HANDOUT ON ADOLESCENT MEDICINE HEIGHT
PUBERTY - NORMAL GROWTH AND DEVELOPMENT
To assess growth and development during puberty it is critical to evaluate
sexual maturity ratings as these correlate to normal growth and also
physiologic changes. Sexual maturity ratings include breast development in
females, genital development in males and pubic hair development in both
males and females.
KEY HORMONES
Many of the body's hormones influence growth, such as growth hormone,
thyroxine, insulin, and corticosteroids (all of which influence growth rate),
leptin (which alters body composition), and parathyroid hormone, 1,25-
dihydroxy-vitamin D, and calcitonin (all of which affect skeletal
mineralization). However, the key hormone in growth is GH which is
mediated by growth hormone-releasing hormone (GHRH) and somatostatin
(SS). Growth hormone secretion is increased by GHRH and decreased by
somatostatin. Both growth hormone levels and IGF-I (somatomedin-C)
levels rise during puberty. The increase is most marked during mid and late
puberty and correlates best with pubertal stage, bone age, and time from
peak height velocity (PHV).
The maturation of bones is influenced by thyroid hormones, adrenal
androgens, and gonadal sex steroids, mainly estrogen. An excess secretion
of these hormones can lead to advanced bone maturation, and at the time
of puberty, deficiency causes delay.
At puberty, both sex steroids and growth hormone participate in the
pubertal growth spurt. The ending of the growth spurt is secondary to
epiphyseal closure, due to the action of the sex steroids.
An increase in physical size is a universally recognized event of puberty.
Average growth velocities decrease from the first year of life until puberty
from 25 cm/year during the first year of life to 5-6 cm/year during years 5 to
10. During puberty height velocity increases and peaks during the
adolescent growth spurt. Landmarks include:
The beginning of the increase in growth velocity is about age 11 in boys and
9 in girls but varies widely from individual to individual.
The peak height velocity occurs at a mean of 13.5 years in boys and 11.5
years in girls.
Pubertal growth accounts for about 20% of final adult height, a total
averaging 23-28 cm in females and 26-28 cm in males.
The average growth spurt lasts 24-36 months.
Growth during the year of PHV in the normal female averages 9 cm/yr and
varies normally from 5.4 cm to 11.2 cm. In the normal male, the PHV
averages 10.3 cm/yr and varies normally from 5.8 cm to 13.1 cm.
Males on average are 12-13 cm taller than females primarily because of the
2-year delay in bone closure as compared to females. This accounts for
about a 10-cm difference between the two sexes; in addition, males also
have 2-3 cm more of growth during their growth spurt.
WEIGHT
Weight velocity increases and peaks during the adolescent growth spurt.
Pubertal weight gain accounts for about 50% of an individual's ideal adult
body weight.
The onset of accelerated weight gain and the peak weight velocity (PWV)
attained are highly variable. (Normal weight for age percentile curves are
available through the Centers for Disease Control and Prevention, 6525
Belcrest Road , Hyattsville , MD 20782-2003 . They can also be obtained on
the CDC website at: www.cdc.gov/growthcharts/ .
Differences in Growth Spurts between Males and Females
PHV occurs about 18-24 months earlier in the female than in the male.
PHV in females averages 2 cm/yr less than in males.
PWV coincides with PHV in males, but PWV occurs 6-9 months after PHV in
females.
Prediction of Mature Height
While predicting adult height is a difficult task, individuals have used both
the bone age in calculations or a measure using midparental height as most
individuals have an adult height that is within 2 inches of the midparental
height. This is calculated using:
For girls:
(father's height - 13 cm) + mother's height
2 The increase in skeletal muscle mass during puberty is critical and peak
For boys:
(father's height + 13 cm) + mother's height
2 potential.
The BMI declines until ages 4-6 years and gradually increases through
adolescence and adulthood. Children with an earlier increase in BMI are
more likely to have increased BMIs in adulthood. BMI tables can be
obtained from the National Center for Chronic Disease Prevention and
Health Promotion ( www.cdc.gov/growthcharts/)
Lean Body Mass
Lean body masses decreases in females from about 80% to 75% at maturity
while in males it increases from about 80% to about 90% at maturity due to
an increase in skeletal muscle mass. In females the percentage of body fat
increases.
Skeletal Mass
bone mass is achieved by early adulthood (the lifetime "bone bank").
Epiphyseal maturation occurs under the influence of estradiol and
testosterone. The assessment of this skeletal maturation (bone age) is an
excellent index of physiological maturation and assessment of growth

BODY COMPOSITION Assessment of sexual maturity ratings are listed below:

BODY MASS INDEX  Males

o Genital stage 1 (G1) : Prepubertal
Body Mass Index (BMI) is an important measure for assessment of  Testes: Volume less than 1.5 mL
appropriate weight for height  Phallus: Childlike
o Genital Stage 2 (G2)
BMI is determined as follows:  Testes: Volume 1.6-6 mL
 Scrotum: Reddened, thinner, and larger
Metric Formula:  Phallus: No change
o Genital Stage 3 (G3)
Weight in kilograms ÷ height in meters ÷ height in meters = BMI  Testes: Volume 6-12 mL
 Scrotum: Greater enlargement
English Formula:  Phallus: Increased Length
o Genital Stage 4 (G4)
Weight in pounds ÷ by height in inches ÷ height in inches X 703 = BMI  Testes: Volume 12-20 mL
 Scrotum: Further enlargement and darkening
  Phallus: Increased length and circumference o Pubic hair stage 5 (PH5)
o Genital stage 5 (G5)  Adult type and quantity, extending to medial
 Testes: Volume more than 20 mL surface of thigths
 Scrotum and phallus: Adult
 Females Sexual Maturity Ratings: female pubic hair stages
o Breast stage 1 (B1)
 Breast: Prepubertal; no glandular tissue
 Areola and papilla: Areola conforms to general
chest line
o Breast stage 2 (B2)
 Breast: Breast bud; small amount of glandular tissue
 Areola: Areola widens
o Breast stage 3 (B3)
 Breast: Larger and more elevation; extends beyond
areolar parameter
 Areola and papilla: Areola continues to enlarge but
remains in contour with the breast
o Breast stage 4 (B4) click for full-size image
 Breast: Larger and more elevation
 Areola and papilla: Areola and papilla form a mound MALE SEXUAL DEVELOPMENT
projecting from the breast contour
o Breast stage 5 (B5) Male sexual development generally begins with the attainment of stage G2,
 Breast: Adult (size variable) at an average age of 11.6 years (range 9.5-13.5 years). The first physical sign
 Areola and papilla: Areola and breast in same plane, of puberty in 98% of males is testicular enlargement. Ejaculation often
with papilla projecting above areola occurs during SMR3 while SMR4 is often associated with fertility but may
 Male and female: pubic hair occur during SMR3. Puberty takes about 3 years to complete but may range
o Pubic hair stage 1 (PHI) from 2 to 5 years. The typical sequence of pubertal events in males is seen
 None below which demonstrates the usual late occurrence of peak height velocity
o Public hair stage 2 (PH2) at an average SMR of 4. The typical sequence is adrenarche, beginning of
 Small amount of long, slightly pigmented, downy growth spurt, testicular development, beginning of pubic hair, peak height
hair along the base of the scrotum and phallus in velocity
the male or the labia majora in females; vellus hair
versus sexual type hair (PH3)
o Pubic hair stage 3 (PH3)
 Moderate amount of more curly, pigmented, and
coarser hair, extending more laterally
o Pubic hair stage 4 (PH4)
 Hair that resembles adult hair in coarseness and
curliness but does not extend to medial surface of
thighs
Sequence of pubertal events in males: occurrence of peak height velocity at an average SMR of 2 and the late
occurrence of menarche at an average SMR of 4. Menarche occurs in 19% of
adolescents during PH3 and in 5 6% during PH4. There is little or no
correlation between adult height and either age of onset of growth spurt,
age of PHV, velocity at peak, or pubertal height gain. However, there is a
correlation between adult height and the height at onset of growth spurt or
height at PHV.

