[Show abstract][Hide abstract] ABSTRACT: Background: Physician-adolescent sexuality discussions are a recommended element in health maintenance visits, but such discussions - if they occur at all - probably vary by adolescents' characteristics and situations, and physicians' personal beliefs and training. However, little is known about the form and content of physician-adolescent sexuality discussions during health maintenance visits. Methods: We evaluated 245 physician-adolescent sexuality conversations. Using latent class analysis, we identified conversation types based on 13 sexually related topics, which occurred in at least 10% of all conversations. Results: We found four discrete types of sexuality conversations, which differed in terms of emphasis, topics addressed as part of the sexual history and risk assessment, and topics addressed in anticipatory guidance. Inquiry about partnered sexual experience was typical across all conversation types, as well as over half including discussions about body development and protective behaviours. In all four types of conversation, sexuality discussions were typically embedded in a sequence of psychosocial and behavioural topics recommended for health maintenance visits. Conclusions: The presence of sexuality conversations in the majority of these visits suggests that physicians consider sexuality to be an important issue and part of their responsibility in caring for their adolescent patients. However, the substantial variability in the types of sexuality conversations, particularly the notable omissions of many key topics, supports the importance of teaching sexual health interview skills in medical school and residency, and as part of continuing medical education and quality improvement.
Sexual Health 09/2015; DOI:10.1071/SH15080 · 1.37 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Practice-based studies are needed to assess how physicians communicate health messages about weight to overweight/obese adolescent patients, but successful recruitment to such studies is challenging. This paper describes challenges, solutions, and lessons learned to recruit physicians and adolescents to the Teen Communicating Health Analyzing Talk (CHAT) study, a randomized controlled trial of a communication skills intervention for primary care physicians to enhance communication about weight with overweight/obese adolescents.
A “peer-to-peer” approach was used to recruit physicians, including the use of “clinic champions” who liaised between study leaders and physicians. Consistent rapport and cooperative working relationships with physicians and clinic staff were developed and maintained. Adolescent clinic files were reviewed (HIPAA waiver) to assess eligibility. Parents could elect to opt-out for their children. To encourage enrollment, confidentiality of audio recordings was emphasized, and financial incentives were offered to all participants.
We recruited 49 physicians and audio-recorded 391 of their overweight/obese adolescents’ visits. Recruitment challenges included 1) physician reticence to participate; 2) variability in clinic operating procedures; 3) variability in adolescent accrual rates; 4) clinic open access scheduling; and 5) establishing communication with parents and adolescents. Key solutions included the use of a “clinic champion” to help recruit physicians, pro-active, consistent communication with clinic staff, and adapting calling times to reach parents and adolescents.
Recruiting physicians and adolescents to audio-recorded, practice-based health communication studies can be successful. Anticipated challenges to recruiting can be met with advanced planning; however, optimal solutions to challenges evolve as recruitment progresses.
International journal of adolescent medicine and health 01/2015; DOI:10.1515/ijamh-2015-0064
[Show abstract][Hide abstract] ABSTRACT: Purpose:
The National Eating Disorders Quality Improvement Collaborative evaluated data of patients with restrictive eating disorders to analyze demographics of diagnostic categories and predictors of weight restoration at 1 year.
Fourteen Adolescent Medicine eating disorder programs participated in a retrospective review of 700 adolescents aged 9-21 years with three visits, with DSM-5 categories of restrictive eating disorders including anorexia nervosa (AN), atypical AN, and avoidant/restrictive food intake disorder (ARFID). Data including demographics, weight and height at intake and follow-up, treatment before intake, and treatment during the year of follow-up were analyzed.
At intake, 53.6% met criteria for AN, 33.9% for atypical AN, and 12.4% for ARFID. Adolescents with ARFID were more likely to be male, younger, and had a longer duration of illness before presentation. All sites had a positive change in mean percentage median body mass index (%MBMI) for their population at 1-year follow-up. Controlling for age, gender, duration of illness, diagnosis, and prior higher level of care, only %MBMI at intake was a significant predictor of weight recovery. In the model, there was a 12.7% change in %MBMI (interquartile range, 6.5-19.3). Type of treatment was not predictive, and there were no significant differences between programs in terms of weight restoration.
