Pediatric Annals

EDITORIAL 

Adolescence: Some Medical Aspects

Milton I Levine, MD

Abstract

I used to believe that many of the problems of our modern-day adolescents were related to the difficult world in which they were living.

They were the children of insecure and anxious parents brought up under the shadow of Hitler and World War II. There was the dangerous period of McCarthyism and a difficult and negative encounter in Vietnam. And now they are living under the everpresent threat of a nuclear war. Is there any wonder that our adolescents are problems?

But maybe adolescents were always problems.

As far back as the 4th Century BC, Socrates, the great Greek philosopher, said of adolescents (according to his disciples): "Our youths now love luxury; they have bad manners and contempt for authority. They show disrespect for their elders, and love idle chatter in place of exercise. Children are now tyrants, not servants of their households. They no longer rise when elders enter the room. They disrespect their parents, chatter before company, gobble up their food, and tyranize their teachers."

All pediatricians realize that adolescence is a challenging period. There are many difficulties and concerns, but the problems vary and each child must be viewed independently.

I have had numerous experiences in my many years of practice. Adolescent care today, however, is not only open to most of the old problems, but some new hazards as well. Among these are the use of drugs and the freer sex mores with increased chance of pregnancy and venereal disease.

There are many physical concerns encountered during the teen years related to growth and sexual development. We see numerous cases of acne, vaginitis, hirsutism, overweight and underweight patients.

But added to the physical problems are many new emotional ones. Teenagers have the tendency to respond to peer pressure and are resentful of parental authority. There is the sudden awakening of the sex urge, but some teenagers worry because they have no interest in the opposite sex. Then there is the concern about appearance. And there are often periods of depression. The problems are seemingly endless.

As I write I am reminded of one of my cases - a girl of 15 brought to me by her mother with three complaints. She was short for her age (only 4 feet 11 inches tall), had had her menses for 2 years, and was well-developed sexually. The second complaint was her obesity (she weighed 130 pounds). The third complaint was that she had no interest in boys. The mother worried that she might have lesbian tendencies.

The mother herself was of short stature and I felt the girl's height was probably hereditary. I was sure that I could reduce her weight, having had considerable success in limiting calories with a wellbalanced diet. I reassured the mother on her daughter's lack of heterosexual interests, having seen many teenagers slow to develop this instinct, [ ruled out hyperthyroidism, and then proceeded to place the girl on a diet of 1,000 calories daily.

However, after one week there was a gain of one pound, another gain the next week, and a gain of two pounds 2 weeks later. I thought the girl was probably eating on the sly - or more than I had prescribed. Anyway, I decided to examine her again and to my surprise found that this youngster - who "had no interest in the opposite sex" - was about 3 months pregnant.

This incident exemplifies some of the numerous problems met by pediatricians in their care of teenagers. This issue of Ffecfcotric Annals and the following one devoted to adolescence are of special significance. They are essentially the result…

I used to believe that many of the problems of our modern-day adolescents were related to the difficult world in which they were living.

They were the children of insecure and anxious parents brought up under the shadow of Hitler and World War II. There was the dangerous period of McCarthyism and a difficult and negative encounter in Vietnam. And now they are living under the everpresent threat of a nuclear war. Is there any wonder that our adolescents are problems?

But maybe adolescents were always problems.

As far back as the 4th Century BC, Socrates, the great Greek philosopher, said of adolescents (according to his disciples): "Our youths now love luxury; they have bad manners and contempt for authority. They show disrespect for their elders, and love idle chatter in place of exercise. Children are now tyrants, not servants of their households. They no longer rise when elders enter the room. They disrespect their parents, chatter before company, gobble up their food, and tyranize their teachers."

All pediatricians realize that adolescence is a challenging period. There are many difficulties and concerns, but the problems vary and each child must be viewed independently.

I have had numerous experiences in my many years of practice. Adolescent care today, however, is not only open to most of the old problems, but some new hazards as well. Among these are the use of drugs and the freer sex mores with increased chance of pregnancy and venereal disease.

There are many physical concerns encountered during the teen years related to growth and sexual development. We see numerous cases of acne, vaginitis, hirsutism, overweight and underweight patients.

