Children's Doctor

Adolescent Medicine - Winter 2012

Eating Disorders

Rebecka Peebles, MD

A 12-year-old female presents for a check-up. Her mother expresses concern her daughter has been feeling full lately after meals and that her appetite is decreasing. Her weight last year was 121 lbs at 57 inches tall, and her weight today is 90 lbs at the same height. She is on a club soccer team and played in a game the day before the appointment with no difficulty.

On further questioning, she has been playing “Wii Fit” for 30 to 60 minutes daily, and says the game told her last year that her BMI was overweight. She denies intentional weight loss or calorie counting and states that she thinks she might be too thin now. She takes no medications and reports no significant past medical history. On review of systems, she is reporting early satiety, constipation, and some cold intolerance. She has never menstruated. Physical exam shows a heart rate of 54 bpm, a blood pressure of 88/60, and is otherwise unremarkable except for mild acrocyanosis noted, distal capillary refill of 3 to 4 seconds in her fingers and toes, SMR II breasts and SMR III pubic hair, and a slightly less animated affect than she has displayed in years past.

Discussion: The patient described has an eating disorder, not otherwise specified, or EDNOS. This is the most common DSMIV diagnosis given to young children with eating disorders, as they frequently do not meet full-threshold criteria for anorexia nervosa or bulimia nervosa. EDNOS “includes disorders of eating that do not meet the criteria for any specific eating disorder,” according to the Diagnostic and Statistical Manual of Mental Disorders (4th Edition). Children like the patient above who have unexplained dramatic weight loss and have shape and weight concerns, but are not below 85% of their expected weight, would classify as EDNOS. Note that many patients will deny active weight concerns; these often only emerge when the patient is challenged with the task of weight gain.

It is important for clinicians to recognize that EDNOS is a diagnosis with significant medical and psychiatric morbidity. Numerous studies have documented the severity of EDNOS, showing that there are many patients with this diagnosis who have similar scores on eating disorder behavior scales and are as medically ill as those with full-threshold diagnoses. For example, patients who have lost 25% or more of their premorbid weight, but are still in a normal weight range, have been noted to be equally likely to show signs of medical compromise such as bradycardia, hypotension, and orthostasis.

This patient presents with many features common to children and adolescents with eating disorders. She was clinically obese at age 11, with a BMI greater than the 95th percentile for age a year ago. Now she has not grown any taller but has lost significant weight. The first sign of an eating disorder in a child or early adolescent may be a slowing of linear growth, as noted in this patient. Most patients with eating disorders experience delayed gastric transit, which can manifest as early satiety, constipation, and even abdominal pain with eating. She also has cold intolerance, acrocyanosis, delayed distal capillary refill, mild bradycardia, and hypotension. She should be followed closely medically; bradycardia with heart rates less than 50, systolic blood pressures less than 90, or orthostasis, in the context of an eating disorder or malnutrition, are all signs that the heart may require inpatient medical stabilization. In addition, QTc prolongation, syncope, and electrolyte abnormalities often require hospitalization as well. Mortality rates are higher for eating disorders than for any other mental health condition, and appropriate medical and psychiatric treatment are imperative.

Clinicians who evaluate adolescent patients for weight loss need to consider the full range of differential diagnoses. A complete history, physical examination, and judicious laboratory testing is warranted to narrow diagnostic possibilities. Common laboratory tests are a complete metabolic panel including a phosphorus level, a complete blood count and erythrocyte sedimentation rate to screen for inflammatory causes, and thyroid function testing. If pubertal function appears impaired or regressed, or a previously menstruating patient has developed amenorrhea, then prolactin, FSH, and LH levels are indicated. If, once the differential diagnosis has been entertained, the most likely diagnosis is an eating disorder, then treatment should be initiated without delay. Even though this patient is at a “normal” BMI, she is still exhibiting both behaviors consistent with an eating disorder on history and physical findings consistent with malnutrition on physical exam. It is likely that her health and growth will not improve without some weight gain, and given her prior growth history, her body may function best at a BMI that is above the median for her age.

