I. PHYSICAL GROWTH AND DEVELOPMENT

A. Goals

a. Student: Know the Tanner stages of development.

b. Resident: Understand how Tanner staging is used clinically.

c. Fellow: Know how the physiologic and hormonal changes associated with each Tanner stage affect body habitus and the risk of physical and psychological disease.

B. Objectives

a. Student: Describe normal patterns of physical growth and pubertal development during adolescence; demonstrate that you can counsel families about normal adolescent physical growth and development, and provide guidance that would help teens develop comfort with their new bodies.

b. Resident: Demonstrate your knowledge of patterns of physical growth and pubertal development during adolescence by evaluating variations in growth patterns and pubertal changes during adolescence.

c. Fellow: Demonstrate your knowledge of the physiologic and hormonal changes associated with each Tanner stage by explaining how variations in growth patterns and pubertal changes affect body habitus and predispose adolescents to various physical and psychological problems.

C. Subtopics

1. Factors Controlling the Onset of Puberty (Hormonal Changes)

2. Musculoskeletal Changes

a. Linear growth

b. Weight

c. Muscle and bone changes

3. Secondary Sexual Development

4. Normal Conditions/Variants

a. Breast asymmetry

b. Gynecomastia

c. Physiologic leukorrhea

5. Abnormal Patterns of Growth and Development (See Section XV.6. Endocrinologic)

6. Relationship of Sexual Maturity to Physiologic Variables

a. Epistaxis

b. Acne

c. Osteochondrosis

d. Myopia

e. Laboratory measures

D. Suggested Reading

CORE:

Dorn LD, Rotenstein D. Early puberty in girls: the case of premature adrenarche. Women’s Health Issues. 2004;14:177-83.

Herman-Giddens ME, Kaplowitz PB, Wasserman R. Navigating the recent articles on girls' puberty in Pediatrics: what do we know and where do we go from here? Pediatrics. 2004;113:911-7.

Herman-Giddens ME, Wang L, Koch G. Secondary sexual characteristics in boys: estimates from the national health and nutrition examination survey III, 1988-1994. Arch Pediatr Adolesc Med. 2001;155:1022-8.

Plant TM. Neurophysiology of puberty. J Adolesc Health. 2002;31:185-91.

Rosen DS. Physiologic growth and development during adolescence. Pediatr Rev. 2004;25:194-200.

Anderson SE, Dallal GE, Must A. Relative weight and race influence average age at menarche: results from two nationally representative surveys of US girls studied 25 years apart. Pediatrics. 2003;111:844-50.

Anderson SE, Must A. Interpreting the continued decline in the average age at menarche: Results from two nationally representative surveys of U.S. girls studied 10 years apart. J Pediatr. 2005;147:753-760.

Biro FM, Lucky AW, Simbartl LA, Barton BA, Daniels SR, Striegel-Moore R, Kronsberg SS, Morrison JA. Pubertal maturation in girls and the relationship to anthropometric changes: pathways through puberty. J Pediatr. 2003;142:643-6.

Bonat S, Pathomvanich A, Keil MF, Field AE, Yanovski JA. Self-assessment of pubertal stage in overweight children. Pediatrics. 2002;110: 743-7.

Hannon TS, Janosky J. Longitudinal study of physiologic insulin resistance and metabolic changes of puberty. Pediatr Res. 2006;60:759-763.

Heymsfield SB, Gallagher D, Mayer L, Beetsch J, Pietrobelli A. Scaling of human body composition to stature: new insights into body mass index. Am J Clin Nutr. 2007;86:82-91. BMI is a good measure of body composition – except that short women burn more calories thinking than tall women do.

Kaplowitz PB, Slora EJ, Wasserman RC, Pedlow SE, Herman-Giddens ME. Earlier onset of puberty in girls: relation to increased body mass index and race. Pediatrics. 2001;108:347-53.

Krupa B, Miazgowski T. Bone mineral density and markers of bone turnover in boys with constitutional delay of growth and puberty. J Clin Endorinol Metab. 2005;90:2828-2830.

Lever J, Frederick DA, Laird K, Sadeghi-Azar L. Tall women's satisfaction with their height: general population data challenge assumptions behind medical interventions to stunt girls' growth. J Adolesc Health. 2007;40:192-4. It may be best to leave well enough alone.

Pinto SM, Garden AS. Prepubertal menarche: a defined clinical entity. Am J Obstet Gynecol. 2006;195:327-9.

Rogol AD, Roemmich JN, Clark PA. Growth at puberty. J Adolesc Health. 2002;31:192-200.

Sandberg DE, Bukowski WM, Fung CM, Noll RB. Height and social adjustment: are extremes a cause for concern and action? Pediatrics. 2004;114:744-50.

Slyper AH. The pubertal timing controversy in the USA, and a review of possible causative factors for the advance in timing of onset of puberty. Clin Endocrinol (Oxf). 2006;65:1-8.

Wren TA, Kim PS, Janicka A, Sanchez M, Gilsanz V. Timing of peak bone mass: discrepancies between CT and DXA. J Clin Endocrinol Metab. 2007;92:938-41.What does this mean for our assessments of bone mineral density in patients with anorexia?

