed to identify factors associated with indications for PrEP. RESULTS: Forty-four percent of 429 adolescents (between 15 and 21 years) had a PrEP indication; 77% were women and 95% heterosexual. Significant factors associated with an indication for PrEP included living with a nonparent or nonrelative and polysubstance use. No adolescents with an indication for PrEP were prescribed PrEP. A sensitivity analysis comparing indications for PrEP between the 2014 and 2017 The Centers for Disease Control and Prevention Guidelines revealed no significant differences in percent with an indication (44.5% vs. 42.8%) or factors associated with indications. CONCLUSIONS: Pre-exposure prophylaxis as a biomedical tool for adolescents and young adults (AYAs) may remain underutilized. A key factor in improving utilization involves providers being able to recognize AYAs who may have an indication for PrEP with a specific focus on those AYAs who do not live in households with parents or a surrogate family member and those who are polysubstance users.

Sexual matters among teenagers.

In the complex developmental period of puberty, adolescents experience biophysical changes and adapt to societal and cultural expectations of adulthood. Development of their sexuality is an important biopsychosocial change during this period that, when neglected, may result in unmet sexual and reproductive health needs. Patterns of behaviour in adolescence have repercussions across the lifespan. HEADSSS (home, education/employment/eating, activities, drugs, sexuality, sleep, suicide/depression and safety) is a systematic clinical screening tool for use with adolescents. Adolescents may view risk-seeking lifestyle patterns as appropriate behaviours, and physicians can help them recognise the risks and develop less harmful alternatives and strategies. Personal biases should not affect healthcare providers' duty to respect the rights of adolescents and ability to provide developmentally appropriate care. Healthcare professionals should be familiar with the relevant legal statutes in Singapore and refer suspected sexual abuse or violence, risk of self-harm, teenage pregnancy, newly diagnosed sexual transmitted infections or multiple risk-seeking behaviours for further evaluation and help.

Provision of paediatric and adolescent gynaecology in Europe today: A joint review by the European Association of Paediatric and Adolescent Gynaecology (EURAPAG) and European Board and College of Obstetrics and Gynaecology (EBCOG).

Paediatric and Adolescent Gynaecology (PAG) is a multidisciplinary field combining aspects of gynaecology but also includes paediatrics, endocrinology, genetics, radiology, psychology and urology. Specialist knowledge is warranted for the care of these youngsters, and it is important that doctors attending to the gynaecological needs of children must understand that they are not just "little women". Their needs and accompanying clinical approaches required are very different from those of adults in this sensitive area, as is the spectrum of diseases and problems. A multidisciplinary collaboration is as important as the establishment and adoption of standards in education, training and management. The situation in Europe in PAG is varied, reflecting the relative youth of this area of special interest and thereby allowing for earlier consolidation of standards and services across Europe. This article summarises the background to PAG in Europe, inequitable current provision of care and issues relating to education and training all of which are relevant in providing a common approach to PAG problems and endeavouring to obtain the best outcomes. There remains huge diversity how the services for "young women" are currently delivered across different countries within Europe. A concerted European approach is urgently required to streamline standards of training and clinical care, to ensure high quality care by using agreed national and European pathways.

Obstetric and gynaecology trainees' knowledge of paediatric and adolescent gynaecology services in the UK: A national qualitative thematic analysis.

BACKGROUND: The British Society of Paediatric and Adolescent Gynaecology (BritSPAG) was created in 2000 with specific aims to include raising the profile of paediatric and adolescent gynaecology (PAG) within the United Kingdom (UK). The Society has since developed a set of clinical standards for all acute hospitals providing gynaecological services to enable successful provision of paediatric and adolescent gynaecology care. AIMS: To determine the depth of knowledge that obstetric and gynaecology trainees have with regards to the PAG services provided at their Hospital, reflecting how widely PAG services have had an impact on trainees. METHOD: The national survey was distributed to all deaneries in the UK for circulation to all their trainees via e mail during Nov 2017-March 2018. RESULTS: 28% of the trainees said there was a PAG clinic at their hospital, 46.9% did not have a clinic and 24.7% were unsure. 41.6% of the respondents were aware of BritSPAG, however only 10.4% were aware of the BritSPAG clinical standards for service planning with regards to PAG clinics. Nearly half were aware of the PAG specialist centre for their region but only 6.5% were aware of the BritSPAG UK map of services. A large majority (93.24%) didn't believe that trainees in O&G received adequate exposure to PAG in their training. CONCLUSION: This study represents the largest and first national survey to seek obstetric and gynaecology trainees' thoughts on the provision of PAG training in the UK today. Given that only 28% of trainees answering said that they were aware of a PAG clinic at their hospital, this indicates not only that many hospitals did not have a dedicated PAG clinic but more worryingly five of the trainees were not aware of the existence of a confirmed PAG clinic at their hospital, and therefore are potentially losing out on training opportunities. Disappointingly the results of our survey reveal that trainees in Obstetrics and Gynaecology still have very little experience or exposure to PAG during their training despite there being opportunities to do so.

