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Adolescent
Medicine:
A Handbook for
Primary Care
Victor C. Strasburger, MD
Division of Adolescent Medicine
Department of Pediatrics
University of New Mexico School
of Medicine
Albuquerque, New Mexico
Robert T. Brown, MD
Section of Adolescent Health
Children’s Hospital
Department of Pediatrics
The Ohio State University College
of Medicine
Columbus, Ohio
Paula K. Braverman, MD
Division of Adolescent Medicine
Cincinnati Children’s Hospital
Medical Center
Cincinnati, Ohio
Peter D. Rogers, MD, MPH
Section of Adolescent Health
Children’s Hospital
Department of Pediatrics
The Ohio State University College
of Medicine
Columbus, Ohio
Cynthia Holland-Hall, MD,
MPH
Section of Adolescent Health
Children’s Hospital
Department of Pediatrics
The Ohio State University College
of Medicine
Columbus, Ohio
Susan M. Coupey, MD
Department of Pediatrics
Albert Einstein College of Medicine
Section of Adolescent Medicine
Children’s Hospital at Montefiore
Bronx, New York
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© 2006 by Lippincott Williams & Wilkins
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quotations embodied in critical articles and reviews.
Printed in the United States
Library of Congress Cataloging-in-Publication Data
Adolescent medicine: a handbook for primary care / Victor Strasburger ... [et al.].
p. ; cm.
Includes bibliographical references.
ISBN 0-7817-5315-5
1. Adolescent medicine--Handbooks, manuals, etc. 2. Teenagers--Diseases--
Handbooks, manuals, etc. 3. Teenagers--Health and hygiene--Handbooks, manuals,
etc. I. Strasburger, Victor C., 1949-
[DNLM: 1. Adolescent Medicine--methods. 2. Adolescent Health Services.
3. Mental Disorders--Adolescent. WS 460 M294 2005]
RJ550.M366 2005
616'.00835--dc22
2005005661
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Dedication
To my two teenagers, Max & Katya, who continue to teach me more
than I want to know about Adolescent Medicine, and to Alya with love.
—Victor C. Strasburger
To William A. Daniel, Jr., who remains a guiding light for me.
—Robert T. Brown
To my father, Irwin, who has been a source of support and
encouragement as well as a role model throughout my career
in medicine.
—Paula K. Braverman
To my best friend and beautiful wife, Emilie, the woman I love.
—Peter D. Rogers
To my husband Mark for his unwavering support.
—Cynthia Holland-Hall
To all of my former and current adolescent medicine fellows from
whom I have learned so much.
—Susan M. Coupey
iii
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Contents
Contributing Authors vi
Foreword vii
Preface viii
Acknowledgments ix
Part I
Growth and Development 1
1
Adolescent Growth
and Development 3
Part II
Office Problems 11
2
The Office Visit 13
Part III
Common Medical Problems 23
3
Headache 25
4
Seizures 33
5
Syncope 37
6
Common Respiratory
Infections 40
7
Asthma 47
8
Acne 53
9
Infectious Mononucleosis 63
10
Chronic Fatigue 70
11
Hepatitis 74
12
Abdominal Pain 82
13
Musculoskeletal Problems 85
14
Urinary Tract Infection 97
15
Diabetes Mellitus 104
iv
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Contents v
16
Thyroid Disease 114
17
Hypertension 123
18
Obesity 130
Part IV
Common Behavioral
Problems 139
19
Attention-Deficit/
Hyperactivity Disorder 141
20
Substance Abuse 147
21
Adolescent Tobacco Use 163
22
Eating Disorders 172
23
Mood and Anxiety
Disorders 177
24
Psychosomatic Problems
in Adolescence 189
25
Adolescent Violence
and Suicide 199
Part V
Reproductive Health 209
26
Adolescent Sexuality
and Reproductive Health 211
27
Sexually Transmitted
Infections 244
Part VI
Sports Medicine 261
28
Sports Medicine 263
Part VII
Common Legal Issues 285
29
Legal Issues 287
Part VIII
Appendix:Commonly
Prescribed Medications 293
Index 313
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Contributing Authors
Paula K.Braverman,MD Professor of Clinical Pediatrics,
Pediatrics, University of Cincinnati
College of Medicine; Director of
Community Programs, Division of
Adolescent Medicine, Cincinnati
Children’s Hospital Medical Center,
Cincinnati, Ohio
Robert T.Brown,MD Professor of Clinical Pediatrics and
Obstetrics/Gynecology, The Ohio State
University College of Medicine; Chief,
Section of Adolescent Health,
Children’s Hospital, Columbus, Ohio