E. Topics for Research and Thought

Research conferences:

Evidence-based conferences:

Suggestions for evidence-based conferences:

· Low body weight and high levels of psychosocial stress suppress the hypothalamic-pituitary-gonadal axis. This both retards pubertal maturation and impairs fecundity. What is the evidence that during childhood, high body weight and low levels of psychosocial stress kindle the hypothalamic-pituitary-gonadal axis, thereby creating an environment that is conducive to early childbearing?

Ferin M. Clinical review 105: Stress and the reproductive cycle. J Clin Endocrinol Metab. 1999;84:1768-74.

Shalitin S, Phillip M. Role of obesity and leptin in the pubertal process and pubertal growth--A review. Int J Obes Relat Metab Disord. 2003;27:869-74.

Posner RB. Early Menarche: A review of research on trends in timing, racial differences, etiology and psychosocial consequences. Sex Roles. 2006;54:315-22.

Slyper AH. The pubertal timing controversy in the USA, and a review of possible causative factors for the advance in timing of onset of puberty. Clin Endocrinol (Oxf). 2006;65:1-8

Teilmann G J clin endo met 2007;92:2538.

Suggestions for meditation:

· Why do heavy children tend to start pubertal development at a younger age than thin children? Or is it the other way around; do early maturing teens tend to get fatter?

· Why do patients with gonadal dysgenesis have normal gonadotropin levels prior to pubarche?

· What causes “growing pains?” Are they real? If not, what causes the symptoms grandmothers call “growing pains?” What can be done to help relieve the pain?

F. Handouts

Patient:

Student:

II. PSYCHOLOGICAL, SOCIAL, AND SEXUAL DEVELOPMENT

A. Goals

1. Student: Know the stages of adolescent psychosocial and cognitive development and how they influence sexual behavior at this age.

2. Resident: Understand how the stages of adolescent psychosocial, cognitive, and sexual development are used clinically to evaluate the appropriateness of behavior.

3. Fellow: Know how various patterns of psychosocial development predispose adolescents to healthy and risky social and sexual behaviors and be able to offer anticipatory guidance to parents, teachers, and other healthcare providers.

B. Objectives

1. Student: Describe the stages of adolescent psychosocial development and the ages at which they usually occur; demonstrate that you can counsel families about normal adolescent psychosocial and sexual development and provide guidance about ways to help the teen develop appropriate independence, self-esteem, social competency, and safely define their sexuality.

2. Resident: Demonstrate your knowledge of the stages of adolescent psychosocial development by exploring an adolescent’s perspective on peer and family relationships and gather information about an adolescent’s sexual development, identity, and activity using organized interview techniques (HEADSS) or trigger questions (Bright Futures, GAPS) to identify covariate risk and protective behaviors.

3. Fellow: Demonstrate your knowledge of the stages of adolescent psychosocial and sexual development by counseling adolescents and their family members about how to manage normal emotional changes in ways that promote mental health and mitigate potentially adverse effects of peer pressure and ridicule and sexual experimentation.

C. Subtopics:

1. Stages of Adolescence

a. Early (10-14 years)

b. Middle (15-16 years)

c. Late (17-20 years)

2. Tasks of Adolescence

a. Adjustment to the somatic changes of puberty

b. Establish independence/personal identity

c. Sexual development

d. Cognitive maturation

e. Self-esteem and self-image

3. Theories of Adolescent Development

a. Piaget

b. Erickson

c. Freud

d. Kohlberg/Gilligan

4. Spheres of Development

a. School

b. Peers

c. Family

d. Work

5. Sexual Developmental Stages

a. Undifferentiated

b. Heterosexual/homosexual

c. Intimacy

6. Initiation of Sexual Activity/Sexual Decision Making

a. Homosexuality

b. Risk Taking

c. Vulnerability and Resiliency

d. Media

e. Chronically Ill/Disabled

7. Race/Ethnicity / Cultural values

D. Suggested Reading (See also Section VI. Reproductive Health)

CORE:

Byrnes JP. The development of decision-making. J Adolesc Health. 2002;31:208-15.

Frankowski BL; American Academy of Pediatrics Committee on Adolescence. Sexual orientation and adolescents. Pediatrics. 2004;113:1827-32.

Gutgesell ME, Payne N. Issues of adolescent psychological development in the 21st century. Pediatr Rev. 2004;25:79-85.

Harris DR, Sim JJ. Who is multiracial? Assessing the complexity of lived race. Am Soc Rev. 2002;67:614-27.

Jessor R. Risk behavior in adolescence: a psychosocial framework for understanding and action. J Adolesc Health. 1991;12:597-605.

Ryan C, Futterman D. Caring for gay and lesbian teens. Contemp Pediatr. 1998;15:107-130.

Gessner BD. Reproductive health, criminal activity, and abuse among 10- to 15-year-old females enrolled in Medicaid. Obstet Gynecol. 2006;108:111-8.

L'Engle KL, Jackson C, Brown JD. Early adolescents' cognitive susceptibility to initiating sexual intercourse. Perspect Sex Reprod Health. 2006;38:97-105.

Marin BV, Kirby DB, Hudes ES, Coyle KK, Gomez CA. Boyfriends, girlfriends and teenagers' risk of sexual involvement. Perspect Sex Reprod Health. 2006;38:76-83.