The National Eating Disorders Quality Improvement Collaborative provides a description of the patient population presenting to a national cross-section of 14 Adolescent Medicine eating disorder programs and categorized by DSM-5. Treatment modalities need to be further evaluated to assess for more global aspects of recovery.
Journal of Adolescent Health 09/2014; 55(6). DOI:10.1016/j.jadohealth.2014.06.014 · 3.61 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Objective
Physicians’ use of Motivational Interviewing (MI) techniques when discussing weight with adolescent patients is unknown.
We coded audio-recorded encounters between 49 primary care physicians and 180 overweight adolescent patients. During weight discussions, we used the MITI 3.0 to assess: Empathy, MI Spirit, open-ended questions, reflections, MI consistent behaviors (e.g., praising,) and MI inconsistent behaviors (e.g., confronting). We examined associations of patient and physician characteristics with 1) MI techniques, 2) time discussing weight, and 3) encounter time.
Physicians used more MI consistent techniques with female patients (p = 0.06) and with heavier patients (p = 0.02). Physicians with prior MI training also used more MI consistent techniques (p = 0.04) and asked more open-ended questions (p = 0.05). Pediatricians had a higher MI Spirit score than family physicians (p = 0.03). Older patient age was associated with physicians spending less time discussing weight-related topics (p = 0.04) and higher BMI percentile was associated with physicians spending more time discussing weight-related topics (p = 0.01). Increased use of MI inconsistent techniques was associated with longer encounters (p = 0.02).
Physicians’ weight discussions vary based on adolescent and physician characteristics. Importantly, not using MI lengthened encounter time.
Physicians might consider using MI techniques more and attempt to use these equally with all adolescents.
[Show abstract][Hide abstract] ABSTRACT: Purpose: Physicians are encouraged to use inclusive language regarding sexuality in order to help all adolescent patients feel accepted. Non-inclusive language by physicians may influence relationships with adolescent pa-tients, especially those with still-developing sexual identities. The aim of this study was to identify patterns of physicians' use of inclusive and non-inclusive language when discussing sexuality. Method: A total of 393 conversations between 393 adolescents and 49 physicians from 11 clinics located throughout the Raleigh-Durham, North Carolina, area were audio recorded. Conversations were coded for the use of inclusive talk (language use that avoids the use of specific gender, sex, or sexual orientation language), direct non-inclusive talk (language use that assumes the teenager is heterosexual or exclusively engages in het-erosexual sexual activity), and indirect non-inclusive talk (language use that frames talk heterosexually but does not pre-identify the adolescent as heterosexual). Results: Nearly two-thirds (63%, 245) of the visits contained some sexuality talk. Inclusive talk rarely occurred (3.3%) while non-inclusive language was predominant (48.1% direct and 48.6% indirect). There were no signif-icant differences in language use by gender, age, adolescent race, or visit length. These non-significant findings suggest that all adolescents regardless of race, gender, or age are receiving non-inclusive sexuality talk from their providers. Conclusion: Physicians are missing opportunities to create safe environments for teenagers to discuss sexuality. The examples of inclusive talk from this study may provide potentially useful ways to teach providers how to begin sexuality discussions, focusing on sexual attraction or asking about friends' sexual behavior, and maintain these discussions.
