Adolescent medicine (Philadelphia, Pa.)最新文献

The relationship among eating disorders (EDs), psychosexual and identity development, and physical maturation (puberty) is reviewed. The developmental tasks of adolescence are summarized, and research from both community studies and clinical samples on the association between the development of an ED and putative risk factors that include pubertal development and psychosexual behaviors and attitudes for children and adolescents is reviewed. Specific issues explored include the role of child and adolescent abuse and EDs in males. Overall evidence suggests the following: there are inconsistent findings regarding early pubertal development as a risk factor; there is some support for differences between the ED subtypes in sexual attitudes, behaviors, and experiences; sexual abuse is not a specific risk factor; and gender identity issues may play more of a role for adolescent males than females. However, psychosexual issues are neither sufficient nor necessary for the development of an ED in a young person. It should be considered as only one factor in the multidimensional, multifactorial framework needed to clarify this complex and still poorly understood set of disorders.

The female athlete triad is a syndrome consisting of disordered eating, amenorrhea, and osteoporosis. The syndrome is increasing in prevalence as more women are participating in sports at a competitive level. Behaviors such as intense exercise or disordered eating patterns can lead to dysregulation of the hypothalamic-pituitarian-ovarian (HPO) axis, resulting in amenorrhea. Hypothalamic amenorrhea can lead to osteoporosis and increased fracture risk. Adolescents may particularly be at risk because it is during this crucial time that females attain their peak bone mass. Prevention of the female athlete triad through education and identification of athletes at risk may decrease the incidence of long-term deleterious consequences. Treatment of the female athlete triad is initially aimed at increasing caloric intake and decreasing physical activity until there is resumption of normal menses. Treatment of decreased bone mineral density and osteoporosis in the adolescent population, however, is controversial, with new treatment modalities currently being investigated in order to aid in the management of this disorder.

Lack of physical activity is a known determinant of obesity. Unfortunately, children become less and less active as they reach and progress through adolescence. This behavior leads to detrimental effects on body composition and other components of health-related physical fitness. Various types of exercise and activities have different effects on fitness, body composition, and metabolic state. For a physician to recommend activities or sports and exercise type, he or she should examine and discuss the patients fitness and physique goals to maintain their enthusiasm and promote lifelong physical activity benefits.

Indirect calorimetry is a noninvasive, inexpensive technique used to determine resting energy expenditure. Its use provides the clinician with objective information that can be used to design, implement, and evaluate efficacy of treatment in the nutritional management of adolescents with anorexia nervosa, bulimia nervosa, chronic dieting behavior, and obesity. This chapter outlines the theoretical framework, interpretation of data, and clinical applications of indirect calorimetry and presents case examples to underscore its utility in adolescents with eating disorders.

Bulimia nervosa (BN) and binge-eating disorder (BED) are separate entities with the common denominator of binge eating. In this chapter, Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) criteria for BN are reviewed, including both recurrent episodes of binge eating and inappropriate compensatory behaviors to prevent weight gain in one whose self-evaluation is unduly influenced by body weight and shape. Two percent of adolescent females and 0.3% of adolescent males fulfill criteria for BN. Risk factors, medical complications of binge eating (vomiting, use of ipecac, diet pills, diuretics, and laxatives), physical and laboratory findings, and treatment options and outcome are discussed. BED is seen in 1-2% of adolescents. The DSM-IV lists BED under Eating Disorder Not Otherwise Specified. DSM-IV research criteria for BED is reviewed, including binge eating, distress over binge eating, and absence of regular extreme compensatory behaviors. The mean age of onset is 17.2 years. Up to 30% of obese patients have BED. Risk factors are discussed. Because most patients with BED are obese, medical evaluation is similar to that for obesity. Treatment goals must be geared not only toward decreased binge eating but toward weight loss. Outcome is discussed.