Miller L, Gur M. Religiousness and sexual responsibility in adolescent girls. J Adolesc Health. 2002;31:401-6.

Murphy NA, Elias ER. Sexuality of children and adolescents with developmental disabilities. Pediatrics. 2006;118:398-403.

Ott MA, Millstein SG, Ofner S, Halpern-Felsher BL. Greater expectations: adolescents' positive motivations for sex. Perspect Sex Reprod Health. 2006;38:84-9.

Rosenbaum JE. Reborn a virgin: Adolescents' retracting of virginity pledges and sexual histories. Am J Public Health. 2006;96:1098-103.

Wingood GM, DiClemente RJ, Bernhardt JM, Harrington K, Davies SL, Robillard A, Hook EW 3rd. A prospective study of exposure to rap music videos and African American female adolescents' health. Am J Public Health. 2003;93:437-9.

E. Topics for Research and Thought

Research conferences:

Evidence-based conferences:

Suggestions for Evidence-based conferences:

· Problem behaviors cluster but do generic preventions interventions help?

Guilamo-Ramos V, Litardo HA, Jaccard J. Prevention programs for reducing adolescent problem behaviors: Implications of the co-occurrence of problem behaviors in adolescents. J Adol Health. 2005;36:82-86.

· This is certainly consistent with public opinion and intuitively reasonable… but, is it true?

South SJ, Haynie DL, Bose S. Residential mobility and the onset of adolescent sexual activity. J Marr Fam. 2005;67:499-514.

· Do group interventions do more harm than good? Do they promote more problem behaviors than they prevent?

Barlow J, Johnston I, Kendrick D. Individual and group-based parenting programmes for the treatment of physical child abuse and neglect. Cochrane Database Syst Rev. 2006: 3: CD005463.

Dishion TJ, McCord J, Poulin F. When interventions harm. Peer groups and problem behavior. Am Psychol. 1999;54:755-64.

Hallfors D, Cho H, Sanchez V, Khatapoush S, Kim HM, Bauer D. Efficacy vs effectiveness trial results of an indicated "model" substance abuse program: implications for public health. Am J Public Health. 2006;96:2254-9.

Vreeman RC, Carroll AE. A systematic review of school-based interventions to prevent bullying. Arch Pediatr Adolesc Med. 2007;161:78-88.

Suggestions for meditation:

· Do children who are raised in restrictive homes and social environments engage in more or less risk-taking behavior than children raised in more permissive environments?

· How might the physiologic changes of puberty affect the psychosocial and cognitive changes of adolescence? Is there a physiologic reason why males tend to be better at math than females? Is there a physiologic reason why rapidly maturing children tend to excel academically?

· Is the “personal fable” adaptively advantageous?

· Does homosexuality have a physiologic etiology or a social etiology?

· Are there sets of risk and protective factors that differ quantitatively between teens but assert the same effects on their behavior?

F. Handouts

Patient:

Student:

III. HEALTH MAINTENANCE

A. Goals

1. Student: Understand the process and content of an effective adolescent history and physical examination, including issues related to confidentiality and privacy.

2. Resident: Understand key strategies for scheduling and organizing health supervision visits for adolescents; including office environment, laboratory testing, immunizations, and anticipatory guidance.

3. Fellow: Understand key elements of health supervision related to adolescent psychosocial development, diet and eating patterns, exercise, school performance, injury and risk-taking, sexual activity, tobacco and substance abuse, depression and suicide.

B. Objectives

1. Student: Demonstrate how to obtain and interpret a detailed medical and psychosocial history from an adolescent and the parent of an adolescent, including a discussion of the purpose and limits of confidentiality. In so doing, demonstrate that you can integrate findings from your physical examination into your assessment and plan.

2. Resident: Discuss how to organize an adolescent office visit, including a description of the office environment, how you plan to use questionnaires (e.g.: initial and periodic Adolescent Preventive Services Visit forms developed as an adjunct to GAPS), trigger questions (e.g.: from Bright Futures) and organized interview techniques (e.g.: HEADSS), and explain the rationale for the timing of specific laboratory screening tests and immunizations.

3. Fellow: Demonstrate your ability to recognize when adolescents and their families cannot resolve interpersonal conflicts related to family and peer pressures, diet/eating problems, school problems, risk-taking and experimentation with sex and substance use, poor self-esteem, and depression, by counseling adolescents and their parents to recognize and avoid the adverse effects of peer pressure, risks for eating disorders, early signs and symptoms of school failure, tendency toward sedentary life-style, unrealistic sense of personal vulnerability, risky situations with regard to sexual activity, substance use, and suicide.