Sequence of pubertal events in females

click for full-size image

FEMALE SEXUAL DEVELOPMENT

In most females, the beginning of a breast bud is the first physical sign of
puberty. While the traditional mean age of female sexual development was
in the early 11s, over the past decade in developed countries, this age has
been decreasing. For example, in the United States , the mean age of onset
of breast development is 8.87 years for African-American girls and 9.96 click for full-size image
years for white girls. The mean ages for the onset of pubic hair are 8.78
years and 10.51 years, respectively. Potential reasons for this decrease in There are wide variations of puberty between individuals and these are
age of onset, while unknown, might include improved nutrition, increasing discussed in B1.
obesity, hormonal exposures and other environmental/societal alterations.
There may be important future consequences of earlier maturation with Interviewing and communicating with adolescents
regards to teen behavior, sexual activity and pregnancy as well as future
lifetime health consequences of early sexual maturation such as potential " The style and personality of the practitioner and his/her philosophy of
increase risk of breast cancer. medical care are considered to be most important in the medical care of
adolescents. The practitioner should be mature and open-minded. He/she
During puberty, the female's breasts develop and the ovaries, uterus, should be genuinely interested in teenagers as persons first, then in their
vagina, labia, and clitoris increase in size. The uterus and ovaries increase in problems, and also in their parents. He/she should not only like teenagers
size fivefold to sevenfold. Completion of puberty in females averages 4 but must also feel at ease with them. He/she should be able to
years but can range from 1.5 years to 8 years. In the average adolescent communicate well with his/her patients and their parents. The practitioner
female, the growth spurt starts about 1 year before breast development should help to enhance family communication while assuring confidentiality
and this is followed by an average of 1.1 years until PHV and then followed when requested around personal issues."
in an average of 1 year by menarche. The typical sequence of pubertal
events in females is seen below which demonstrates the usual early
( Adapted from: Committee on Care of Adolescents in Private Practice of the
Society for Adolescent Medicine).
GENERAL GUIDELINES FOR THE OFFICE VISIT
There are a few important guidelines in working with teens:
Liking the Adolescent - Important for the clinician working with adolescent
to like adolescents. If the clinician has an aversion to adolescents and their
problems, it is likely best to refer this age group to another colleague.
Involving the family - The family is a critical component in the care of an
adolescent and it is important for the clinician to introduce himself or
herself to the family. It is also important to spend time discussing the
concerns of the parents. While more of the visit may be spent with the
adolescent alone, it is important for the parents, in most cases, to be
included at some point in the visit. This might be at the beginning, end or
both depending on the age of the adolescent and the complexity of the
problem. At the end of the visit, the clinician should summarize the findings
and plan with the teen and if the parents or guardians are involved,
summarize issues that can or must be discussed with family members.
Although the adolescent may be the primary patient, the parents cannot be
overlooked. Parents' input and insight are crucial, for in a real sense the
family is the patient.
It is also important to consider that the definition of a family has changed
and there may be many possible family constellations including blended
families, stepfamilies, adoptive families and foster families. Family cultural
and ethnic backgrounds are also critical to helping to understand the teen
and their family.
Establishing rapport - It is important but not always easy to establish
rapport with an adolescent during the first visit or several visits. Helpful
suggestions include:
 Introducing yourself to the teen and parents or guardians.
 Chatting for brief period about the teens outside activities including
hobbies or school.
 Letting the teen talk for awhile on topics or areas they feel like
talking about.
 Treating the adolescent's comments seriously
 Moving from less threatening health subjects such as review of
systems to more difficult topics such as sexuality and drugs.
 Exploring the issues that concern the teen - not only those concerns
of the parents.
Ensuring confidentiality - It is critical to insure a sense of confidentiality
with the teen. In this regard the health care practitioner should be familiar
with those laws and regulations that cover consent and confidentiality
among minors in their particular country, state, province or other locality.
The limits of confidentiality should also be discussed. Parents should also be
aware of these confidentiality guidelines.
Acting as an advocate - Since the adolescent may have had encounters with
some adults who have been non-supportive, this is an opportunity for the
clinician to stress the teen's positive attributes, characteristics and abilities.
This is not the same as supporting high-risk behaviors.
Listening and displaying interest - Listening closely to the teen can be a key
to developing rapport. This can include being cautious in giving advice when
asked, trying to understand the teen's perspective and staying focused on
what the teen is telling you. Demonstrating concern and interest is also
helpful in establishing rapport.
Discovering the hidden agenda - It is very common for an adolescent to
present with a complaint that does not represent the major issues that the
teen is concerned about. It is also common that parents may present
concerns that are not the major issue for the teen. For example, a teen may
come in complaining of a headache or acne, but is really concerned about
being pregnant or having a sexually transmitted infection. It is critical for the
clinician to be aware of these other issues that may be more threatening to
the teen's health then their chief complaint. A review of the HEADSS
assessment below can help elicit this information.
Using a developmentally oriented approach - While it is important to cover
areas of sex, family, peer group, and drug use, the clinician must keep in
mind the developmental state of the adolescent. A 12 year old pre-pubertal
male would not be asked the same questions in the same manner as would
be asked a 18 year old fully mature male.
Information gathering - There are several methods that might be used to
elicit both health information and psychosocial information. Traditionally
this is through one and one interviews. Another method is a health
assessment form. Examples for adolescents from the AMA Guidelines for
Adolescent Preventive Services (GAPS) are at http://www.ama-
assn.org/ama/pub/physician-resources/public-health/promoting-healthy-
lifestyles/adolescent-health/guidelines-adolescent-preventive-
services.shtml . There has been a growing interest in using computerized
techniques to help assess health status in both teens and adults. In some
studies, this may even be preferred by many teens. One approach that was
developed at Childrens Hospital of Los Angeles is to obtain psychosocial
information using the HEADSS interview. This includes the topics of Home,
Education, Activities, Drugs, Sex (activity, orientation, and sexual abuse),
and Suicide. This includes questions such as:
Home Where is the teen living? Who lives with the teen? How is the teen
getting along with parents and siblings?
Education Is the teen in school? What classes is he or she doing well in?
What goals does the teen have when he or she finishes school? If the teen is
older out of school, the practitioner should ask about employment.
Activities What does the teen do after school? What does the teen do to
have fun and with whom? Does the teen participate in any sports activities?
Community or Church activities? What are the teen's hobbies? This may be
an opportunity to explore issues of seat belt safety or bicycle helmet safety.
It is useful to reassure confidentiality again before questions about drugs
and sexuality.
Drugs What types of drugs are used by the teen's peers or family members
use? What types of drugs does the teen use and what amount and
frequency and is there intravenous use? This includes both alcohol and
tobacco. It can be useful to begin questioning with a less invasive approach
such as: "I know that drugs are fairly common on school campuses. What
drugs are common on your campus?" and "It is not uncommon for some
teens to try some of these drugs. Have any of your friends tried them? and
"How do you handle the situation when your friends are using drugs? Do
you ever try?
Sexuality Is the teen dating and what are the degree and types of sexual
experience? Is the teen involved with another individual in a sexual