[Show abstract][Hide abstract] ABSTRACT: IMPORTANCE Physicians may be important sources of sexuality information and preventive services, and one-on-one confidential time during health maintenance visits is recommended to allow discussions of sexual development, behavior, and risk reduction. However, little is known about the occurrence and characteristics of physician-adolescent discussions about sexuality. OBJECTIVE To examine predictors of time spent discussing sexuality, level of adolescent participation, and physician and patient characteristics associated with sexuality discussions during health maintenance visits by early and middle adolescents. DESIGN, SETTING, AND PARTICIPANTS Observational study of audio-recorded conversations between 253 adolescents (mean age, 14.3 years; 53% female; 40% white; 47% African American) and 49 physicians (82% pediatricians; 84% white; 65% female; mean age, 40.9 years; mean [SD] duration in practice, 11.8 [8.7] years) coded for sexuality content at 11 clinics (3 academic and 8 community-based practices) located throughout the Raleigh/Durham, North Carolina, area. MAIN OUTCOMES AND MEASURES Total time per visit during which sexuality issues were discussed. RESULTS One hundred sixty-five (65%) of all visits had some sexual content within it. The average time of sexuality talk was 36 seconds (35% 0 seconds; 30% 1-35 seconds; and 35% ≥36 seconds). Ordinal logistic regression (outcome of duration: 0, 1-35, or ≥36 seconds), adjusted for clustering of patients within physicians, found that female patients (odds ratio [OR] = 2.58; 95% CI, 1.53-4.36), older patients (OR = 1.37; 95% CI, 1.13-1.65), conversations with explicit confidentiality discussions (OR = 4.33; 95% CI, 2.58-7.28), African American adolescents (OR = 1.58; 95% CI, 1.01-2.48), and longer overall visit (OR = 1.07; 95% CI, 1.03-1.11) were associated with more sexuality talk, and Asian physicians were associated with less sexuality talk (OR = 0.13; 95% CI, 0.08-0.20). In addition, the same significant associations between adolescent, physician, and visit characteristics were significantly associated with greater adolescent participation. CONCLUSIONS AND RELEVANCE Our study may be the first to directly observe sexuality talk between physicians and adolescents. We found that one-third of all adolescents had annual visits without any mention of sexuality issues; when sexuality talk occurred, it was brief. Research is needed to identify successful strategies physicians can use to engage adolescents in discussions about sexuality to help promote healthy sexual development and decision making. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01040975.
[Show abstract][Hide abstract] ABSTRACT: To describe the theoretical basis, use, and satisfaction with Teen CHAT, an online educational intervention designed to improve physician-adolescent communication about healthy weight.
Routine health maintenance encounters between pediatricians and family practitioners and their overweight adolescent patients were audio recorded, and content was coded to summarize adherence with motivational interviewing techniques. An online educational intervention was developed using constructs from social cognitive theory and using personalized audio recordings. Physicians were randomized to the online intervention or not, and completed post-intervention surveys.
Forty-six physicians were recruited, and 22 physicians were randomized to view the intervention website. The educational intervention took an average of 54min to complete, and most physicians thought it was useful, that they would use newly acquired skills with their patients, and would recommend it to others. Fewer physicians thought it helped them address confidentiality issues with their adolescent patients.
The Teen CHAT online intervention shows potential for enhancing physician motivational interviewing skills in an acceptable and time-efficient manner.
If found to be effective in enhancing motivational interviewing skills and changing adolescent weight-related behaviors, wide dissemination will be feasible and indicated.
[Show abstract][Hide abstract] ABSTRACT: Objective:
To examine gastric function, as well as the presence of somatic complaints, anxiety symptoms, and functional gastrointestinal disorders (FGIDs), in adolescents with anorexia nervosa (AN) before and after nutritional rehabilitation.
Sixteen females with AN and 22 healthy controls with similar demographic profiles were included. Gastric emptying (measured as residual gastric volume) and gastric accommodation (measured as postprandial antral diameter) were assessed with abdominal ultrasonography. Participants completed the Children's Somatization Inventory (CSI), the Screen for Child Anxiety-Related Emotional Disorders, and the Questionnaire on Pediatric Gastrointestinal Symptoms-Rome III version. All testing was repeated 3-4 months later.