C. Subtopics:

1. Confidentiality: Legal Rights and Clinical Limitations

2. History and Screening for Risk and Protective Factors

a. Personal

b. Family

c. School

d. Community

e. Media

3. Interview with Adolescent and Parents Together/Separately - Techniques to Facilitate Communication, Honesty and Transparency

4. General Physical / Breast / Pelvic / Testicular Examinations - Techniques to Facilitate Comfort

5. Self-Examination: Breast and Testicular

6. Laboratory Screening

a. Sexually transmitted diseases (STDs) (See Section VI.3.Sexually Transmitted Diseases)

b. Genital Cancer (See Section VI. Reproductive Health)

c. Anemia

d. Urinary tract infections/renal pathology

e. Cardiovascular/diabetes/syndrome X

f. Toxicology (See Section IX. Drug Use and Abuse)

7. Immunizations

8. Anticipatory Guidance for teens

a. Tobacco and substance use/abuse

b. Nutrition/eating patterns

c. Exercise

d. Media

e. Accidents/injury

f. Emotional liability/depression

g. Peer pressure

h. School performance

i. Sexuality

j. Violence/Bullying

k. Sleep

9. Anticipatory Guidance for parents

10. Health Literacy

D. Suggested Reading

CORE:

Alderman EM, Rieder J, Cohen MI. The history of adolescent medicine. Pediatr Res. 2003;54:137-47.

Bright Futures. Guidelines for health supervision of infants, children, and adolescents. Bright Futures is sponsored by MCHB, HRSA, http://www.brightfutures.org/

Brindis CD, English A. Measuring public costs associated with loss of confidentiality for adolescents seeking confidential reproductive health care: How high the costs? How heavy the burden? Arch Pediatr Adolesc Med. 2004;158:1182-4.

Committee on Public Education. Sexuality, contraception, and the media. Pediatrics. 2001;107:191-4.

DiMatteo MR: Variations in patients' adherence to medical recommendations: A quantitative review of 50 years of research. Med Care. 2004, 42:200-209.

English A, Ford CA. The HIPAA Privacy Rule and Adolescents: Legal Questions and Clinical Challenges. Perspect Sex Reprod Health. 2004;36:80-6.

Ginsburg KR, Slap GB, Cnaan A, Forke CM, Balsley CM, Rouselle DM. Adolescents’ perceptions of factors affecting their decisions to seek health care. JAMA. 1995;273:1913-8.

Guidelines for adolescent preventive services (GAPS). Recommendations for physicians and other health professionals. AMA, http://www.ama-assn.org/ama/upload/mm/39/gapsmono.pdf

Millman RP. Excessive sleepiness in adolescents and young adults: causes, consequences, and treatment strategies. Pediatrics. 2005;115:1774-86.

Resnick MD, Bearman PS, Blum RW, Bauman KE, Harris KM, Jones J, Tabor J, Beuhring T, Sieving RE, Shew M, Ireland M, Bearinger LH, Udry JR. Protecting adolescents from harm: Findings from the National Longitudinal Study on Adolescent Health. JAMA. 1997;278:823-32.

Bixler EO, Vgontzas AN, Lin H-M, Calhoun SL, Vela-Bueno A, Kales A. Excessive daytime sleepiness in a general population sample: The role of sleep apnea, age, obesity, diabetes, and depression. J Clin Endocrinol Metab. 2005;90: 4510-4515.

Bleakley A, Hennessy M, Fishbein M. Public opinion on sex education in US schools. Arch Pediatr Adolesc Med. 2006;160:1151-6.

Brogly SB, Watts DH, Ylitalo N, Franco EL, Seage GR 3rd, Oleske J, Eagle M, Van Dyke R. Reproductive health of adolescent girls perinatally infected with HIV. Am J Public Health. 2007;97:1047-52. This group clearly deserves increase surveillance.

Brown JD, L’Engle KL, Pardun CJ, Gou G, Kenneavy K. Sexy media matter: Exposure to sexual content in music, movies, television, and magazines predicts Black and White Adolescents' sexual behavior. Pediatrics. 2006;117;1018-1027.

Card JJ, Lessard L, Benner T. PASHA: facilitating the replication and use of effective adolescent pregnancy and STI/HIV prevention programs. J Adolesc Health. 2007;40:275.e1-14.

Chen C, Storr CL, Anthony JC. Influences of parenting practices on the risk of having a chance to try cannabis. Pediatrics. 2005;115: 1631-1639.

Dahl RE, Lewin DS. Pathways to adolescent health sleep regulation and behavior. J Adolesc Health. 2002;31:175-84.

Erickson SJ, Gerstle M, Feldstein SW. Brief interventions and motivational interviewing with children, adolescents, and their parents in pediatric health care settings: A review. Arch Pediatr Adolesc Med. 2005;159:1173-1180.Presented by Stevens-Simon; January 2006.

Franzini L, Marks E, Cromwell PF, Risser J, McGill L, Markham C, Selwyn B, Shapiro C. Projected economic costs due to health consequences of teenagers' loss of confidentiality in obtaining reproductive health care services in Texas. Arch Pediatr Adolesc Med. 2004;158:1140-6.

Gardner P. Clinical practice. Prevention of meningococcal disease. N Engl J Med. 2006;355:1466-73.

Halpern-Felsher BL, Ozer EM, Millstein SG, Wibbelsman CJ, Fuster CD, Elster AB, Irwin CE Jr. Preventive services in a health maintenance organization: how well do pediatricians screen and educate adolescent patients? Arch Pediatr Adolesc Med. 2000;154:173-9.

Hansen M, Janssen I, Schiff A, Zee PC, Dubocovich ML. The impact of school daily schedule on adolescent sleep. Pediatrics. 2005;115: 1555-1561.