relationship? Does the teen prefer sex with the same, opposite, or both sex
(es)? Has the teen had sexual intercourse? This is also to find out how many
partners the teen may have and also a history of both sexually transmitted
infections and contraceptive use.
An approach might be to ask something like: "Laurie, I mentioned that I
might be asking some questions that were personal but very important to
your health. Again, this is information that I will be keeping confidential. The
area I want to discuss has to do with relationships. Are you going out with
anyone right now?" and something like: " As you know, there are many
teens who are sexually active. By that I mean that they have had sexual
intercourse. There are also many teens who have chosen not to have sexual
intercourse. How have you handled this part of your relationship with Bill or
with other boys you have dated?
Suicide Has the teen had any prior suicide attempts? Does the teen have
any current suicidal ideation?
Sexual Abuse or Physical Abuse These can be critical areas to ask about
particularly in adolescents with any significant problems in the areas listed
above such as family dysfunction, change in school grades, lack of friends,
substance abuse, early onset of sexual activity, history of suicide attempts
or runaway behavior.
Interview tips: Help interview tips with adolescents include:
 Shaking hands with the adolescent first.
 Avoiding lecturing and admonishing.
 Focusing on the initial history taking on the presenting
complaints/problems.
  Having a positive attitude towards the adolescent
 Avoiding judgmental responses - taking a neutral stance
 Avoiding medical jargon
 Being attentive, genuine and empathic
 Identifying who has the problem (i.e., is this problem the teen's
concern or the parents').
 Avoiding writing during the interview, especially during sensitive
questions.
 Criticizing the activity, not the adolescent and highlighting the
positive.
Physical examination : The physical examination may provide another
opportunity to teach the adolescent about their changing body.
Reassurance about normal findings may also be helpful. Sometimes the true
chief complaint is disclosed during the examination.
Closure: When the history and physical assessment are complete, the
clinician should give the teen a brief summary of the proposed diagnosis
and treatment. Issues that should be discussed with the family should also
be addressed at this time. Also at this time resources should be discussed
and a follow-up appointment made as needed. The adolescent should also
have time to ask final questions.
OFFICE SETUP
The space that adolescents are seen for their care can also be helpful in
their overall care.
Space: Adolescents prefer not to be treated as children and the more
private their space and waiting area the better. Materials in the waiting area
and clinical offices appropriate for their age group is helpful. The
examination table should not face the door and curtain should be available
for privacy. If possible the desk in the office should be oriented so that the
health-care provider sits beside the desk, not behind it.
Appointments : Time can be a problem with the adolescent visit particularly
for the first visit. More time should be allotted for this visit to allow for
discussing their past medical and psychosocial history. If the clinician is
pressed for time, doing the history at the first visit and the physical
examination on another day is a reasonable approach.
Billing : In regions where teens may be required to pay for their visit or the
parents will receive a bill, arrangements should be discussed early.
Confidentiality can become a problem in certain billing situations and may
require special arrangements. The adolescent must realize that an insurance
payment may result in parents finding out about visits and the diagnosis;
however, a neutral diagnosis can be used in most situations.
Availability of educational materials : It is helpful to place books,
pamphlets, hot line numbers and reliable web site information in the
waiting room or office on topics such as puberty, sexually transmitted
diseases, sexuality, and contraception.
Note taking: The practitioner should take as few notes as possible during
the interview.
PARENTS
Often parents come to the health care professional with requests for help
with parenting their teens. Helpful suggestions include:
Guidelines for parenting
 Listening to the teenager
 Treating his or her comments seriously and avoid minimizing a
problem.
 Being flexible
 Avoiding power struggles
 Showing interest in the teen and their activities
 Spending time together both working together and having fun
together
 Showing trust in the adolescent
 Avoiding comparison with other teenagers
 Avoiding lecturing or moralizing
 Avoiding overreacting, especially reaching conclusions based only
on appearance, dress, or language.
  Avoiding phrases such as: "The trouble with you is...." or "How could
you do this to me?" or "Is that all? I thought it was something
important." Or "in my day" or "That's a dumb thing to say"
 Stressing positive attributes of the adolescent.
 Respecting each other's privacy
 Keeping a sense of humor
 Resolving conflicts together. Decisions that occur in the home about
the adolescent should involve the adolescent's input and may
involve the whole family.
House Rules: House rules may help a family work together better. These
include the expectations for behaviors for the family to live together as a
group. It is helpful to have these rules worked out with input from the
whole family and for them to be written down. The rules should be fair and
consistent with associated consequences if the rule is broken. Teens may be
eager to participate in the establishment of such rules when they find out
that they might include a rule such as "no one will enter someone else's
room without knocking first." Rules are mainly needed for teen or family
member behaviors that are a problem and there should be a maximum of 5
- 10 rules. Some examples include:
 Dinner will be at about 6 PM and everyone is expected to be home
and ready to eat at that time.
 Family members are expected to speak courteously to each other.
 Before opening someone's door, knock and wait for an answer.
Other parenting issues include:
As teen's peers become an increasingly important influence and the teen
seeks more independence, parents must adapt to change in relationship
with their teen.
Experimentation by teens: Important for parents to remember that while
teens may experiment with many types of behaviors, most teens accept
their parent's basic values. Parents can set firm, fair and explicit limits
around teens behavior.
Parents must not overreact to rejection of one or both parents by the teen
for a time period.
A dolescents are at maximal growth velocity and change and may be more
vulnerable to social risks such as drugs, risks of parts of sexuality, domestic
violence, and poverty.
Modern family issues such as less intact families and less extended families
add additional challenges.
The violent messages added through the media add to the challenges.
Invulnerability: Adolescents feelings of invulnerability also add to the risks
that teens place themselves.
Confidentiality Issues
The rights of minors and in particular adolescents can be confusing.
Adolescents are individuals who have more mental capacity for decision
making than younger children but are not yet full adults. There are many
specific areas regarding consent and confidentiality that are particularly
difficult for teens, parents, health care professionals and lawmakers. These
usually surround areas of reproductive health, mental health and substance
abuse. There are also significant differences between countries and
individual states or provinces within countries regarding particular laws of
adolescent rights to consent and confidentiality.
Over the last several decades the legal framework that applies to the
delivery of adolescent health care has changed in several ways.
 The United Nations has enacted the UN Convention on the Rights of
the Child (http://www.unicef.org/crc/index_30160.html or see
summary below)
 Courts have recognized that minors, as well as adults, have
constitutional rights.
 All states in the U.S. have enacted statutes to authorize minors to
give their own consent for health care in specific circumstances.
 The financing of health care services for all age groups and income
levels has undergone major change
In the United States , the rights of adolescents took a major step with Gault
in 1967, in which the United States Supreme Court stated that "neither the
Fourteenth Amendment nor the Due Process Clause is for adults alone."
However, most specific legal provision that that affect adolescents' access
to health care are contained in state and federal statutes or in “common
law” decisions of the courts.
It becomes essential that health-care practitioners treating adolescents
have a clear understanding of the legal framework within their particular
country or state including checking:
In most states and countries, children under 18 have legal status that differs
