Medical Professional Publications

Addressing the Unique Needs of Adolescent Health

Terrill Bravender, MD MPH, Section Chief, Adolescent Health 

Cynthia M. Holland-Hall, MD, MPH, Section of Adolescent Health

Sarah O’Brien, MD, MSc, Section of Hematology/Oncology/BMT, and Health Services Researcher in the Center for Innovation in Pediatric Practice at The Research

Adolescents are physically the healthiest of all age groups. However, the rapid social, cognitive, emotional and physical changes that occur during this age can make this a critical and often difficult time period to negotiate. For more than 40 years, the Section of Adolescent Health at Nationwide Children’s Hospital has been providing general and specialty care for adolescents, helping teens and parents navigate what can sometimes be a treacherous path to adulthood.

“Sometimes I have to ask myself: who is this person who says she’s my daughter? Where did she come from and what did she do with my easy-going little girl?” asks the mother of a 14 year old girl.

 “I tell you, this child of mine…it seems like he just doesn’t think about things. Like sometimes he thinks he can do anything, but then other times, he wants my help with the simplest thing. It just doesn’t make sense!” says the father of a 15 year old boy.

 Both parents were expressing familiar frustrations, familiar, at least, to other parents of adolescents.

Although the majority of adolescents are responsible, energetic and healthy, teens do have high rates of preventable health problems. Each year, about 1 million adolescents and young adults are diagnosed with Chlamydia, gonorrhea, or syphilis, and almost 750,000 teenage girls become pregnant.

From 2003 to 2004, almost 25 percent of young women between the ages of 15 and 19 years contracted human papillomavirus (HPV).

Teens often have a sense of invulnerability, which may result in heightened risk-taking behaviors. For instance, 29 percent of Ohio high school students get drunk each month and almost 25 percent ride in a car driven by someone who has been drinking. One third of Ohio high school students have tried marijuana, and eight percent have tried cocaine. The statistics for Ohio teens are repeated in varied degrees from state to state across the country. Twelve percent of these students are obese, and one-third of students watch television for more than three hours each day. Finally, the vast majority of deaths in teens are preventable. The top three causes of death in young people between the ages of 15 and 24 are unintentional injuries, homicide and suicide, which account for more than three fourths of all deaths.

Each year, the Section of Adolescent Health at Nationwide Children’s Hospital has been helping teens and their parents negotiate this potentially treacherous time of life. Each year, the section sees more than 10,000 teens for a wide range of health issues. Staff members provide primary care for teens whose health care needs range from sports physicals and routine health care, to management of complex chronic illnesses, (See Dr. Campo’s information in this article regarding Functional Abdominal Pain). Consultative programs include special clinics for adolescents with reproductive healthcare needs, gynecology, eating disorders, and medical management of opiate addiction. Physicians in the Section also care for adolescents admitted to Nationwide Children’s Hospital with problems as diverse as complicated gynecological conditions, eating disorders, the severe consequences of substance abuse, as well as other medical problems requiring hospitalization. (See information in this article regarding Menorrhagia by Drs. O’Brien and Holland-Hall.)

Education is a major part of the Section of Adolescent Medicine. Nationwide Children’s Hospital’s pediatric residents each spend one concentrated month in the clinic, as well as several additional clinical sessions throughout the course of their training. Students from The Ohio State University College of Medicine may train in the clinic during their pediatric clerkship, or during a senior year elective. In addition, the Section of Adolescent Medicine provides an educational venue for trainees in family medicine, nursing students and social work students. A number of research activities are conducted in the Section of Adolescent Medicine, including work examining medical complications of eating disorders, the promotion of doctor/ patient communication, and health screening issues in teens.

Addressing Pediatric Functional Abdominal Pain
With a median prevalence of 8.4% in school aged children and adolescents, chronic or recurrent abdominal pain is a common problem, accounting for 2 to 4% of pediatric visits. Most affected youth are free of explanatory physical disease and are considered to be suffering from functional abdominal pain (FAP). Pediatric FAP is associated with real impairments such as poor school attendance and performance, greater use of ambulatory health services, and other somatic and emotional symptoms and disorders, with headache and migraine occurring in two-thirds and one-third of youth with FAP in primary care, respectively, anxiety in three-fourths, and depression in more than one-third. Mothers of affected children are at greater risk of FAP, headaches, migraine, anxiety, and depression than those of pain-free controls.