Johnson EO, Roth T, Schultz L, Breslau N. Epidemiology of DSM-IV insomnia in adolescence: Lifetime prevalence, chronicity, and an emergent gender difference. Pediatrics. 2006;117: e247 - e256.

Kirby DB, Laris BA, Rolleri LA. Sex and HIV education programs: their impact on sexual behaviors of young people throughout the world. J Adolesc Health. 2007;40:206-17.^.

Joyce T, Kaestner R, Colman S. Changes in abortions and births and the Texas parental notification law. New Engl J Med. 2006;354:1031-1038.

Kann L, Brener ND, Warren CW, Collins JL, Giovino GA. An assessment of the effect of data collection setting on the prevalence of health risk behaviors among adolescents. J Adolesc Health. 2002;31:327-35.

Kimm SY, Glynn NW, Kriska AM, Barton BA, Kronsberg SS, Daniels SR, Crawford PB, Sabry ZI, Liu K. Decline in physical activity in black girls and white girls during adolescence. N Engl J Med. 2002;347:709-15.

Kalmuss D, Tatum C. Patterns of men's use of sexual and reproductive health services. Perspect Sex Reprod Health. 2007;39:74-81.

Knutson KL, Lauderdale DS. Sleep duration and overweight in adolescents: self-reported sleep hours versus time diaries. Pediatrics. 2007;119:e1056-62. This raises important methodological concerns for studies of the effects of sleep on adolescent behavior.

Marcell AV, Halpern-Felsher BL. Adolescents' beliefs about preferred resources for help vary depending on the health issue. J Adolesc Health. 2007;41:61-8.

Osterberg L, Blaschke T. Adherence to medication. N Engl J Med. 2005;353:487-97.

Pawelski JG, Perrin EC, Foy JM, Allen CE, Crawford JE, Del Monte M, Kaufman M, Klein JD, Smith K, Springer S, Tanner JL, Vickers DL. The effects of marriage, civil union, and domestic partnership laws on the health and well-being of children. Pediatrics. 2006;118:349-64.

Rand CM, Shone LP, Albertin C, Auinger P, Klein JD, Szilagyi PG. National health care visit patterns of adolescents: implications for delivery of new adolescent vaccines. Arch Pediatr Adolesc Med. 2007;161:252-9.

Sieverding JA, Adler N, Witt S, Ellen J. The influence of parental monitoring on adolescent sexual initiation. Arch Pediatr Adolesc Med. 2005;159:724-729.

Stafstrom CE. Counseling youth about military service options and Selective Service registration: an integral part of anticipatory guidance of adolescents. Pediatrics. 2007;119:1199-203. This is a profession we often forget to discuss.

Steinberg L. Gallagher lecture. The family at adolescence: transition and transformation. J Adolesc Health 2000;27:170-8.

Thomsen SR, Fulton K. Adolescents' attention to responsibility messages in magazine alcohol advertisements: an eye-tracking approach. J Adolesc Health. 2007;41:27-34.So they don’t even see the black box.

Whitelaw S, Baldwin S, Bunton R, Flynn D. The status of evidence and outcomes in Stages of Change research. Health Ed Res. 2000;15: 717-18.

E. Topics for Research and Thought

Research conferences:

Evidence-based conferences:

Jumping-Eagle S. Is it possible to teach parents of teens to parent? 2004.

Cohen G. Should we teach breast self-examination to teens? 2003.

Suggestions for Evidence-based conferences:

· Studies do not concur; what should we be telling mothers to do?

McNeely C, Shew ML, Beuhring T, Sieving R, Miller BC, Blum RW. Mothers' influence on the timing of first sex among 14- and 15-year-olds. J Adolesc Health. 2002;31:256-65.

· Is this true of teens? Is this why Black women report more fears about using contraception? How should we adjust our practice?

Nicholson WK, Grason HA, Powe NR. The relationship of race to women's use of health information resources. Am J Obstet Gynecol. 2003;188:580-5.

· Which is the chicken and which the egg?

Johnson JG, Cohen P, Kasen S, First MB, Brook JS. Association between television viewing and sleep problems during adolescence and early adulthood. Arch Pediatr Adolesc Med. 2004;158:562-8.

Suggestions for meditation:

· If parents pay the bills, do they have the right to know?

· Why might the type of parental intervention that is most effective in preventing drug and alcohol use be different or similar to the type that is most effective for preventing teen pregnancies and high school dropout (i.e., those that emphasize the carrot or those that emphasize the stick?)

· Is it possible to counsel parents who believe in abstinence before marriage to allow their children access to contraception without undermining their family values?

F. Handouts

Patient:

Student:

· Gawande A. Naked. New Engl J Med. 2005;353: 645-649.

IV. HEALTHCARE DELIVERY AND ECONOMICS

A. Goals

1. Student: Understand how socioeconomic status impacts access to health services.

2. Resident: Understand how cultural background and social environment effect adolescents’ abilities to recognize and meet their healthcare needs.

3. Fellows: Understand the impact of managed care on various public health programs and access to care.

B. Objectives

1. Student: Discuss common barriers to healthcare for lower, middle, and upper socioeconomic status adolescents, including the effects of health insurance and provider availability.