from that of adults. Several areas are of particular concern. These include:
CONSENT
Who is authorized to give consent for health care and whose consent is
required?
In general, U.S. law requires the consent of a parent before medical care can
be provided to a minor. However, there are numerous exceptions to this
requirement. These may include:
 Consent by someone other than a biologic parent - such as a foster
parent, a juvenile court, a social worker, or probation officer
 Emergency situations where care may be provided without prior
consent to safeguard the life and health of the minor.
 Specific legal provisions in particular states that allow minors to
consent for specific areas of care. Some of these include
 Contraceptive care
 Pregnancy related care
 Diagnosis and treatment for sexually transmitted diseases (STDs)
 Diagnosis and treatment of either human immunodeficiency virus
(HIV), or acquired immunodeficiency syndrome (AIDS).
 Diagnosis and treatment of reportable or contagious diseases
 Examination and treatment related to sexual assault
 Counseling and treatment for drug or alcohol problems
 Counseling and treatment for mental health issues.
In addition, many states have given consent rights to minors who have
special status. These include:
 emancipated minors
 married minors
 minors in the armed services
 minors living apart from their parents
 and in some states "mature minors"
Not all states have statutes covering all of these services. Some of these
statutes contain age limits, which most frequently fall between ages 12 and
age 15 years. A state by state analysis is available at:
http://www.guttmacher.org/graphics/gr030406_f1.html As theses vary
from country to country and state to state, clinicians are advised to check
laws in their own area.
Informed consent describes the process during which the patient learns the
risks and benefits of alternative approaches to management and authorizes
a course of action proposed by the clinician. Informed consent has both
ethical and legal derivations. Informed consent also implies that the
individual has the mental capacity to given informed consent.
Assent: Under specific legal circumstances, adolescents may receive
confidential care and may give informed consent for recommended care. If
the legal circumstances do not allow a minor to consent for medical
treatment, the minor¹s views and opinions can still be respected by
obtaining assent. This respects the decision-making skills of a minor by
allowing them to participate in the decision.
PRIVACY AND CONFIDENTIALITY
Aside from consent, there is also the issue of confidentiality of services. This
includes who has the right to control the release of confidential information
about the health care, including medical records, and who has the right to
receive such information?
There are numerous reasons why it is important to maintain confidentiality
in the delivery of health-care services to adolescents. These include:
 The needs of clinical practice: Confidentiality is often needed to
facilitate adolescents seeking necessary care and also in providing
accurate, candid and complete health information.
  Developmental Needs: Confidential discussions and disclosure help
support the adolescents' growing sense of privacy and autonomy.
 Safety Issues : There are also times that confidentiality/consent is
important to protect teen from humiliation and discrimination that
could result from disclosure of confidential information.
There are numerous country and local regulations that can affect this
confidentiality. Because of the potential for many conflicting regulations,
clinicians are advised to check on local regulations that apply to
confidentiality with minors. It is important to check out:
 What information is confidential (since it is confidential information
that is protected against disclosure)?
 What information is not confidential (since such information is not
protected)?
 What exceptions are there in the confidentiality requirements?
 What information can be released with consent?
 What other mechanisms allow for discretionary disclosure?
 What mandates exist for reporting or disclosing confidential
information?
Legal Limits of Confidentiality
It is important to balance the moral needs of protecting the rights of the
adolescent with the legal and ethical obligations to breach this
confidentiality in selected instances. There are circumstances in which it is
neither possible nor appropriate to maintain the confidentiality of
information for legal and other reasons. These include situations in which
the adolescent poses a severe risk of harm to himself or herself or to others,
and cases of suspected physical or sexual abuse for which there is a legal
reporting requirement. There are also specific laws in some geographic
areas that require parental notification in certain circumstances, even if the
care is based on a teen's own consent. Finally, when confidentiality must be
breached for ethical or legal reasons, the adolescent should be informed.
Medical Records
Confidentiality protections apply not only to verbal communications but
also to written information contained in medical records. Patients, who are
permitted to consent to their own health care, should be allowed to review
their own medical records and to protect their medical records from review
by others. It is far more difficult to protect the confidentiality of written
medical records.
It is important to understand local regulations regarding the release of
medical records of adolescents. One should understand that many or most
hospitals and clinics will release minors medical written chart information to
parents with parental consent without requiring the permission of the
minor adolescent. This may break the confidentiality of information with an
adolescent.
Although usually bound together in clinical encounters, confidentiality and
consent are different. Confidentiality can occur during an encounter
whether or not specific informed consent for a treatment or intervention is
given. For example, pregnancy options may be confidentially discussed
before informed consent is given for a pregnancy intervention.
PAYMENT
A last issue that arises with consent and confidentiality is occasionally that
of payment of services. Who is financially liable for payment and is there a
source of insurance coverage or public funding available that the adolescent
can access. The fact that a minor has the right to consent and confidentiality
of services does not necessarily guarantee payment, nor confidentiality of
the information if insurance is used. In addition, some consent laws specify
that if a minor is authorized to consent to care, it is the minor rather than
the parent who is responsible for payment.
A source of payment is essential whether an adolescent needs care on a
confidential basis or not. Adolescents are uninsured and underinsured at
higher rates than other groups in the population and those adolescents
living below the poverty level are at the greatest risk for lacking health
insurance. This can present a significant barrier to care.
IMPORTANT DOCUMENTS REGARDING MINORS' RIGHTS
http://www.unicef.org/crc/index_30160.html
Overall the UN Convention:
 Reinforces fundamental human dignity
  Highlights and defends the family's role in children's lives
 Seeks respect for children – but not at the expense of the human
rights or responsibilities of others
 Endorses the principle of non-discrimination .
 Establishes clear obligations
 If a decision is being made by any organisation about a child or
youth, then their interests must be considered when making the
final decision.
Article 4: Governments have made a commitment to live up to the
Convention's standards
Article 5: Governments must value and support parents and other adults in
their roles as carers. Parents and others have a responsibility to listen to
children/youth and vice-versa.
Article 6: Children have the right to life and must have the best possible
chance to develop fully
Article 7: Every child has the right to a name at birth and the right to
become a citizen of a country.
Article 8: Governments must be committed to respect children's right's to
preserve their nationality and identity
Article 9: Children can only be separated from parents if it is in their own
best interests and if that happens, then someone who is an interested party
must be given the opportunity to take part in proceedings and have their
views heard.
Article 10: States shall act quickly and in a positive and humane manner in
applications by families for reunification.
Article 11: As they mature, children have the right to freedom of thought
and religion.
Article 15: Children have a right to join organisations and to meet with each
other. They can also take part in meetings and peaceful gatherings.
Article 16: Children have the right to their own privacy.
Article 17: Both parents have the main responsibilities for bringing up their
children but governments are expected to recognise that some parents may
need help to care properly for their children if they are both working.