Body mass index in the AN group improved over time (P = .012). Fasting gastric parameters were similar in the 2 groups. Maximum postprandial antral diameter was significantly greater in controls compared with the AN group (P = .008). Only adolescents with AN demonstrated a significant increase in maximum postprandial diameter at repeat testing (P = .009). There was no difference in residual gastric volume between the 2 groups. Initial CSI scores were higher in adolescents with AN (P < .0001), including higher scores for nausea and abdominal pain. CSI scores were significantly lower in adolescents with AN (P = .035). Initial scores on the Screen for Child Anxiety-Related Emotional Disorders were significantly higher in adolescents with AN (P = .0005), but did not change over time. Adolescents with AN met significantly more criteria for FGIDs (P = .003).
Adolescents with AN have impaired gastric accommodation that improves after nutritional rehabilitation, have significantly more somatic complaints, and meet more criteria for anxiety disorders and FGIDs. After nutritional rehabilitation, somatization improves and FGIDs become less common, but symptoms of anxiety persist.
The Journal of pediatrics 04/2013; 163(3). DOI:10.1016/j.jpeds.2013.03.011 · 3.79 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Objective:
To determine whether children with symptoms of internalizing psychiatric disorders have a greater prevalence of pain-predominant functional gastrointestinal disorders (FGIDs) and migraine-like headaches.
Children and adolescents aged 6-18 years were recruited from a behavioral health center (n = 31) and a primary care center (n = 36). Subjects completed Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition-based symptom inventory questionnaires to screen for internalizing psychiatric disorders, the Questionnaire on Pediatric Gastrointestinal Symptoms, and a somatic distress assessment interview.
Thirty-three subjects (19 of 31 from the behavioral health center and 14 of 36 from the primary care center) screened positive for symptoms of anxiety or depressive disorders. The remainder screened negative and served as controls. Pain-predominant FGIDs were more common in the group with symptoms of anxiety or depression compared with controls (prevalence, 51.5% vs 8.8%; P = .0002). Migraine headaches occurred in 57.6% of the subjects with internalizing psychiatric disorders vs 23.5% of the control group (P = .006). The prevalence of functional constipation did not differ significantly between the 2 groups. The data remained essentially unchanged when analyzed within each center of recruitment.
Youths with anxiety or depressive symptoms are more likely to suffer from pain-predominant FGIDs and migraine-like headaches, but not from functional constipation. The lack of an association between functional constipation and internalizing psychiatric symptoms suggests that FGIDs associated with pain may bear a specific relationship to emotional disorders.
The Journal of pediatrics 03/2013; 163(3). DOI:10.1016/j.jpeds.2013.02.033 · 3.79 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Intrauterine devices are being used more frequently in adolescents requiring long-term reversible contraception. This population of sexually active adolescents is also at risk for pelvic inflammatory disease (PID).
We report two cases of PID in adolescents with IUDs in place, both of whom had symptom resolution with removal of their IUDs, and in whom both IUDs were culture positive for Enterococcus.
Whether these results indicate vaginal contamination or a causative agent for PID is unclear, but one should consider alternative causes of PID in adolescents with IUDs, particularly in those with prolonged symptoms.
Journal of pediatric and adolescent gynecology 06/2012; 25(3):e73-4. DOI:10.1016/j.jpag.2012.02.002 · 1.68 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: This quality improvement project collected and analyzed short-term weight gain data for patients with restrictive eating disorders (EDs) treated in outpatient adolescent medicine-based ED programs nationally.
Data on presentation and treatment of low-weight ED patients aged 9-21 years presenting in 2006 were retrospectively collected from 11 independent ED programs at intake and at 1-year follow-up. Low-weight was defined as < 90% median body weight (MBW) which is specific to age. Treatment components at each program were analyzed. Risk adjustment was performed for weight gain at 1 year for each site, accounting for clinical variables identified as significant in bivariate analyses.