While the cause is unknown, individuals with FAP appear to be more “sensitive” to gastrointestinal sensations than those without. This has been referred to as “visceral hyperalgesia”, and may be mediated by serotonin, a neurotransmitter commonly associated with anxiety and depression. Approximately 95% of the body’s serotonin is found in the gastrointestinal tract.

Treatment Options
Conclusive evidence for the efficacy of any single treatment for pediatric FAP is lacking. Trials of dietary interventions such as lactose restriction and fiber supplementation have been disappointing or inconclusive. Studies of antispasmodics and medications that suppress acid secretion have also been discouraging.

Because of observed associations between FAP, anxiety, and depression, interest in applying treatments for emotional disorders has grown. Nonpharmacologic interventions such as cognitive behavioral psychotherapy, behavioral interventions, and self-management strategies such as guided imagery or selfhypnosis currently have the most empirical support. The use of tricyclic antidepressants for pediatric FAP has been examined in two small trials, one positive and one negative, but both trials had significant limitations. We conducted an open trial that found citalopram, a selective serotonin reuptake inhibitor (SSRI) commonly used as an antidepressant, to show promise as a treatment for pediatric FAP and associated symptoms.

Clinical Research Efforts
Our group at Nationwide Children’s Hospital is now studying treatments for children and adolescents ages 7 to 18 years with FAP:

  • Brief Cognitive Behavioral Therapy (BCBT)
    Participants are randomly assigned to receive either BCBT, which includes relaxation and coping skills training, for eight weeks or to usual care dictated by the referring clinician, which can include offsite referral.

  • Citalopram
    This is the first double blind placebo randomized controlled trial of citalopram as a treatment for pediatric FAP. There is no cost to participate in either study, and participants are compensated for their time. Our research team closely monitors physical and psychiatric symptoms and adverse events, including suicidal thinking or behavior, and works collaboratively with the referring clinician. Visits are typically at Nationwide Children’s Hospital Main Campus or within the practice site. Anyone interested should contact:

Sue Timan, APRN, MS
Telephone: 614-722-2293

Evaluating Menorrhagia
Prolonged or excessive vaginal bleeding is a common complaint among adolescent females. The clinical spectrum may vary from mild “nuisance” bleeding to severe anemia with hemodynamic instability. Although these patients frequently are referred to adolescent medicine specialists or gynecologists, their first point of contact is likely to be the primary care provider.

Contrary to the belief that “anything goes” during the first year following menarche, in fact 80 percent of menstrual cycles during this year are 21 to 45 days long, and are associated with menstrual bleeds lasting two to seven days. A pattern of bleeding that repeatedly falls outside of this range merits further evaluation. Menorrhagia is defined as prolonged or heavy uterine bleeding that occurs at regular intervals (typically monthly). Metrorrhagia is bleeding that occurs at irregular intervals. Many girls report both, menometrorrhagia. Practically speaking, physicians may consider a diagnosis of menorrhagia in adolescent girls whose menstrual periods have some of the following features:

  • Periods lasting more than seven days
  • Bleeding soaks through a pad or tampon in one hour, for at least 2-3 consecutive hours
  • Passage of blood clots greater than one inch in diameter (“about the size of a quarter”)
  • Periods interfere with school attendance or other activities due to the challenges of menstrual hygiene
  • Patient experiences “flooding” with unexpected onset of flow
  • Associated iron deficiency or anemia

Causes of Menorrhagia
In adolescents, menorrhagia most commonly is caused by immaturity or dysfunction of the hypothalamicpituitary- ovarian (HPO) axis, resulting in an ovulation. During a normal, ovulatory cycle, the corpus luteum secretes progesterone during the latter half of the cycle (luteal phase). Progesterone stabilizes the endometrium, and its presence is associated with controlled, manageable menstrual bleeds. In an anovulatory cycle, no corpus luteum forms, so there is no progesteronedominant phase of the cycle. Unopposed estrogen may lead to overgrowth of the endometrium; in the absence of progesterone, the subsequent bleeding episodes may be heavy and prolonged, and may occur at irregular intervals. Maturation of the HPO axis takes two or more years to occur, so anovulation and resultant menstrual irregularity during this time is common. Other causes of anovulation include polycystic ovary syndrome (PCOS), thyroid disease, and lateonset congenital adrenal hyperplasia (CAH). Menorrhagia also may be caused by pelvic infections, pregnancy complications, or hormonal contraceptive use. Menorrhagia without an identifiable underlying cause is often referred to as dysfunctional uterine bleeding (DUB), a diagnosis of exclusion.