Article 19: Children must be kept safe from violence and they must be kept
safe from harm.
Article 20: If children cannot live with their family, they must be properly
looked after in some other way, for example, by another family or in a
children's home. The child's religion, race, culture and language must all be
considered when a new home is being chosen for the child.
Article 21: Children being adopted must only be adopted under very strict
rules which ensure that what is happening is in their best interests.
Article 22: States shall take appropriate measures to ensure that children
who are seeking refugee status or who are refugees shall receive
appropriate protection and humanitarian assistance.
Article 23: Governments shall recognise that a mentally or physically disable
child should enjoy a full and decent life.
Article 24: Children have the right to be as healthy as possible. If they are ill,
they must be given good health care to enable them to become well again.
The Government must try to reduce the number of deaths in childhood and
to make sure that women having babies are given good medical care.
Article 25: If a child is cared for by a local authority, the authority must
review the children's situation regularly.
Article 26: Governments should recognise that children have the right to
benefit from social security type of benefits.
Article 27: Every child has the right to expect an adequate standard of living.
The Government shall help parents to achieve this for their children.
Article 28: Every child has the right to free education at primary school
level. Different kinds of secondary school education should be available for
children. For those with ability, higher education should also be provided .
Article 29: Schools should help children develop their skills and personality
fully, teach them about their own and other people's rights and prepare
them for adult life.
Article 30: Children have the right to access their own culture, use their own
language and practice their own religion.
Article 31: Every child is entitled to rest and play and to have the chance to
join in a wide range of activities.
Article 32: The Government shall protect children from doing work which
could be dangerous or which could harm their health or interferes with their
education.
Article 33: The Government shall take measures to protect children from
dangerous drugs.
Article 34: The Government shall protect children from sexual abuse.
Article 35: The Government shall take measures to protect children from
being abducted or sold.
Article 36: Children shall be protected from all sorts of exploitation which
can damage their welfare
Article 37: No child shall be subject to torture or inhumane treatment or
punishment.
Article 38: The Government should respect and ensure respect for rules of
international humanitarian law applicable to children during armed
conflicts. No child under 15 can be enlisted into an army.
Article 39: The Government shall promote physical and psychological
recovery and social reintegration for victims of neglect, abuse or torture.
Article 40: Children who have committed a crime, or who are alleged to
have committed a crime, should be shown respect for their human rights by
those who are dealing with them. They should have access to appropriate
help including legal assistance.
Article 41: If a country's own law better meets the rights of the child than
the Convention does, then the terms of the Convention will not apply.
The Government must publicise the Convention to parents and young
people throughout their country.
European Convention on Human Rights
http://www.hri.org/docs/ECHR50.html
Position Paper on Confidential Health Care: Society for Adolescent
Medicine
Journal of Adolescent Health 1997;21:4008-415
http://www.adolescenthealth.org/AM/Template.cfm?Section=Position_Pap
ers&Template=/CM/ContentDisplay.cfm&ContentID=2597
Highlights of position paper:
 Health providers should inform adolescent patients and their
parents, if available about the requirements of confidentiality,
including a full explanation of what confidential care entails and the
conditions under which confidentiality might be breached.
 Health providers must remain flexible when delivering confidential
care to adolescents. Blind adherence to absolute confidentiality, or
absence of confidentiality (in deference to parental wishes), is
neither desirable nor required by ethics or law.
 Health providers should develop a disclosure plan for those
adolescents who are deemed not to have capacity to give informed
consent or for whom disclosure of information to responsible adults
becomes necessary which involves adolescent wishes about the
manner in which information is shared.
 Confidentiality considerations regarding record keeping are
necessary. Health providers must consider the manner in which
written and electronic medical records might be available to parties
 in ways that verbal communication are not, and in ways that would unsafe driving etc.). As lifetime habits may form during this age group, it is
be objectionable to adolescent patients. an important time to implement health promotion and preventive services.
 Expanded efforts are needed to increase the education of health
professionals regarding the laws and regulations in their jurisdiction Evidence based research on preventive services guidelines is only in its
relating to confidentiality and informed consent for adolescents. In infancy. This is an important area of research given the limitation on health
addition, specific training is needed to increase providers' skills in resources and the focus on evidence-based medicine.
effectively and appropriately incorporating confidentiality into
clinical practice. COMPARISONS AMONG RECOMMENDATIONS FOR ADOLESCENT
PREVENTIVE SERVICES
American Academy of Pediatrics Policy on Confidentiality in Adolescent (Adapted from Elster AB. Comparison of recommendations for adolescent
Health Care (RRE9151) clinical preventive services developed by national organizations. Arch
Pediatr Adolesc Med 1998;152:193. )
Key points in this policy include:
Subject AAFP AAP AMA BF USPSTF
 Clinicians should make every reasonable effort to encourage the
adolescent to involve parents
Immunizations
 The adolescent will have an opportunity for examination and
counselling apart from parents ACIP recommendations Yes Yes Yes Yes Yes
 Confidentiality will be preserved between the adolescent patient Health guidance for teens
and the provider as between the parent/adult and the provider. Normal development Yes Yes Yes Yes No
 The adolescent must understand under what circumstances (e.g., Injury prevention Yes Yes Yes Yes Yes
life-threatening emergency), the provider will abrogate this Nutrition Yes Yes Yes Yes Yes
confidentiality. Physical activity Yes Yes Yes Yes Yes
Dental health Yes Yes No Yes Yes
Confidentiality of Health Care: Canadian Paediatric Society - Adolescent
Medicine Committee Breast or testicular self-
Yes Yes No Yes No
exam
Health Screening Skin protection Yes Yes Yes Yes Yes
Health guidance for
Yes Yes Yes Yes No
Goal: To promote optimal physical and mental health, and to support parents
healthy physical, psychological, and social growth and development. Screening/counseling
Obesity Yes Yes Yes Yes Yes
As many of the common morbidities and moralities of adolescence are Contraception Yes Yes Yes Yes Yes
related to preventable health conditions associated with behavioral,
Tobacco use Yes Yes Yes Yes Yes
environmental and social causes, it is important that preventive services for
this age group reflect these issues. It is important to both reinforce positive Alcohol use Yes Yes Yes Yes Yes
health behaviors (e.g. exercise and good nutrition) while discouraging Substance use Yes Yes Yes Yes Yes
potentially health-risk behaviors (e.g. unsafe sexual practices, smoking, Hypertension Yes Yes Yes Yes Yes
Depression/suicide No Yes Yes Yes No
 Eating disorders No Yes Yes Yes No  Lack of health care providers trained and interested in caring for
School problems No Yes Yes Yes No adolescents
Abuse No Yes Yes Yes No
Solutions include a broader base of health care settings including private
Hearing Yes Yes No Yes No
physicians' offices, within health maintenance organizations (HMOs), in
Vision No Yes No Yes No school-based health clinics, in family planning clinics and in public health
Tests clinics.
Tuberculosis Yes Yes Yes Yes Yes
Papanicolaou test Yes Yes Yes Yes Yes Other useful information regarding prevention strategies in adolescents
HIV infection Yes Yes Yes Yes Yes include:
STDs Yes Yes Yes Yes Yes
 Position Paper on Clinical preventive Services for Adolescents from
Cholesterol Yes Yes Yes Yes No
Society for Adolescent medicine:
Urinalysis No Yes No No No http://www.adolescenthealth.org/AM/Template.cfm?Section=Positi
Hematocrit No Yes No No No on_Papers&Template=/CM/ContentDisplay.cfm&ContentID=1464
Periodicity of visits Tailored Annual Annual Annual Tailored  The United States goal in Healthy People 2010 for adolescents at:
Target age group (yr) 13-18 11-21 11-21 11-21 11-24 www.health.gov/healthypeople