Further support for diagnostically meaningful ARFID symptom presentations in an adolescent medicine partial hospitalization program.

OBJECTIVE: To identify potential presentations of avoidant/restrictive food intake disorder (ARFID) in a pediatric eating disorder partial hospitalization program (PHP) based on the nature of the eating restriction leading to core symptoms of ARFID. METHOD: A retrospective chart review of 83 patients ages 8-17 admitted to a PHP and diagnosed with ARFID. Charts were independently reviewed by two coders, with high inter-rater agreement (κ = 0.77). Distinct categories were identified and groups were compared on demographics, anthropometrics, comorbid psychopathology, and core ARFID symptoms. RESULTS: We identified cases characterized by predominantly selective eating based on aversions to the sensory properties of foods, lack of interest in eating/low appetite, and fear of aversive consequences from eating. We also distinguished a subset of patients with eating restrictions consistent with both selectivity and limited interest/appetite. The four primary ARFID presentation groups differed on core ARFID criteria, symptom trajectory and illness duration, mood and medical comorbidities, age, gender, and parent-reported symptoms of psychopathology. DISCUSSION: The present findings suggest that there are diagnostically meaningful ARFID subtypes that can be differentiated based on the nature of their eating restrictions, as well as other demographic, illness history features, and psychiatric comorbidity. As treatments for youth with ARFID are developed and refined, it will be important to take into consideration not only demographic differences, but also the variability in symptoms, as this might require distinct interventions and levels of care. Additionally, differing mechanisms that maintain different types of eating restrictions might necessitate unique psychological and psychiatric interventions.

Developmentally appropriate care for adolescents and young adults with cancer: how well is Australia doing?

PURPOSE: Developmentally appropriate care underpins quality cancer treatment. This study aimed to describe how well Australian cancer services deliver patient-focussed, developmentally appropriate care to adolescents and young adults (AYAs) with cancer. METHODS: In a national, cross sectional study, 196 AYAs with cancer aged between 15 and 25 years at diagnosis reported their general experiences of the cancer care team (Cancer Needs Questionnaire), access to age-appropriate treatment environments (Cancer Needs Questionnaire) and frequency of psychosocial assessment (Adolescent Friendly Hospital Survey). RESULTS: Very positive responses were reported around engagement and communication with staff who were reported as approachable, friendly and trustworthy; 11 of the 14 items were positively rated by over 90% of respondents. In contrast, over 70% of AYAs expressed unmet need around their physical and social environments, whether in relation to the opportunity to be nursed in wards designed for AYAs, spend time with other young people with cancer, or talk to young people their own age; less than a third reported their needs had been met on the majority of these items. The frequency that specific psychosocial assessment domains were discussed was highly variable; responses suggested that AYAs were less commonly questioned about overtly sensitive topics. AYAs who experienced private consultations with health care providers (41%) were significantly more likely to experience thorough psychosocial assessment. CONCLUSION: Australian cancer services are generally communicating well with AYAs. There is room for improvement around more developmentally specific aspects of healthcare quality, such as psychosocial assessment, and around treatment environments that promote greater social interaction between AYAs.

Health care service in paediatric and adolescent gynaecology throughout Europe: A review of the literature.

BACKGROUND: Paediatric and adolescent gynaecology is a special field of interest within general gynaecology and obstetrics. The care for children and young people differs from adults. In gynaecology, children should not be treated like little adults. Within Europe, there is great variability in the provision of care, availability of clinical networks and lack of national standards within paediatric and adolescent gynaecology. Therefore, this review aims to summarize the current evidence regarding best clinical practice within Europe. METHODS: A search was performed in Embase and Medline from 1974 onwards. Inclusion criteria were paediatric and adolescent population, gynaecology or reproductive health, care provision and evidence based clinical guidelines. In most papers recommendations were made, so no outcome measures could be used. It was, therefore, not possible to perform a meta-analysis. The risk of bias of the studies was assessed according to the GRADE and AGREE-2 guidelines. RESULTS: 91 papers were identified and a total of 7 papers were included in the final analysis. The main recommendations are: - improvement for accessibility for healthcare facility, - training of healthcare staff in communication and examination according to developmental age, - develop evidence based clinical guidelines and standardize content of care delivered, - add training in general adolescent topics to training curriculum of paediatric and adolescent gynaecology. CONCLUSION AND IMPLICATIONS: There is limited information about best clinical practice and low quality of evidence of healthcare service available in the field of Paediatric and Adolescent Gynaecology. As a result there is a need to refine standards of training and care. EURAPAG should encourage adaptation of the unified standards of care in each European country. Furthermore, at this moment, there is insufficient inclusion of curriculum related to PAG in the undergraduate and post graduate training for recognition of patterns and symptoms in young women. EURAPAG should not only take a lead to develop common curriculum for undergraduate and post graduate education and training to address this unmet need but should also lead on their implementation within Europe.