Anorexia nervosa (AN) commonly arises during adolescence and is associated with significant medical morbidity. Abnormalities in brain structure and function are among the most common, early, and concerning physical consequences. Advances in neuroimaging technology have played an important role in delineating the structural and functional changes found in patients with AN. Studies using computed tomography and magnetic resonance imaging have demonstrated changes in brain structure in the low-weight stages of AN. In addition, functional neuroimaging techniques have demonstrated altered brain metabolism. Debate continues as to whether these brain abnormalities are fully reversible with weight restoration. Neuropsychological research has demonstrated that cognitive dysfunction is also a common feature of AN. Multiple studies have indicated deficits in various neuropsychological domains. Whether the reported cognitive deficits are reversible with weight gain remains unknown. To date, some preliminary evidence suggests that reported cognitive deficits in patients with AN may be associated with structural brain abnormalities. This chapter reviews the current literature about neuroimaging studies and cognitive function in adolescents with AN, discusses the possible underlying mechanisms causing these changes, and explores the possible association between them.

Many of the behavioral interventions designed to promote dietary change in individuals include medical assessment, initial assessment of diet history, assessing readiness, establishing dietary goals, self-monitoring, stimulus control training, training in problem solving, relapse prevention training, enlisting social support, nutrition education, dietary therapy, and ongoing contact to maintain progress. The comprehensive nature of a cognitive-behavioral weight management program is of value in modifying behaviors that are linked to adverse health effects and psychological distresses, without necessarily causing a drastic weight loss in obese individuals. The behavioral treatments for overweight and obesity directly modify behaviors that bear on health and illness, such as improving dietary choices, decreasing sedentary behaviors, and increasing habitual physical activity and exercises. Cognitive-behavioral treatment can be used to help overweight adolescents become more assertive in coping with the adverse social stigma of being overweight, enhance their self-esteem, and reduce their dissatisfaction with body image regardless of their weight loss. Cognitive-behavioral treatments seem to be more effective in children when delivered before puberty than they are for adults.

Osteopenia is a frequent and severe complication of anorexia nervosa. Once established, it is difficult to treat and is only partially reversible. Osteoporosis is a preventable disease, and intervention should begin during childhood and adolescence. Optimizing peak bone mass accrual during adolescence is essential, and an episode of anorexia nervosa during adolescence interferes with that process. In anorexia nervosa, results with hormone replacement therapy have been disappointing. Calcium and vitamin D supplementation should be prescribed where necessary. Excessive exercise should be avoided and moderate weight-bearing exercise encouraged. Ongoing research studying newer modalities such as IGF-1, DHEA, and bisphosphonates looks promising. Until more effective treatment regimens become available, the mainstay of treatment remains weight gain, nutritional rehabilitation, and spontaneous resumption of menses.

This article addresses practical issues facing the primary care practitioner caring for an adolescent with an eating disorder. It is grounded in the four elements of successful treatment noted by Comerci: (1) recognizing the disorder and restoring physiologic stability early in its course, (2) establishing a trusting, therapeutic partnership with the adolescent, (3) involving the family in treatment, and (4) using an interdisciplinary team approach. Although primary care practitioners often have an established relationship with their patients, adolescents with eating disorders present special challenges. These adolescents tend to be bright, strong-willed, and wary of any recommendations to change their weight-control practices for fear that they will lose control. Their families are often distraught by the conflicts that arise as a result of the disordered eating behaviors and the fear that the condition is associated with significant morbidity and mortality. The article provides primary care clinicians with pragmatic ways to diagnose and initiate treatment and engage the patient and parents as active participants and members of the therapeutic team in the early phases of treatment. In addressing these principles, the authors combine the nurturant-authoritative approach described by Levenkron with the biopsychosocial model proposed by Engel.

Neurocutaneous syndromes are congenital or hereditary conditions that have many features in common: hereditary transmission, involvement of organs of ectodermal origin (nervous system, eyeball, retina, and skin), slow evolution of lesions in childhood and adolescence, and disposition to fatal malignant transformation. Except for Sturge- Weber syndrome, these major neurocutaneous syndromes are genetically determined, although sporadic cases can occur. This article reviews the clinical features of the more common neurocutaneous syndromes, including tuberous sclerosis complex, neurofibromatosis, Sturge-Weber syndrome, Ehlers-Danlos syndrome, and von Hippel-Lindau disease.