How Parents Can Help Their Children with Eating Disorders

We do not yet know what causes eating disorders. They are clearly not volitional diseases, although some patients may feel that they choose their behaviors. There are strong genetic links, and the National Institute of Mental Health is now referring to anorexia nervosa as a brain disorder. Patients often do not feel ill or have any awareness of how serious their disease is. Full nutrition and weight restoration seem to repair brain function and often will reverse many of the original symptoms.

Unfortunately, for many years there was a perception that eating disorders developed because of control struggles, and many parents were made to feel guilty if their child developed an eating disorder. One of the most important things a pediatrician can do when faced with a patient with a new-onset eating disorder is to reassure the worried parents that they did not cause their child’s illness, and to empower them by reassuring parents that, in time, they are likely to be their child’s best chance at normal health. Remind the entire team, parents included, that ensuring adequate nutrition is integral to healing and critical to treatment success.

Involving families and caregivers in the treatment of eating disorders has led to some significant advances over the past decade. Therapy now will often coach parents to support their children and set appropriate limits to help them succeed in their efforts at weight restoration. For many young people with these destructive diseases, involving parents provides a natural support structure that allows them to recover faster, and often in a home setting.

References and Suggested Readings

Peebles R, Hardy K, Wilson J, Lock J. Are diagnostic criteria for eating disorders markers of medical severity? Pediatrics. 2010;125(5):e1193-e1201.

Rosen D, American Academy of Pediatrics Committee on Adolescence. Identification and management of eating disorders in children and adolescents. Pediatrics. 2010;126(6):1240-1253.

NIMH's Dr. Thomas Insel: Group Advocacy, More Data, Will Improve Eating Disorders Research Funding. Eating Disorders Review. January/February 2007 Volume 18, Number 1, 2007 Gürze Books. http://www.eatingdisordersreview.com/nl/nl_edr_18_1_6.html 

Adolescent Sexual Health Screening

Kenisha Campbell, MD, and Nadia Dowshen, MD

According to the Youth Risk Behavior Survey (2009), 32% of ninth grade and 62% of 12th grade high school students reported having had sex. Annually, 1 in 4 adolescents acquires a sexually transmitted infection (STI), also known as sexually transmitted diseases (STDs), with females aged 15 to 19 years having the highest rates of chlamydia and gonorrhea. While HIV rates have stabilized in the United States, new infections are increasing among youth, with young men who have sex with men, and youth of color being disproportionately affected. The U.S. Preventive Services Task Force (USPSTF) recommends screening and high-intensity behavioral counseling for all sexually active adolescents. Despite these recommendations, in 2005 only 50% of pediatricians recommended that all sexually active youth be screened for STIs, with 28% recommending HIV screening.

Setting the Stage for the Sexual Health Discussion

Pediatricians are in a unique position because of long-term trusting relationships to work with adolescents and their families around sexual health. When addressing sexual health issues, providers must create a safe space and set the stage for confidentiality. Adolescents should spend at least part of each healthcare visit privately with providers. Providers should explain what confidentiality means, and detail its protections and limitations, including mandatory reporting of sexual abuse. Adolescents should know that parental involvement is the goal, but teens have a right to access testing and treatment for STIs and HIV confidentially.

The Sexual Health Discussion

The American Academy of Pediatricians (AAP) recommends that developmentally appropriate sexuality education be placed within a lifetime perspective and incorporated into routine clinical practice.