AAFP - American Academy of Family Physicians Some of these include:

AAP - American Academy of Pediatrics
AMA - American Medical Association  Consistent use of seat belts while driving
BF - Bright Futures  Never driving while drinking or using drugs
USPSTF - US Preventive Services Task Force  Consistent use of condoms if sexually active
 Never smoking
Overall, the guidelines of the various groups are more similar than different.  Eating a prudent diet
One difference between the recommendations is the periodicity which for  Getting regular aerobic exercise
GAPS, BF, and the AAP are annual visits for preventive services versus the
USPSTF and AAFP which recommend visits every 1-3 years based on the QUESTIONNAIRES AND OTHER HEALTH SCREENING TOOLS
specific needs of the individual.
There are several ways to obtain screening health information from teens
Blockades to preventive services to adolescents include:
 Interview during the routine examination. Use of the HEADS
 The concept that adolescents are "generally healthy" and do not psychosocial intake profile is helpful as outlined in section: A4
need services  Screening forms - These can often complement the personal
 The reluctance of adolescents to seek care interview. The GAPS screening forms are available at the AMA web
 Low reimbursement rate site
 Lack of confidentiality  Computer Aided Screening and Assessment: There has been
 Transportation problems increased interest in this technology for assisting in screening.
 Further work needs to be done on the best programs and ways to LABORATORY TESTS
implement this technology.
Few laboratory tests are needed to screen adolescents. These might
The history should include include:

 Past Medical history including  Hemoglobin: Recommended at first encounter or at the end of
 Childhood infections and illnesses puberty.
 Prior hospitalizations and surgery  Routine urinalysis recommended at first encounter with an
 Significant injuries adolescent however up to 1/3 rd of healthy adolescents will have
 Disabilities small amounts of proteinuria.
 Medications, including prescription medications, over-the-counter  Sickle cell screening in African American youth should be done if the
medications, complementary or alternative medications, vitamins, individual has not previously tested.
and nutritional supplements.  Targeted or routine cholesterol screening should be done.
 Allergies  Sexually active adolescents should be screened for gonorrhea and
 Immunization history chlamydia. If indicated by risk profile, syphilis serology and/or HIV
 Prior developmental history and mental health history screening should be offered.
 Family history including  Tuberculosis screening with PPD should be done based on
 Health status and age of family members assessment of individual risk factors and recommendations of the
 Significant physical or mental illnesses in the family local health department.
 Psychosocial profile - See A4
 Review of systems IMMUNIZATIONS

The physical examination should include: An immunization history should be obtained and immunizations should be
updated. This age group still has significant rates for non-immunization.
 Height, Weight, Vital Signs - Body mass should be calculated. Schedules are available from the Advisory Committee on Immunization
Practices (ACIP) of the CDC. Specific countries and areas should examine the
 Vision Screening
recommendations of their area as these vary from country to country and
 Hearing Screening
even state to state. The current U.S. recommended immunization schedule
 Sexual Maturity Rating
is available at www.cdc.gov. In addition, international travel information is
 Skin exam
available at: http://www.cdc.gov/travel
 Teeth and Gums
 Neck exam for thyromegaly or adenopathy Potential needs in adolescents include dT booster, MMR, hepatitis A and B,
 Cardiopulmonary and varicella.
 Abdominal exam
 Musculoskeletal Part of the GAPS project has been to develop both methods of assessment
 Breast exam and interventions. GAPS recommends the use of the mnemonic G-A-P-S -
 Neurologic: Cursory unless specific neurologic problem
 Genitalia in males and pelvic exam as indicated in females Gather information - Screen for problems
Assess further - If a problem identified then assess level and nature of risk
Problem Identification - Work with teen toward agreement on the problem
and to make changes
Specific Solutions. - This involves helping the teen with self-efficacy, giving
the teen support, solving problems in working toward a solution and
shaking on a contract.
A publication from the AMA, GAPS: Clinical Evaluation and Management
Handbook, includes fully developed algorithms for each of the GAPS
recommendations ( http://www.ama-
assn.org/adolhlth/ama/pub/category/1947.html).
Web Sites
Available websites with preventive health guidelines include:
Department of Health and Human Services:
http://odphp.osophs.dhhs.gov
Recommendations on periodic health examinations based on the health
risks of specific age groups. The recommendations are evidence based or
expert opinion based.
GAPS - Guide to Adolescent Preventive Services - American Medical
Association
These are the comprehensive guidelines puts in place by the AMA's Division
of Adolescent Health. The recommendations are called GAPS - Guide to
Adolescent Preventive Services. GAPS recommendations cover both the
content and delivery of health care to adolescents. Several web sites are
available:
For survey questionnaires: http://www.ama-assn.org/ama/pub/physician-
resources/public-health/promoting-healthy-lifestyles/adolescent-
health/guidelines-adolescent-preventive-services/screening-health-
guidance-suicide-depression.shtml
For actual recommendations http://www.ama-
assn.org/ama/pub/physician-resources/public-health/promoting-healthy-
lifestyles/adolescent-health/guidelines-adolescent-preventive-
services/suicide-depression-resources.shtml
Other useful links are available at the adolescent health section of AMA at
http://www.ama-assn.org/ama/pub/category/1947.html including
 healthy people 2010 recommendations for
adolescents
 Adolescent health resources and links
Bright Futures
The Bright Futures (BF) guidelines for the health care supervision of infants,
children, and adolescents were published in 1994 and represent the work of
expert panels convened through a collaboration of the Maternal and Child
Health Bureau of the Health Resources and Services Administration, and the
Medicaid Bureau of the Health Care Financing Administration. The
guidelines are both evidence-based and based on expert opinion. They are
available at:
www.brightfutures.org/
American Academy of Pediatrics
The AAP has also reviewed the preventive care for children and adolescents
and published revised recommendations in 1995. These recommendations
represent “a consensus by the Committee on Practice and Ambulatory
Medicine in consultation with national committees and sections of the
American Academy of Pediatrics.” In 1996, the AAP also released Guidelines
for Health Supervision III which more comprehensively describes the
elements of health supervision visits for children and adolescents.
However, currently the AAP is working with Bright Futures through two
cooperative MCHB grants to help facilitate usage of Bright Futures among
child health professionals and the public. The new web site starting in June
2003 will be:
http://brightfutures.aap.org
The American Academy of Pediatrics recent guidelines are posted at
http://aappolicy.aappublications.org/practice_guidelines/index.dtl
These are from March 2000.
American Academy of Family Physicians (AAFP)
AAFP offers age-specific recommendations for periodic health examinations
for healthy patients. The AAFP recommendations are derived from the
USPSTF report by the Commission on Public Health and Scientific Affairs of
the AAFP. The website is at:
http://www.aafp.org
Also available are:
Canadian Task Force on Preventive Health Care
http://www.ctfphc.org
World Health Organization
http://www.who.int/child-adolescent-health/prevention/adolescent.htm
SEXUALITY
It is not always comfortable for a clinician to deal with sexual issues of
adolescents. Suddenly the 6 or 8 year old child that has been coming in for
ear infections or rashes is turning into an adult. In the process the teen is
developing both physical changes but is becoming much more interested
and involved in their sexual identity and relationships. An additional part of
this is dealing with the consequences of sexual behaviors including sexually
transmitted diseases and pregnancy. However, clinicians must be aware
that all teenagers are sexual beings whether or not they are sexually active
and also that teens engage in sexual activities other than vaginal
intercourse. The reality is that sexual development and behavior does not
start during adolescence or adulthood, but with childhood sexual curiosity.
It is critical for health-care providers caring for adolescents to understand
sexuality during the teenage period and to be familiar with ways to deal
with teenagers' questions, feelings, and problems.
A FEW DEVELOPMENTAL ISSUES
Preadolescent period:
Biological sex is determined based on chromosomes, gonads, and
hormones. In general, gender identity or sense of masculinity and femininity
is established during this period also. During this period there is low physical
and mental time spent on sexuality issues.
Early Adolescence
This period is characterized by:
 Early pubertal developmental changes
 Curiosity and concern over one's body and one's peers
 Sexual fantasies are common as well as beginning of masturbation
activity
 Most sexual activity is nonphysical such as phone conversations