2. Resident: Discuss how cultural background affects an adolescent’s perceptions of healthcare needs and service availability.

3. Fellow: Discuss the pros and cons of managed care for lower, middle, and upper socioeconomic status adolescents.

C. Subtopics

1. Settings

a. School-based clinics

b. Community-based clinics

c. Institutionalized settings

d. Handicapped programs

e. Private offices – pediatric/family medicine/internal medicine

2. Finances

3. Subspecialists Role

D. Suggested Reading

CORE:

Braveman PA, Cubbin C, Egerter S, Chideya S, Marchi KS, Metzler M, Posner S. Socioeconomic status in health research: One size does not fit all. JAMA. 2005;294:2879-2888.

Duberstein L, Lindberg J, Frost J, Sten C, Dailard C. The Provision and Funding of Contraceptive Services at Publicly Funded Family Planning Agencies: 1995–2003. Perspect Sex Repro Health. 2006;38: 37-45.

English A. Financing adolescent health care: legal and policy issues for the coming decade. J Adolesc Health. 2002;31:334-46.

Lear JG. Schools and adolescent health: strengthening services and improving outcomes. J Adolesc Health. 2002;31:310-20.

Link BG, Phelan JC. Understanding sociodemographic differences in health – the role of fundamental social causes. Am J Public Health. 1996;86:471-2.

Cohen DA, Nsuami M, Martin DH, Farley TA. Repeated school-based screening for sexually transmitted diseases: a feasible strategy for reaching adolescents. Pediatrics. 1999;104:1281-5.

Seid M, Varni JW, Cummings L, Schonlau M. The impact of realized access to care on health-related quality of life: A two-year prospective cohort study of children in the California State Children's Health Insurance Program. J Pediatr. 2006;149:354-361.

Stone N, Ingham R. When and why do young people in the United Kingdom first use sexual health services? Perspect Sex Reprod Health. 2003; 35:114-20.

Wang JK, Herzog NS, Kaushal R, Park C, Mochizuki C, Weingarten SR. Prevention of pediatric medication errors by hospital pharmacists and the potential benefit of computerized physician order entry. Pediatrics. 2007;119:e77-85.Another vote against IT.

E. Topics for Research and Thought

Research conferences:

Evidence-based conferences:

Suggestions for Evidence-based conferences:

Does mixing personal belief with clinical practice do more harm than good? Can it be avoided?

Curlin FA, Lawrence RE, Chin MH, Lantos JD. Religion, conscience, and controversial clinical practices. N Engl J Med. 2007;356:593-600.

Bramstedt KA. When pharmacists refuse to dispense prescriptions. Lancet. 2006 15;367:1219-20.

Grossoehme DH, Ragsdale JR, McHenry CL, Thurston C, DeWitt T, VandeCreek L. Pediatrician characteristics associated with attention to spirituality and religion in clinical practice. Pediatrics. 2007;119:e117-23.

Do computerized doctors do more harm than good?

American Academy of Pediatrics Council on Clinical Information Technology, Gerstle RS. Electronic prescribing systems in pediatrics: the rationale and functionality requirements. Pediatrics. 2007;119:1229-31.

Del Beccaro MA, Jeffries HE, Eisenberg MA, Harry ED. Computerized provider order entry implementation: No association with increased mortality rates in an intensive care unit. Pediatrics. 2006; 118:290-5.

Gerstle RS, Lehmann CU; American Academy of Pediatrics Council on Clinical Information Technology. Electronic prescribing systems in pediatrics: the rationale and functionality requirements. Pediatrics. 2007;119:e1413-22.

Han YY, Carcillo JA, Venkataraman ST, Clark RS, Watson RS, Nguyen TC, Bayir H, Orr RA. Unexpected increased mortality after implementation of a commercially sold computerized physician order entry system. Pediatrics. 2005;116:1506-12.

Suggestions for meditation:

· Why do racial differences in preventive healthcare utilization persist in the military?

· Why has public funding for prenatal care not eliminated age, racial, and socioeconomic differences in the birth weight distribution?

· Does prepayment alter the quality of medical care dispensed?

F. Handouts

Patient:

Student:

V. EDUCATION/ACADEMIC

A. Goals

1. Student: Understand the personal and environmental ingredients that are necessary for academic achievement.

2. Resident: Be able to identify the major personal and environmental threats to academic achievement.

3. Fellow: Understand the special academic needs of pregnant and parenting adolescents, gifted adolescents, adolescents with specific learning disabilities, and adolescents who have been physically, sexually, or emotionally abused.

B. Objectives

1. Student: Collect a screening history, which includes school performance, school attendance, and parental involvement in education.

2. Resident: Demonstrate your understanding of the common personal and environmental threats to academic achievement by identifying risk factors for school problems such as learning disabilities, attention deficit hyperactivity disorder, psychopathology, lack of parental involvement, cultural barriers, homelessness, and gang involvement. Include in your discussion how to evaluate and manage the adolescent who fails school health screening tests (e.g.: vision, hearing, scoliosis).

3. Fellow: Demonstrate your understanding of the special academic needs of pregnant and parenting adolescents, gifted adolescents, adolescents with specific learning disabilities, and adolescents who have been physically, sexually, or emotionally abused, by identifying early signs/symptoms of inappropriate educational placement. Include in your discussion how to manage problems such as school avoidance, classroom behavior problems, homework problems.