The sites contained 6-51 patients per site (total N = 267); the mean age was 14.1-17.1 years; duration of illness before intake was 5.7-18.6 months; % MBW at intake was 77.5-83.0; and % MBW at follow-up was 88.8-93.8. In general, 40%-63% of low weight ED subjects reached ≥90% MBW at 1-year follow-up. At intake, patients with higher % MBW (p = .0002) and shorter duration of illness (p = .01) were more likely to be ≥90% MBW at follow-up. Risk-adjusted odds ratios controlled for % MBW and duration of illness were .8 (.5, 1.4)-1.3 (.3, 3.8), with no significant differences among sites.
A total of 11 ED programs successfully compared quality improvement data. Shorter duration of illness before intake and higher % MBW predicted improved weight outcomes at 1 year. After adjusting for risk factors, program outcomes did not differ significantly. All adolescent medicine-based ED programs were effective in assisting patients to gain weight.
Journal of Adolescent Health 12/2011; 49(6):594-600. DOI:10.1016/j.jadohealth.2011.04.023 · 3.61 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Infectious mononucleosis (IM) is a clinical syndrome that is common in adolescents and young adults and is characterized by fever, lymphadenopathy, pharyngitis, and fatigue. IM is most commonly associated with Epstein-Barr virus (EBV) infection in which case laboratory findings include a lymphocytosis with an elevated number of atypical lymphocytes seen on peripheral smear and a heterophile or EBV-specific antibody response. Approximately 10% of those with IM will not be acutely infected with EBV. Many of these individuals will have their symptoms attributed to cytomegalovirus (CMV) infection. This chapter reviews the history, diagnosis, clinical management, and potential complications of both EBV- and CMV-associated IM in adolescents and young adults.
Adolescent medicine: state of the art reviews 08/2010; 21(2):251-64, ix.
[Show abstract][Hide abstract] ABSTRACT: Childhood and adolescence are critical periods of neural development and physical growth. The malnutrition and related medical complications resulting from eating disorders such as anorexia nervosa (AN), bulimia nervosa (BN) and eating disorder not otherwise specified may have more severe and potentially more protracted consequences during youth than during other age periods. The consensus opinion of an international workgroup of experts on the diagnosis and treatment of child and adolescent eating disorders is that (a) lower and more developmentally sensitive thresholds of symptom severity (e.g. lower frequency of purging behaviours, significant deviations from growth curves as indicators of clinical severity) be used as diagnostic boundaries for children and adolescents, (b) behavioural indicators of psychological features of eating disorders be considered even in the absence of direct self-report of such symptoms and (c) multiple informants (e.g. parents) be used to ascertain symptom profiles. Collectively, these recommendations will permit earlier identification and intervention to prevent the exacerbation of eating disorder symptoms.
[Show abstract][Hide abstract] ABSTRACT: To determine if reading an age-appropriate novel has the potential to improve BMI percentile and exercise- and nutrition-related knowledge and behaviors in girls aged 9 to 13 years who were enrolled in a childhood obesity-treatment program.
This preliminary, randomized, controlled trial followed 81 obese girls aged 9 to 13 years who were enrolled in the Duke University Healthy Lifestyles Program, a comprehensive clinical and behavioral lifestyle-modification program for overweight and obese children. Thirty-one girls were randomly assigned to read the intervention novel, which describes an overweight girl who discovers improved health and self-efficacy, and 33 participants were given a control novel to read. Participants were evaluated at the study intake and again at their scheduled follow-up appointments 1 to 2 months later. Intake and follow-up BMI percentiles were evaluated for 17 girls in the program who did not receive either book.
Follow-up data were available for 11 of 31 girls in the intervention-book group, 14 of 33 girls in the control-book group, and 14 of 17 girls who did not receive a book. There was a significantly greater reduction in BMI percentile among those in the intervention-book group (-0.71) versus those in the control-book group (-0.33; P = .03). Girls who read either book had a significantly greater reduction in BMI percentile (-0.49) than girls who were followed in the program but who were not assigned a book (0.05; P = .02).
Age-appropriate fiction, particularly if it addresses health-oriented behaviors, shows potential for augmenting weight loss in girls who participate in a weight-management program. Future research is needed to determine if the novel is effective for healthy lifestyle promotion among all overweight and obese adolescents.