An estimated 5 to 20 percent of girls and women with menorrhagia may have a bleeding disorder. Menorrhagia often is the first clinical manifestation of a mild bleeding disorder, such as Type 1 von Willebrand disease, or certain platelet function abnormalities. Acquired bleeding diatheses such as those associated with immune thrombocytopenic purpura, malignancy, or other systemic illnesses, are likely to have other clinical features suggesting them.

When to Suspect a Bleeding Disorder
Personal and family history are the most important elements to consider when evaluating for a possible bleeding disorder. It is reasonable to test for a bleeding disorder when history of the following is elicited in the patient and/or family members:

  • Menorrhagia with onset at the time of menarche
  • Frequent or prolonged nosebleeds
  • Mouth and gum bleeding
  • Heavy bleeding with minor dental procedures
  • Easy or excessive bruising following minor bumps or injuries
  • Heavy bleeding after surgery or childbirth

Evaluation
A complete history and physical examination should be performed, with particular attention paid to certain elements. Assess for hemodynamic instability by inquiring about dizziness or lightheadedness with rising, and by checking for tachycardia and orthostatic blood pressure changes. Pallor of nailbeds and mucous membranes, and a systolic ejection murmur suggest anemia as well. Skin should be evaluated for excessive bruising or petechiae. The presence of acne, hirsutism, and obesity are consistent with PCOS, whereas excessive virilization is seen with CAH. Assess for thyromegaly and historical features suggesting hyper- or hypo-thyroidism. Patients with pelvic pain or severe cramping may be further evaluated for pelvic infection or an anatomic anomaly. Sexually active patients should be evaluated for pregnancy.

Laboratory Studies When the history and physical are reassuring, patients may not need any further testing. The following may be considered on a case-by-case basis:

  • Hemoglobin or hematocrit
  • Platelet count
  • Von Willebrand factor and Ristocetin co-factor
  • Platelet function analysis
  • Free and total testosterone level 
  • Thyroid function tests
  • Pregnancy test
  • Sexually transmitted infection screening
  • Pelvic ultrasound

Management
For a patient who is not anemic and has no evidence of an underlying systemic disorder, it is important to frame the problem as a nuisance that certainly does affect her lifestyle, but that is not medically serious. Combination oral contraceptive pills (OCPs) may be offered to regulate cycles, shorten the duration of the menstrual bleed, and minimize blood loss. Patients who are actively bleeding and who are mildly anemic may be managed with OCPs given three to four times daily until bleeding stops, then tapered down to once a day over the next one to two weeks. When this regimen is prescribed, it is important to counsel the patient to discard the placebo pills at the end of each pack, and to ensure that the pharmacy gives her enough pills to complete the regimen and to continue on one pill daily. A monophasic pill containing 30 to 35 mcg of ethinyl estradiol, such as Lo-Ovral, should be used.

Patients who are severely anemic and/or hemodynamically unstable may need to be admitted to the hospital for stabilization, treatment with oral or intravenous estrogen and/or progesterone, and possibly packed red cell transfusion. When bleeding is controlled, they can subsequently be managed with an OCP. Physicians need to remember that laboratory tests to evaluate for a bleeding disorder are affected by estrogen therapy and blood transfusions, so it is helpful to draw these studies prior to instituting therapy if possible. Duration of treatment with hormonal therapy must be determined on a case-by-case basis, taking into account the severity of the anemia as well as patient and family requests. It is common to continue OCPs for 6 to12 months, and then consider discontinuation.

The Section of Adolescent Health at Nationwide Children’s cares for adolescents 12 to 21 years old, providing both primary care and consultative services in the areas of substance abuse, gynecologic/reproductive health care and eating disorders. Pediatric gynecologic services are available to all girls from birth through 21 years old. Girls with menorrhagia may be evaluated at Nationwide Children’s Hospital’s Adolescent Hematology Clinic, which assesses for both hormonal and hematologic contributions to menorrhagia.