C. Subtopics:

1. Measures of Academic Achievement

2. Mental Retardation

a. Definition/etiology

b. Educational rights

3. Chronically Ill/Disabled

4. School Avoidance

5. Causes of School Failure/Drop Out

a. Learning disabilities

b. Underachievement

c. Attention deficit/hyperactivity disorder

d. Medical problems: chronic disease/pregnancy

e. Behavioral problems: truancy

f. Social problems: work, home responsibilities

D. Suggested Reading

CORE:

Grunbaum JA, Lowry R, Kann L. Prevalence of health-related behaviors among alternative high school students as compared with students attending regular high schools. J Adolesc Health. 2001;29:337-43.

Rappley MD. Clinical practice. Attention deficit-hyperactivity disorder. N Engl J Med. 2005;13;352:165-73.

Reiff MI. Adolescent school failure: failure to thrive in adolescence. Pediatr Rev. 1998;19:199-207.

Wolraich ML, Wibbelsman CJ, Brown TE, Evans SW, Gotlieb EM, Knight JR, Ross EC, Shubiner HH, Wender EH, Wilens T. Attention-deficit/hyperactivity disorder among adolescents: A review of the diagnosis, treatment, and clinical implications. Pediatrics. 2005;115: 1734-1746.

Cooke M, Irby DM, Sullivan W, Ludmerer KM. American medical education 100 years after the Flexner report. N Engl J Med. 2006;355:1339-44.

Wender EH. Managing stimulant medication for attention-deficit/hyperactivity disorder. Pediatr Rev.2001;22:183-90.

Wilens TE, Prince JB, Spencer TJ, Biederman J. Stimulants and sudden death: What is a physician to do? Pediatrics. 2006;118:1215-9.

E. Topics for Research and Thought

Research conferences:

Evidence-based conferences:

Suggestions for Evidence-based conferences:

Suggestions for meditation:

· How many high school dropouts, teen pregnancies and juvenile delinquents could be avoided by proper diagnosis and treatment of learning disabilities?

· What are the effects of early childbearing on academic achievement and vice versa? How have special educational programs for pregnant and parenting teenagers altered these associations?

· What are the implications of the association between participation in health risky behaviors and alternative high school attendance for the health care system? How might the expanded education opportunities that alternative schools offer teens who drop out of the traditional education system be changing the socioeconomic and epidemiologic significance of a high school education?

F. Handouts

Patient:

Student:

VI. REPRODUCTIVE HEALTH

A. Goals

1. Student: Be able to recognize common antecedents of risky sexual behavior and sexual problems during adolescence and know the names of the common sexually transmitted diseases (STDs) and the causal organisms.

2. Resident: Understand how to diagnose and manage common problems related to sexual activity during adolescence and develop criteria for referring patients with specific disorders, also to know the common signs and symptoms of STDs, their incubation periods, and usual modes of transmission.

3. Fellow: Know how sex education and the availability of contraceptive services influences adolescent sexual behavior at the individual and population level and understand the public health implications and long-term sequelae of common STDs (e.g.: risk of cancer, ectopic pregnancy, infertility).

B. Objectives

1. Student: Gather information about an adolescent’s sexual development, identity, activity, and knowledge about reproduction and STDs using organized interview techniques (HEADSS) or trigger questions (GAPS, Bright Futures). Perform an exam for STDS, interpret the findings and integrate your physical examination findings in your assessment of risk for common co-morbidities (e.g.: STDs, pregnancy, rape).

2. Resident: Demonstrate your understanding of common sexual problems in adolescents and sexually transmitted diseases by describing how you would diagnose and manage an adolescent patient with specific sexual morbidities; provide anticipatory guidance to teens and their parents on reproductive health issues; and counsel an adolescent about how to avoid infection and when to seek testing for possible infection.

3. Fellow: Demonstrate your understanding of the ways in which sex education and the availability of contraceptive services influences adolescent sexual behavior by explaining why adolescent sexual activity need not be synonymous with reproductive morbidity, including the advantages and disadvantages of various preventive interventions and international comparisons. Also demonstrate your understanding of the long-term sequelae of common STDs by counseling an adolescent with pelvic inflammatory disease about the need for contraception and the risk of ectopic pregnancy, and an adolescent with venereal warts about her need for frequent pap smears.