Middle Adolescence
This period is characterized by:
 Full physical maturation including menstruation in females
 High sexual energy with more emphasis on physical contact
 Sexual exploration activity including dating, kissing, casual
relationships of both coital and noncoital nature
 Denial of consequences of sexual behaviors
Late Adolescence
This period is characterized by:
 More expressive and less exploitative sexual behaviors
 More intimate sharing relationships
Adolescents are filled with questions about their sexuality including?
 Am I normal?
 Is masturbation ok?
 Am I ready for a sexual relationship or intercourse?
 How do I say no?
 What is safe sex?
 What is contraception?
  Am I gay?
SEXUAL BEHAVIORS
Given the need, do physicians address issues of adolescent sexuality?
In a recent CDC news release (PACT5, December 8, 2000) it was found that
in a survey of 15,000 high school students from the U.S., only 43% of
teenage females and 26% of teenage males discuss pregnancy or sexually
transmitted infections with their physicians during routine exams.
UNWANTED SEXUAL EXPERIENCES
Unfortunately not all adolescent sexual involvement is consensual.
 Over 80% of females in grades 8-11 and over 2/3 of males
experienced unwanted sexual comments or actions in 1993.
 Sexual intercourse in young adolescents in particular may not be
voluntary. Data presented by the Alan Guttmacher Institute
indicates that about 74% of women who had intercourse before age
14 and 60% of those who had sex before age 15 report having had
sex involuntarily (Alan Guttmacher Institute, 1994
Suggestions to help adolescents better deal with their sexuality include:
 Listening to teen's feeling and concerns and tempering ones own
reactions.
 Parents can exert a strong positive influence, not through
moralizing, lecturing, or invasion of privacy, but through helping the
adolescent in his or her decision-making process.
 Timing: Because sexuality begins in childhood, it is important to
treat sexuality as a natural part of life from birth onward. Given this
perspective, it is much less awkward to have discussions about
sexuality when children grow up.
 Education: Adolescents should be informed and knowledgeable -
with the aid of parents, school, or community resources in areas
including basic reproductive anatomy and physiology, basic sexual
functioning, health consequences of sexual intercourse, decision
making skills
 Avoid joking about sexuality
 Admit personal discomfort
 Have available resources including books and pamphlets or web
sites.
 Respect the adolescent's privacy
 Be aware of community resources.
MEDICAL PROBLEMS
ABDOMINAL PAIN
Chronic abdominal complaints are a frequent concern or complaint of
adolescents and young adults. One definition is three or more separate
episodes of pain that occur over a 3 - month period. In most cases of
recurrent abdominal pain in adolescents, no specific organic problem is
found. The prevalence is as high as 5-10% or more of all adolescents.
Differential Diagnosis includes:
 Functional abdominal pain often related to stress and eating habits.
The pain tends to be periumbilical, crampy and nonspecific without
radiation. It usually does not wake adolescents. There may be
associated nausea and vomiting, headaches, fatigue, dizziness and
diarrhea. It does not usually cause weight loss or other systemic
symptoms. It distinction organic abdominal pain usually includes
more localized pain and may awake the teen from sleep.
 Irritable Bowel Syndrome : Pain is usually colicky in nature and is
usually more common in older adolescents and more common in
females.
 Lactose intolerance which is associated with crampy abdominal
pain, diarrhea, flatulence and belching
 Gynecologic conditions such as ectopic pregnancy, mittleschmerz,
ruptured ovarian cysts and pelvic inflammatory disease.
 Musculoskeletal conditions like costochondritis or muscle wall strain
 Hepatitis and pancreatitis
 Gastrointestinal infections such as giardiasis
 Referred pain from lower lungs such as pneumonia or spinal cord
tumor
  Gastrointestinal disease such as peptic ulcer disease, inflammatory
bowel disease or obstructed bowel.
 Systemic conditions : Occasionally systemic conditions in
adolescents may lead to abdominal pain such as diabetic
ketoacidosis, sickle cell crisis,
Diagnosis
An organic disease is usually suggested by the history, physical examination
and results of screening laboratory tests. The history should include pain
description, family history, current stresses and relationship to pain. It may
be helpful to have teen keep a pain and dietary diary. The examination
should include height and weight and growth charts, careful examination of
abdomen for tenderness, rebound, hepatosplenomegaly or masses. Signs of
systemic diseases should be looked for and a pelvic examination if indicated.
Screening laboratory tests include CBC, sedimentation rate, urinalysis, basic
chemistry panel and liver enzymes. In addition, stool samples for occult
blood, ova and parasite may be needed. Other helpful tests might include
stool alpha-antitrypsin test as screen for IBD or protein losing enteropathy
as well as plain film of abdomen and H.pylori antibody titer. More
complicated or invasive tests might be needed depending on initial
evaluation.
If the diagnosis of functional abdominal pain is made, the clinician will need
to explain to the need the meaning of this disorder. In addition, the clinician
needs to explain that the symptoms are real but can result from emotions
and feelings. The clinician can use the example of blushing, a physiological
response to the feeling of embarrassment. The teen should be reassured
that they can return to their activities and school.
CHEST PAIN
As many as 5% of adolescents in medical clinics complain about chest pain.
In contrast to adults, acute chest pain in adolescents is rarely of cardiac
origin. However, many teens fear having a heart attach or having cancer.
The common causes of chest pain in adolescents includes:
 Musculoskeletal including precordial "stitch", muscle strain,
costochrondritis, Tietze's syndrome and much less commonly
slipping rib syndrome, fibromyalgia, thoracic outlet obstruction and
metatstatic bone disease.
 Psychogenic including stress, hyperventilation and depression
 Pulmonary causes including cough, asthma, pneumonia, pleural
effusion, pleurodynia, pneumothorax, acute chest syndrome with
sickle cell disease and acute pulmonary embolism.
 Gastrointestinal including reflux, peptic ulcer disease, gastritis,
cholecystitis
 Trauma to ribs
 Breast lesions or mastitis
 Cardiac conditions such as mitral valve prolapse, pericarditis,
myocarditis and rare congenital problems
 Less common problems also include herpes zoster
The diagnosis is usually based on history and physical examination.
Important historical items include characterization of pain, precipitating and
alleviating factors, recent activity, trauma, recent infections, associated
symptoms and recent stress. Physical examination includes vital signs, chest
wall palpation, cardiopulmonary examination, breast examination and
abdominal examination. Most adolescents will not require any further
laboratory tests and usually an electrocardiogram and chest radiograph are
normal. Symptoms that should be of particular concern to the clinician
include acute chest pain precipitated by exercise, pain that interferes with
sleep or associated with dyspnea, palpitations, dizziness or syncope.
FATIGUE
Another common complaint among teens is fatigue. This may be a common
complaint from parents who may be concerned that their teens seem to not
be doing enough. It is less common to have teens complain of severe
fatigue. The most common cause of fatigue in teens is nonorganic
representing a reaction to stress, anxiety or depression. Causes include
psychosocial causes (stress, anxiety, depression), inadequate sleep, dieting,
pregnancy, medications, infections, allergies, systemic diseases (renal,
anemia, malignancy, collagen vascular diseases, thyroid dysfunction,
diabetes mellitus, IBD) and chronic fatigue syndrome.
The evaluation should include careful review of systems, medical history,
psychosocial history including alcohol and substance use and sleep history.
History suggestive of organic causes include fatigue that increases during
the day, that decreases with rest, history of fever, weight loss, night sweats,
arthritis or lymphadenopathy. The physical examination may point to an
organic problem. Many teens will not require any laboratory tests but if
there is any questions, a screening evaluation might include, CBC with
differential, urinalysis, mononucleosis test, sedimentation rate and perhaps
a screening chemistry panel. Other tests would be based on the history and
examination.
Chronic fatigue syndrome
Chronic fatigue syndrome (CFS) is a clinically defined syndrome for adults
that is characterized by new onset, severe, disabling fatigue and a
combination of symptoms highlighted by self-reported impairments in
concentration and short-term memory, musculoskeletal or joint pains, sleep
disturbances, headaches, sore throat, tender lymph nodes and post
exertional malaise. Diagnosis excludes uncontrolled chronic illness, past or
current mental illnesses like depression, bipolar affective disorder or
anorexia nervosa. The criteria for adults can be found at the CDC web site at
http://www.cdc.gov/ncidod/diseases/cfs and then going to the CFS
definition. However, there are no accepted criteria for CFS in adolescents.
The etiology and pathophysiology is controversial and unknown. It has been
linked to various viruses and may be associated with various immunological
abnormalities. The evaluation is similar to that discussed for general fatigue.
Treatment has involved reassurance, low-dose antidepressants,
psychotherapy and physical therapy.
HEADACHES
Recurrent headaches are also a frequent problem in adolescents and young
adults. Almost 75% of teens by age 15 have experienced headaches. Most
recurrent headaches in adolescents and young adults are not associated
with severe organic pathology. However, they may be signs of stress,
anxiety, or depression. This is in contrast to a isolated single very severe
acute headache that may be a sign of organic disease. Most headaches are a
result of either vascular dilation, muscular contraction, traction of structures
or local inflammation.
Epidemiology
By age 12 about 66% of adolescents have had headaches and this increases
to 75% by age 15. About 25% of migraine headaches begin during childhood
and adolescence. After age 12 headaches become more common in
females.
Differential Diagnosis
 With acute severe headache
 Febrile patients: meningitis, brain abscess, sinusitis, other infections
 Afebrile patient: Subarachnoid hemorrhage, intracerebral
hemorrhage, post-seizure headache, severe hypertension, acute
dental disease, or acute orbital disease
 With episodic, recurrent headaches and complete recovery
between episodes
 Muscle tension type headaches - Associated with bandlike, bilateral,
steady pain and usually lack nausea, vomiting, photophobia or
neurologic symptoms
 Classic Migraine: Classic migraine is associated with aura, unilateral
throbbing headache and also nausea and/or vomiting. Photophobia,
family history and history of motion sickness are common.
 Common migraine is similar to classic but lacks aura and may be
bilateral.
 Migraine variants include hemiplegic migraine, confusional
migraine, abdominal migraine and ophthalmoplegic migraine.
 Cluster headaches - Associated with burning or pain behind one eye
with sudden onset also rhinorrhea, lacrimation and conjunctival
injection on same side.
 Chronic headaches but continuous or increasing in intensity after
onset
 Intracranial mass lesions, hydorcephalus, post-lumbar puncture
headaches, pseudotumor cerebri, depressive headaches, post-
trauma, local extracranial disease, pregnancy, chronic meningitis,
substance abuse, obstructive sleep apnea.
Diagnosis
In diagnosing the cause of headaches, the history is the primary diagnostic
tool with examination being also key. The history should include onset,
pattern and chronology of the pain, associated symptoms, preceding
symptoms or visual symptoms, precipitants including stress, illnesses, foods,
medication and caffeine. Medications can be important including analgesics,
birth control pills and tetracycline. Substance abuse history and stress
history is important as well as history of migraines in the family. The
physical examination includes a good general examination with a careful
neurological examination. In general, teens with recurrent headaches and
separated by periods of complete recovery rarely need further laboratory
evaluation. Neuroimaging is indicated in the acute severe headache or
increasing constant headache or teens with abnormal neurological
examination.
The most frequent problem in teens is insomnia involving either trouble
falling asleep, staying asleep or awakening too early. Treatment involves
identifying any organic problems and psychosocial stresses. Important
interventions include counseling, regularizing bedtime hours, relaxation
techniques, daily exercise, curtailing caffeine and alcohol and avoid daytime
naps.