References

  1. Campo JV, Bridge J, Ehmann M, et al. Recurrent abdominal pain, anxiety, and depression in primary care. Pediatrics 2004;113(4):817- 824

  2.  Di Lorenzo C, Youssef N, Sigurdsson L, et al. Visceral hyperalgesia in children with functional abdominal pain. J Pediatr 2001;139:838-843

  3. Campo JV, Bridge J, Lucas A, et al. Physical and emotional health of mothers of youth with functional abdominal pain. Arch Pediatr Adolesc Med 2007;161(2):131-137

  4. Campo JV, Perel J, Lucas A, et al. Citalopram treatment of pediatric recurrent abdominal pain and comorbid internalizing disorders: An exploratory study. J Am Acad Child Adolesc Psychiatry 2004;43(10):1234-1242

Bravender References:

  1. Centers for Disease Control and Prevention. Sexual and reproductive health of persons aged 10-24 years—United States, 2002-2007. Surveillance Summaries, MMWR. 2009;58(No. SS-6)

  2. Centers for Disease Control and Prevention. Youth risk behavior surveillance—United States, 2007. Surveillance Summaries, MMWR. 2008;57(No. SS-4)


Bios

Terrill D. Bravender, MD, MPH, is Chief of the Section of Adolescent Health at Nationwide Children’s Hospital. He is an Associate Professor of Clinical Pediatrics and an Associate Professor in Psychiatry at the Ohio State University College of Medicine. He is board certified in pediatrics and adolescent medicine. Dr. Bravender’s areas of research interests involve the intersection of behavioral and physical health in adolescents, with a particular emphasis on nutritional health in adolescents. He has had several publications in national journals, as well as numerous teaching and mentoring invitations regionally, nationally and internationally. He is active in the Academy for Eating Disorders, the Society for Adolescent Medicine, and the American Board of Pediatrics.

John V. Campo, MD, is medical director of Behavioral Health Services and Chief of the Section of Child and Adolescent Psychiatry at Nationwide Children’s Hospital and a Professor of Clinical Psychiatry and Clinical Pediatrics at The Ohio State University College of Medicine. Dr. Campo completed medical school at the University of Pennsylvania and residencies in pediatrics at the Children’s Hospital of Philadelphia and in general and child and adolescent psychiatry at the Western Psychiatric Institute and Clinic of the University of Pittsburgh. He is board certified in pediatrics, psychiatry, and child and adolescent psychiatry. Dr. Campo is the recipient of National Institute of Mental Health funding and is an investigator in the Center for Innovation in Pediatric Practice at The Research Institute at Nationwide Children’s Hospital. His interests include the relationship between medically unexplained physical symptoms and emotional disorders, psychosomatic medicine, and the delivery of evidence based behavioral health interventions, most notably in primary care. Dr. Campo has been honored as a NAMI Exemplary Psychiatrist and a recipient of the American Academy of Child and Adolescent Psychiatry’s Simon Wile Leadership in Consultation Award.

Cynthia M. Holland-Hall, MD, MPH, is a member of the Section of Adolescent Health at Nationwide Children’s Hospital and an Associate Professor of Clinical Pediatrics at The Ohio State University College of Medicine. She is board certified in pediatrics and adolescent medicine. Dr. Holland-Hall is an active member of the North American Society for Pediatric and Adolescent Gynecology, the Society for Adolescent Medicine and the American Academy of Pediatrics. Her clinical interests include sexually transmitted infections, reproductive health and eating disorders. She has co-authored two texts on adolescent medicine and authored several review articles.

Sarah O’Brien, MD, MSc, is a member of the Section of Hematology/ Oncology/BMT at Nationwide Children’s Hospital, Assistant Professor of Pediatrics at The Ohio State University College of Medicine, and a health services researcher in the Center for Innovation in Pediatric Practice at The Research Institute at Nationwide Children’s Hospital. Current research projects include examining physician decision making in the use of deep vein thrombosis (DVT) prophylaxis for pediatric and adolescent trauma patients, and the use of hormonal contraception in adolescent females at increased risk of DVT. She is also the institutional investigator for two national clinical trials of new anticoagulants in children.

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