STI screening, testing, and prevention strategies for adolescents*

Gonorrhea
Specimen Source Test M F Frequency
Urine NAAT   * Yearly in sexually active patients
Cervix/vagina NAAT   * Yearly in sexually active patients (urine or genital, not both)
Throat NAAT * * Yearly in MSM who report receptive oral sex
Anus NAAT * * Yearly in MSM who report receptive anal sex
Chlamydia
Specimen Source Test M F Frequency
Urine NAAT * * Yearly in sexually active patients
Cervix/vagina NAAT   * Yearly in sexually active patients (urine or genital, not both)
Anus NAAT * * Yearly in MSM who report receptive anal sex
Bacterial vaginosis
Specimen Source Test M F Frequency
Vaginal (collected by patient or provider) Microscopy/Wet mount, or Affirm nucleic acid probe test   * When symptomatic
Trichomonas
Specimen Source Test M F Frequency
Vaginal (collected by patient or provider) Microscopy/Wet mount, or OSOM© rapid test, or Affirm nucleic acid probe test   * When symptomatic
HIV
Specimen Source Test M F Frequency
Blood HIV antibody, antigen/antibody combo, rapid test or Rapid test only * * Yearly in sexually active patients
Oral Fluid * *
Syphilis
Specimen Source Test M F Frequency
Blood RPR with reflex trponemal test or EIA with reflex titer * * Yearly for MSM or other risk factors like IDU or multiple partners
Hepatitis A
Specimen Source Test M F Frequency
Blood N/A * * MSM should be vaccinated
Hepatitis B
Specimen Source Test M F Frequency
Blood N/A * * All adolescents should be vaccinated
Hepatitis C
Specimen Source Test M F Frequency
Blood Serology * * If patient has risk factors like IDU or is HIV-positive
HPV
Specimen Source Test M F Frequency
N/A N/A * * Start 3-shot series at age 11 to 12 for prevention of genital warts
Cytology (Pap test)
Specimen Source Test M F Frequency
Cervix Conventional Pap smear or liquid-based cytology (ie, thin prep)   *

Yearly starting at age 21, except earlier for women living with HIV who are immunocompromised
Guidelines not available, but recommended for HIV-positive MSM

Anus    

NAAT = nucleic acid amplification testing, RPR = rapid plasma regain, EIA = enzyme immunoassay, IDU = intravenous drug use, MSM = men who have sex with men

*Recommendations are in accordance with the 2010 CDC STI Treatment Guidelines. Screening recommendations apply to adolescents who do not have symptoms. Any patient with symptoms of a potential STD should be tested.

Providers should encourage families to discuss sexuality in ways that are consistent with the family’s values beginning at an early age. Strategies should be developed to routinely address sexual health with adolescents and their families in your practice, including taking sexual histories. Providers should explain that sexual behaviors can affect adolescent health, so during annual visits confidential questions about sexual health and behaviors will be asked in an open-ended, non-judgmental, developmentally and culturally appropriate manner.

Providers should encourage delay of onset of sexual activity among adolescents who have never had sex, based on evidence that delaying sexual debut decreases the likelihood of negative health outcomes. Among adolescents who have had sex, STI and pregnancy risk should be assessed when obtaining an appropriate review of systems and during physical exam. Providers should do a genital external exam annually, and if clinically indicated, perform a more detailed or internal exam.

Routine STI Evaluation and Primary Prevention Strategies

STI and HIV testing should be discussed with all adolescents who have ever had sex. Providers should discuss recommended tests, explain that these tests are routine for youth who have ever had sex and emphasize that most infections are asymptomatic (See STI Tables). Current Centers for Disease Control (CDC) recommendations for patients in primary care settings are:

Sexual Health Risk-Reduction Counseling

Providers should educate patients using evidence-based strategies supporting abstinence, delaying sexual activity, and other risk-reduction behaviors (eg, correct and consistent condom use for oral, anal and vaginal sex). Counseling about pregnancy risk reduction and provision of contraception is indicated if young men and women are at current risk of unwanted pregnancy.

Effective prevention messages must be tailored to the adolescent, directed at personal risk and those situations in which engaging in risk behaviors is most likely for that patient (eg, when drinking alcohol), and use personalized goal-setting strategies for STI/HIV prevention. Pediatricians should also explore with adolescents how they can have healthy, happy, and safe relationships.