But added to the physical problems are many new emotional ones. Teenagers have the tendency to respond to peer pressure and are resentful of parental authority. There is the sudden awakening of the sex urge, but some teenagers worry because they have no interest in the opposite sex. Then there is the concern about appearance. And there are often periods of depression. The problems are seemingly endless.

As I write I am reminded of one of my cases - a girl of 15 brought to me by her mother with three complaints. She was short for her age (only 4 feet 11 inches tall), had had her menses for 2 years, and was well-developed sexually. The second complaint was her obesity (she weighed 130 pounds). The third complaint was that she had no interest in boys. The mother worried that she might have lesbian tendencies.

The mother herself was of short stature and I felt the girl's height was probably hereditary. I was sure that I could reduce her weight, having had considerable success in limiting calories with a wellbalanced diet. I reassured the mother on her daughter's lack of heterosexual interests, having seen many teenagers slow to develop this instinct, [ ruled out hyperthyroidism, and then proceeded to place the girl on a diet of 1,000 calories daily.

However, after one week there was a gain of one pound, another gain the next week, and a gain of two pounds 2 weeks later. I thought the girl was probably eating on the sly - or more than I had prescribed. Anyway, I decided to examine her again and to my surprise found that this youngster - who "had no interest in the opposite sex" - was about 3 months pregnant.

This incident exemplifies some of the numerous problems met by pediatricians in their care of teenagers. This issue of Ffecfcotric Annals and the following one devoted to adolescence are of special significance. They are essentially the result of the government's Division of Maternal and Child's Health effort to emphasize the importance of adolescent health care.

To accomplish this end, the Bureau selected six well-organized adolescent units in medical colleges throughout the United States. Each Center is directed by a pediatrician nationally recognized in the field of both physical and emotional adolescent care. At each unit there had to be faculty members in nutrition, nursing, social work, and a PhD clinical psychologist.

Each of the units was funded, and provided not only training for pediatricians, Fellows, and others in the program, but clinical care for adolescents and also research directed toward adolescents.

The six centers selected with their directors are the following:

University of Alabama, Birmingham - Dr. William Daniel, Jr.

University of Cincinnati - Dr. Jerome Rauh

University of California, San Francisco - Dr. Charles Irwin

University of Minnesota, Minneapolis - Dr. Robert Blum

University of Maryland, Baltimore - Dr. Felix Heald

University of Washington, Seattle - Dr. Robert Deisher

The Guest Editor for these two issues is Dr. William A. Daniel, Jr., Professor of Pediatrics and Chief of the Division of Adolescent Medicine of the University of Alabama, Birmingham, Alabama. Dr. Daniel is the author of the authoritative text on Adolescent Medicine.

The first article in this symposium covers a problem that has long been discussed. What are the "Acute and Long-Term Consequences of Adolescents Who Choose Abortions"? The authors, all from the Division of Adolescent Medicine of the Cincinnati College of Medicine, have approached the subject from three angles. Dr. Frank Biro is a pediatrician, Linda S. Wildey is the Directqr of Nursing, and Dr. Paula J. Hillard is Director of Gynecology. With Dr. Jerome Rauh, Professor of Pediatrics and Director of the Division of Adolescent Medicine, they have produced a most interesting paper. They note at the outset that in 1981 there were 448,570 legal abortions of women under the age of 20 in the United States. What is the emotional effect on these girls? Do they have a long-lasting sense of guilt? Are they depressed? Are there advantages or disadvantages to parental involvement? What is the safest abortion technique? What are the complications and the risks?

These are some of the subjects discussed in this paper. It is very well organized and contains an excellent bibliography.

The second paper deals with a problem that is only too prevalent at the present time - substance abuse - covering drugs and alcohol. How can pediatricians detect such cases and what steps should they take to treat them?

This paper is presented by Dr. James A. Farrow, Assistant Professor of Medicine and i^diatrics, Division of Adolescent Medicine, Department of Pediatrics, University of Washington; and by Dr. Robert Deisher, Professor of Pediatrics at the University of Washington at Seattle.

The authors emphasize that the pediatrician is in a key position to identify the early signs of drug and alcohol abuse. He or she should be able to detect changes in the teenager's studies and activities that would indicate the probability of drug or alcohol abuse.