The future of paediatric and adolescent gynaecology in Europe.

Paediatric and Adolescent Gynaecology (PAG) is a subspecialty under the umbrella of Obstetrics and Gynaecology but linked to other branches of medicine including Paediatrics, Surgery, Endocrinology and Urology. Therefore future developments in clinical care and education requires a multidisciplinary approach combining aspects of all the above medical specialties, and also with inputs from Public Health, Genetics, Radiology and Psychology. A multidisciplinary collaboration among different specialists is as important as the establishment and adoption of standards in education, training and management. PAG in Europe has evolved from its first steps and it is still growing with the aim of providing increasing protection of the gynaecological and reproductive health of female children and adolescents. In fact, without proper advice and care, inappropriate management of gynaecological issues in childhood and adolescence can be expected to have significant repercussions throughout later years, and into adulthood. The aim of this third paper in this mini-symposium is to explore how PAG should develop in Europe in the near future.

Characteristics Associated with Confidential Consultation for Adolescents in Primary Care.

OBJECTIVE: To examine how provider report of confidential consultation in the electronic health record is associated with adolescent characteristics, health risk factors, and provider training. STUDY DESIGN: This prospective cohort study was conducted as part of a larger study implementing computerized clinical decision support in 2 urban primary care clinics. Adolescents used tablets to complete screening questions for specified risk factors in the waiting room. Adolescent-reported risk factors included sexual activity, substance use, and depressive symptoms. Providers were prompted on encounter forms to address identified risk factors and indicate whether confidential consultation was provided. Provider types included adolescent medicine board certified pediatrics and general pediatrics. Differences in proportions of adolescents reporting risk factors by provider type were assessed using χ2 tests. Associations between adolescent characteristics, risk factors, and provider-reported confidential consultation were examined using logistic regression analyses. RESULTS: The sample included 1233 English and Spanish-speaking adolescents 12-20 years of age (52% female; 60% black; 50% early adolescent). Patients seen by adolescent medicine board certified providers reported sexual activity, depressive symptoms, and substance use significantly more often than those seen by general pediatric providers. Among patients seen by board certified adolescent medicine providers, confidential consultation was provided to 90%. For those seen by general pediatric providers, confidential consultation was provided to 53%. Results of multiple logistic regression demonstrated that female sex, later adolescence, and clinic location were significantly associated with confidential consultation. CONCLUSIONS: Provider training is needed to reinforce the importance of confidential consultation for all adolescents.

Paediatric departments need to improve residents' training in adolescent medicine and health: a position paper of the European Academy of Paediatrics.

In many European countries, paediatric junior staff has no formal training in adolescent medicine and is ill-equipped to deal with issues and health problems such as substance use, unprotected sex, eating disorders and transition to adult care. This position paper of the European Academy of Paediatrics proposes a set of competency-based training goals and objectives as well as pedagogic approaches that are expected to improve the capacity of paediatricians to meet the needs of this important segment of the paediatric population. The content has been developed from available publications and training programmes and mostly covers the generic aspects of adolescent healthcare, such as how to communicate effectively, how to review and address lifestyles, how to perform a respectful and relevant physical examination, how to address common problems of adolescents and how to support adolescents in coping with a chronic condition. CONCLUSION: The European Academy of Paediatrics urges national bodies, paediatric associations and paediatric teaching departments to adopt these training objectives and put them into practice, so that paediatricians will be better prepared in the future to meet the challenge of delivering appropriate and effective healthcare to adolescents.

Just between Us: An Integrative Review of Confidential Care for Adolescents.

INTRODUCTION: Confidential care is recommended for all adolescents to facilitate risk behavior screening and discussion of sensitive topics. Only 40% of adolescents receive confidential care. The purpose of this integrative review is to describe research related to the practice of confidential care for adolescents. Evidence was analyzed to identify strategies to increase confidential care and improve risk behavior screening. METHOD: Whittemore and Knafl's integrative literature review process was applied. RESULTS: The 26 research articles included in this review included patients', parents', and physicians' perspectives. Confidential care practice is inconsistent. Strategies to improve practice are known. CONCLUSIONS: Four key elements should be considered to establish a practice culture of confidential care for adolescents. Strategies for implementing the key elements of confidential care and supporting resources for efficient use of time alone are provided.

The Treatment of Dysmenorrhea.

Menstrual disorders and abnormal uterine bleeding are common concerns of young women. Complaints include menses that are: too painful (dysmenorrhea), absent or occur irregularly (amenorrhea or oligoamenorrhea), or prolonged and heavy (menorrhagia, or excessive uterine bleeding). In providing optimal reproductive care, the medical provider must be able to distinguish between normal developmental patterns or symptoms requiring education and reassurance from pathologic conditions requiring prompt assessment and treatment. This article discusses the normal menstrual patterns seen in adolescent females and provides an evaluation and management approach to primary and secondary dysmenorrhea.