Therapy

It is generally better to take medications sooner in the onset of the

headache than later. Reassurance in most teens and families is a key issue.
A headache diary can be helpful in eliminating triggering events or foods.
Helpful interventions in tension headaches include relaxation exercises,
simple analgesics or combined analgesics with both acetaminophen and
nonsteroidal anti-inflammatory medications. Migraine headaches may
respond to elimination of certain triggering items as well as stabilizing
caffeine intake. Medications include simple analgesics, antiemetics,
sedative-analgesic combinations, ergot derivatives, and the triptan
medications for acute severe migraine headaches. Prophylactic treatment
can include beta-blockers, antidepressant medications, low dose non-
steroidal medications, anticonvulsants (valproic acid and phenytoin),
calcium channel blockers and clonidine.

SLEEP DISORDERS

Sleep problems can be a common problem in teens as either a major

complaint or on the review of systems. Problems can include insomnia,
hypersomnia (narcolepsy and excessive daytime sleepiness) and
parasomnias (nightmares, night terrors, sleepwalking and nocturnal
enuresis). Adolescents require about 8 1/2 to 9 1/2 hours of sleep per night
but actually get far less. Early teens sleep about 9 hours, mid adolescents
about 7 1/2 hours and late adolescents about 7 hours. Teens with sleep
problems should be asked about the type of problem, frequency, duration,
daytime symptoms, family history, age of onset, bedtime habits, prior
treatment, psychosocial history and medications and drug history.