Online Bonus: Questions to consider when taking a developmentally tailored sexual history

  • All young people develop sexual feelings and have to make decisions about sexual behaviors as they grow up. Have you ever had a crush or a romantic relationship with a boy or girl? Are you romantically or sexually attracted to men (boys), women (girls), or both?
  • Have you ever had any physical contact, like kissing or touching in private areas, with a boy or a girl? If touching, above or below the waist? Clothes on or off? Has any of this ever happened, even against your will?
  • What about your friends? Have any of your friends started to have sex? What do you think about that? Can you explain how you will make decisions about when to have sex?
  • If you have questions about sex, what adult in your life can you talk to?
  • It's important for you know that doctors and nurses have a responsibility to help young people stay healthy, which means avoiding unwanted pregnancy and STIs. Not having sex is the only 100% safe way to do this. If you ever do decide to have sex, explain to me how you could get to a doctor or nurse to discuss preventing pregnancy and STIs.
  • Are you dating someone? Tell me about who you are dating, and what your relationship is like.
  • Do you or have you ever had vaginal sex? Oral sex? Anal sex?
  • Do you have sex with men (boys), women (girls), or both?
  • How do you protect yourself against sexually transmitted diseases and pregnancy?
  • When you use condoms for anal or vaginal sex, how many times out of 10 do you use them?
  • Do you have sex with anyone other than your boyfriend or girlfriend? In those situations, how often are you using condoms?
  • Has anyone ever pressured you or forced you into doing something sexually that you didn’t want to do?
  • Have you ever needed to trade sex for money, drugs or a place to stay?
  • How would you describe your sexual orientation? Many young people aren’t sure or prefer not to use a label and that’s OK, too. For example, do you consider yourself gay, lesbian, bisexual, or heterosexual (straight)?
  • Are you having any pain or burning with urination or vaginal or penile discharge? Any bumps, sores, or rashes in your genital area?

References and Suggested Readings

Emmanuel PJ, Martinez J: Adolescents and HIV infection: the pediatrician’s role in promoting routine testing. Pediatrics. 2011;128(5):1023-1029.

Workowski KA, Berman S. Sexually transmitted diseases treatment guidelines, 2010. MMWR Recomm Rep. 2010;59(RR-12):1-110.

Branson BM, Handsfield HH, Lampe MA, et al. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR Recomm Rep. 2006;55(RR-14):1-17; quiz CE11-14.

Eaton DK, Kann L, Kinchen S, et al. Youth risk behavior surveillance - United States, 2009. MMWR Surveill Sum. 2010;59(5):1-142.

Hatcher RA, Trussell J, Nelson AL, Willard Cates J, Stewart FH, Kowal D, ed. Contraceptive Technology. 19 ed: PDR Network; 2008.

U.S. Preventive Services Task Force: Behavioral Counseling to Prevent Sexually Transmitted Infections: U.S. Preventive Services Task Force Recommendation Statement. Edited by 08-05123-EF-2 AP; http://www.uspreventiveservicestaskforce.org/uspstf08/sti/stirs.htm. Updated: October 2008. Accessed: Jan 5, 2012.

Assessing Readiness to Drive with Your Teen Patients

Patty Huang, MD, and Flaura Winston MD, PhD

During a routine physical, a 16-year-old patient and her parents express her interest in obtaining a driver’s license. In the past, the patient has had difficulty with learning and has been diagnosed with ADHD; she does not currently receive any medication for her behaviors. The parents are unsure of whether or not she is ready to learn to drive and seek your input.

Discussion: While driving is often an exciting milestone for most teenagers and parents, it can be easy for parents to forget that driving is an extremely complex task for any teen to master. A teen who appears physically ready to drive may not be cognitively ready to drive safely. Although Pennsylvania is 1 of the only states in which teenage applicants for a non-commercial learner’s permit must receive medical certification that they do not have a condition that seriously impairs their ability to drive, we recommend that all pediatricians incorporate a routine “readiness to drive” assessment for their teen patients who are age-eligible and expressing interest in driving. Just as we place a great deal of focus on the sports participation physical to identify fitness to safely engage in team sports, we should apply that same vigilance when it comes to driving, which can be a matter of life or death.