C. Subtopics:

1. Contraception

2. Pregnancy

a. Epidemiology

b. Diagnosis

c. Options: counseling

d. Outcomes

1) Ectopic

2) Miscarriage

3) Abortion

4) Adoption

5) Parenting

3. Sexually Transmitted Diseases (See Section XV. 9. Gynecologic)

a. Vulvar/Penile/Skin

1) Herpes Simplex Virus infection (HSV)

2) Human Papilloma Virus infection (HPV) (warts)

3) Pediculosis Pubis (lice)

4) Syphilis

5) Chancroid

6) Granuloma Inguinale (Donovanosis)

7) Lymphogranuloma Venereum

8) Molluscum contagiosum

b. Vaginal

1) Trichomoniasis

2) Bacterial vaginosis

3) Aerobic vaginosis

c. Cervical/Urethral

1) Neisseria gonorrhoeae

2) Chlamydia trachomatis

3) Herpes Simplex Virus infection (HSV)

4) Human Papilloma Virus infection (HPV) (warts/dysplasia)

d. Blood

1) Human Immunodeficiency virus (HIV) / Acquired Immune Deficiency Syndrome (AIDS)

2) Hepatitis B, C

e. Suppurative complications

1) Female

(a) Pelvic Inflammatory Disease (PID)

(b) Chronic pain

(d) Infertility

2) Male

(a) Epididymitis/Orchitis/Prostatitis

(b) Chronic urethral/groin discomfort

3) Screening vs. Testing

4) Partners/Recurrent Infection

D.1. Suggested Reading - Contraception

CORE:

ACOG Committee on Practice Bulletins-Gynecology. Obstet Gynecol. ACOG practice bulletin. No. 73: Use of hormonal contraception in women with coexisting medical conditions. 2006;107:1453-72.

Armstrong KA, Stover MA. SMART START: an option for adolescents to delay the pelvic examination and blood work in family planning clinics. J Adolesc Health. 1994;15:389-95.

Cromer BA, Scholes D, Berenson A, Cundy T, Clark MK, Kaunitz AM;Society for Adolescent Medicine. Depot medroxyprogesterone acetate and bone mineral density in adolescents--the Black Box Warning: a Position Paper of the Society for Adolescent Medicine. J Adolesc Health. 2006;39:296-301.

Paransky OI, Zurawin RK. Management of menstrual problems and contraception in adolescents with mental retardation: a medical, legal, and ethical review with new suggested guidelines. Pediatr Adolesc Gynecol. 2003;16:223-35.

Peterson HB, Curtis KM. Long-acting methods of contraception. New Engl J Med. 2005;353: 2169-75.

Petitti DB. Clinical practice. Combination estrogen-progestin oral contraceptives. N Engl J Med. 2003;349:1443-50.

Santelli J Ott MA, Lyon M, Rogers J, Summers D, Schleifer R. Abstinence and abstinence-only education: A review of U.S. policies and programs. J Adolesc Health. 2006;38:72-81.

Stevens-Simon C. Providing effective reproductive health care and prescribing contraceptives for adolescents. Pediatr Rev. 1998;19:409-17.

Westhoff C. Clinical practice. Emergency contraception. N Engl J Med. 2003;349:1830-5.

Winter L, Breckenmaker LC. Tailoring family planning services to the special needs of adolescents. Fam Plann Perspect. 1991;23:24-30.

American Academy of Pediatrics Committee on Adolescence. Emergency contraception. Pediatrics. 2005;116: 1026-35.

Belzer M, Sanchez K, Olson J, Jacobs AM, Tucker D. Advance supply of emergency contraception: A randomized trial in adolescent mother. J Pediatr Adolesc Gynecol. 2005;18:347-354? – Presented by Sheeder; December 2005G.

Blake SM, Ledsky R, Goodenow C, Sawyer R, Lohrmann D, Windsor R. Condom availability programs in Massachusetts high schools: relationships with condom use and sexual behavior. Am J Public Health. 2003;93:955-62.

Coffee AL, Kuehl TJ, Willis S, Sulak PJ. Oral contraceptives and premenstrual symptoms: comparison of a 21/7 and extended regimen. Am J Obstet Gynecol. 2006;195:1311-9.

Cole JA, Norman H, Doherty M, Walker AM. Venous thromboembolism, myocardial infarction, and stroke among transdermal contraceptive system users. Obstet Gynecol. 2007;109:339-46. Although in theory decreased hepatic stimulation should decrease the risk of thrombosis – that does not appear to be the case.

Conard LA, Fortenberry JD, Blythe MJ, Orr DP. Pharmacists' attitudes toward and practices with adolescents. Arch Pediatr Adolesc Med. 2003;157:361-5.

Cundy T, Ames R, Horne A, Clearwater J, Roberts H, Gamble G, Reid IR. A randomized controlled trial of estrogen replacement therapy in long-term users of depot medroxyprogesterone acetate. J Clin Endocrinol Metab. 2003;88:78-81.

Davis AR, Westhoff C, O’Connell K, Gallagher N. Oral contraceptives for dysmenorrhea in adolescent girls: A randomized trial. Obstet Gynecol. 2005;106: 97-104.

Espey E, Ogburn T, Howard D, Qualls C, Ogburn J. Emergency contraception: Pharmacy access in Albuquerque, New Mexico. Obstet Gynecol. 2003;102:918-21.

Gold MA, Bachrach LK. Contraceptive use in teens: a threat to bone health? J Adolesc Health. 2004;35:427-9.

Harper CC, Cheong M, Rocca CH, Darney PD, Raine TR. The effect of increased access to emergency contraception among young adolescents. Obstet Gynecol. 2005;106: 483-491.

Hingson R, Heeren T, Winter MR, Wechsler H. Early age of first drunkenness as a factor in college students' unplanned and unprotected sex attributable to drinking. Pediatrics. 2003;111:34-41.

Pediatrics Fellowship in Adolescent Medicine

A. Goals