At the present time, cocaine is the primary offender, with peer pressure directing boys and girls to its use. "Crack," a most potent and dangerous form, is being obtained and used. This is the latest in a long and changing series of drugs used by teenagers in the past 20 years. Among these were LSD, heroin, and, as just mentioned, cocaine. Marijuana has been used for years, as has alcohol.

How should the pediatrician approach and deal with adolescent drug or alcohol abuse? He should certainly maintain a degree of confidentiality with the patient and ability to talk on an individual basis. If the problem appears difficult, the teenager should be referred for group and family therapy, but the pediatrician should continue to monitor the patient.

The third contribution discusses the subject of chest pains in adolescents, a complaint not infrequently brought to the attention of the pediatrician. It has been authored by Dr. Ronald A. Feinstein, Director of the Division of Adolescent Medicine and Assistant Professor of Pediatrics and Dr. William A. Daniel, Professor of Pediatrics, both at the University of Alabama School of Medicine.

Only too often parents are fearful that these chest pains are due to cardiac problems. The authors point out that this is rarely the case and then proceed to define numerous other conditions that must be considered in the differential diagnosis. Some of these conditions such as gynecomastia, the pulmonary "stitch," and heartburn would be readily diagnosed by all pediatricians; but many others, such as Tietze's Syndrome, costosternal syndrome, chest wall syndrome, and slipping rib syndrome are less well known. This is an excellent article on the differential diagnosis of this symptom.

The next paper deals with "Abnormal Vaginal Bleeding in Adolescents" and comes from the Division of Adolescent Medicine of the Department of Pediatrics at the University of California-San Francisco.

It is contributed by Dr. Martin M. Anderson, Dr. Charles E. Irwin, Jr., and Dr. Donald L. Snyder. Dr. Irwin is Professor of Pediatrics and Director of the Division of Adolescent Medicine.

Vaginal bleeding is a fairly frequent condition among teenagers and one that can usually be diagnosed by a pediatrician if he or she obtains a good history and a good knowledge of the many possible causes.

Step by step the authors of this article discuss the areas in the body that might cause the bleeding and discuss the implications. With so many possible causes no attempt is made to advise on the management of each one. However, they do describe clearly the treatment of patients with dysfunctional uterine bleeding.

This article should be kept for ready reference when the complaint is abnormal vaginal bleeding.

The next discussion is on the "Hyperventilation Syndrome," a syndrome which many pediatricians have held to be rather nebulous, but which is said to occur in approximately 10% of all medical patients.

The condition first described in 1871, and generally overlooked, is discussed by David E. Hanna, PhD, Assistant Professor of the Department of Pediatrics, and Chief Psychologist of the Adolescent Health Training Program at the University of Alabama; J. Bart Hodgens, PhD, Staff Psychologist of the same Division; and by Dr. William A, Daniel, Jr., Professor of Pediatrics and Chief of the Division of Adolescent Medicine at the University of Alabama, Birmingham.

This syndrome, not mentioned in recent pediatrie textbooks, is essentially what we would diagnose as respiratory alkalosis, which it is. There may be many clinical symptoms but the most common are shortness of breath, chest pain, and dizziness. The patient has occasional attacks of hyperventilation for which no medical etiology can be detected.

The pediatrician must be aware of the syndrome and should realize that the primary cause is emotional and that reassurance is the basic treatment. This article also advises on methods to treat the symptoms.

The last article discusses the "Laboratory Evaluation of Sexually Transmitted Diseases" and is written by Dr. Mychelle Y. Farmer, Dr. Edward W. Hook, III, and by Dr. Felix P. Heald, all of the University of Maryland Hospital in Baltimore, where Dr. Heald is Professor of Pediatrics.

In these days of increased sexual freedom there are numerous cases of sexually transmitted diseases in adolescent patients. The article reports at the outset that of 900,000 cases of gonorrhea reported in 1984, 26% occurred in people less than 19 years of age.

The authors present a number of relatively simple office laboratory procedures which pediatricians may use in the diagnosis and differentiation of sexually transmitted diseases. Among these are not only bacterial infections, but infections with candida, chlamydia, trichomonas, and genital herpes. They also present certain new rapid diagnostic tests that require special laboratory conditions which, as yet, are not available in an office laboratory.

This is a very valuable article and should be extremely helpful to all practicing pediatricians who care for patients in the adolescent age level.

10.3928/0090-4481-19861001-04

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