Some Questions to Consider in Assessing Driving Readiness

The following questions can help to guide a discussion with parents regarding driving readiness:

  • Do you feel your teen consistently demonstrates good judgment and maturity at school, around peers, and at home, and is receptive to constructive criticism and instruction? Is she ready to accept responsibility for her safety and that of those around her?
  • Is your teen demonstrating knowledge of the rules of the road and other proficiencies based on lessons learned in driver education classes? (Parents can assess by asking the teen to comment on their driving.) If not, is your teen not ready to drive or in need of specialized instruction?
  • Is your teen agreeable to practicing driving (for at least 65 hours required in Pennsylvania as of Dec. 27, 2011) with a skilled adult prior to driving independently; is there an adult who is willing/able to serve in this important role?
  • Are there any medical or physical issues (eg, untreated seizures, significant uncorrected visual impairment, uncontrolled diabetes, amputation, concussion) that may prevent him from driving safely?
  • Are there any behavioral or neuropsychiatric issues (eg, drug dependence, depression, ADHD, intellectual disability) that may prevent her from driving safely?
  • Are there medical interventions that may be needed to ensure safe driving behaviors, such as stimulant medication for treatment of ADHD?

Pediatricians can help parents break down the task of driving into discrete but integrated skills when discussing whether a teen is ready to drive. Doing so highlights the various developmental and behavioral skills needed to learn to drive safely. Most parents limit their assessment to the basic skills associated with operating a vehicle, such as staying in a lane or smoothly stopping and turning. Research from CHOP has identified that parents may not recognize the tactical skills of driving, including the ability to pay attention to the road, scan the environment effectively, and coordinate visual/fine motor skills. They may also neglect higher level cognitive skills, including making sound decisions while driving (such as regulating speed, anticipating and interpreting the actions of other road users, or assessing weather conditions).

Teens who have conditions that impair any of these abilities are at risk for unsafe driving behaviors. For instance, teens with ADHD may be at risk, as they tend to be more impulsive, have impaired reaction times, and have difficulty when it comes to planning, strategizing, and attending to detail during complex tasks. Teens with autism spectrum disorders may have difficulty recognizing the cues of other drivers on the road.

In the earlier vignette, it may be appropriate to optimize the management of the teen’s ADHD with the use of stimulant medications as part of preparing her to learn to drive. Her parents could also seek a driving assessment by a driving professional, such as a trained occupational therapist. Additionally, driving goals can be included in the teen’s individualized education program (IEP), if one is in place, to ensure regular monitoring of her progress toward individualized driving goals.

A discussion with family members during a routine physical about their teen’s neurodevelopmental strengths and weaknesses as they relate to driving is a good first step toward ensuring the safety of our teen drivers. (See Questions to consider above.) However, we need to remind parents that learning to drive is a multistep process; their teens’ skills and behaviors need to be actively and continually assessed—even after they receive a driver’s license.

For more information about available resources to support families while their teen is learning to drive, please direct parents to www.teendriversource.org/support_parents.

References and Suggested Readings

Committee on Injury, Violence, and Poison Prevention and Committee on Adolescence. The teen driver. Pediatrics. 2006;118:2570-2581.

Pennsylvania Department of Transportation Non Commercial Learner’s Permit Application. www.dmv.state.pa.us/pdotforms/dl_forms/dl-180.pdf(PDF). Accessed December 16, 2011.

Huang P, Kao T, Curry AE, Durbin DR. Factors Associated with Driving in Teens with Autism Spectrum Disorders. Journal of Developmental and Behavioral Pediatrics. 2012;33(1):70-4.

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