Jane Chang,MD Post-Doctoral Fellow, Department of
Syncope Pediatrics, Section of Adolescent
Eating Disorders Medicine, Albert Einstein College
of Medicine of Yeshiva University,
Children’s Hospital at Montefiore,
Bronx, New York
Susan M.Coupey,MD Professor of Pediatrics, Director, ICM
Program, Albert Einstein College of
Medicine, Chief, Adolescent Medicine,
Children’s Hospital at Montefiore,
Bronx, New York
Cynthia Holland-Hall,MD,MPH Assistant Professor of Clinical
Pediatrics, The Ohio State University
College of Medicine; Section of
Adolescent Health, Children’s
Hospital, Columbus, Ohio
Unab Khan,MD Post-Doctoral Fellow, Section of
Adolescent Growth and Development Adolescent Medicine, Department of
Hypertension Pediatrics, Albert Einstein College
of Medicine of Yeshiva University,
Children’s Hospital at Montefiore,
Bronx, New York
Peter D.Rogers,MD,MPH,FAAP, Clinical Associate Professor of
FSAM,FASAM Pediatrics, The Ohio State University
College of Medicine; Section of
Adolescent Health, Children’s
Hospital, Columbus, Ohio
Victor C.Strasburger,MD Professor of Pediatrics and Family
and Community Medicine, Division
of Adolescent Medicine, Department
of Pediatrics, University of New
Mexico School of Medicine,
Albuquerque, New Mexico
vi
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Foreword
It is frequently said that adolescence is the neglected age group; perhaps it is more sound
to say that that it is physicians’training in the care of adolescents which has been given
relatively little attention. This astute observation was made by Dr. J. Roswell Gallagher
in 1957 and remains credible today, despite the intervening half century of develop-
ments in the field of adolescent medicine. Pioneers such as Gallagher realized that ado-
lescents are special and have different medical needs; they realized too that young
people are better served, as they always will be, when their health care providers are
appropriately informed.
Many health care professionals feel ill-equipped to deal with adolescents in their prac-
tices, particularly in relation to sexuality and substance use. Adolescents want to dis-
cuss health behaviors but often feel too embarrassed to initiate discussion in these
sensitive areas. And while parents also want clinicians to discuss health issues with
their adolescents, many fail to do so. How can clinicians feel more comfortable talking
with teens and better able to facilitate the conversation?
This excellent manual of adolescent healthhas the answers to this and many other
crucial questions. It has been designed as a handy, pertinent and useful book for pri-
mary care clinicians. Content has been selected for its clinical relevance and does not
purport to cover all known facts within the diverse range of topics covered. But little of
importance has been excluded—from obesity and ADHD to sports medicine, hyperten-
sion and eating disorders. In a clear and accessible format, key issues are highlighted
and well explained; suggested treatments reflect best current knowledge and practice.
And each chapter concludes with a “pearls and pitfalls” section followed by a brief bibli-
ography and helpful Web sites for both parents and clinicians.
At adolescence, perhaps more powerfully than at any other period in the lifespan, or-
ganic and psychosocial issues are complexly intertwined. Psychosomatic illness is “a di-
agnosis of inclusion as well as exclusion,” not what the person has “when no organic
illness can be discovered.” With chronic abdominal pain, we are reminded to “do the min-
imal necessary laboratory/imaging workup” and not “…forget about gynecologic causes of
pain in female adolescents.” Likewise, “Syncope can be a presenting symptom of early
pregnancy in an adolescent girl.”
It is useful to know that parents may report periorbital oedema in a teenager with in-
fectious mononucleosis and that “petechiae of the soft palate are also frequently over-
looked” in this common condition. The almost universal affliction of acne in adolescents
is rife with myths and common management mistakes, and yet “treating it (properly) can
establish an immediate and long-lasting rapport with adolescent patients.”
In working with adolescents, the challenge is to engage their trust, make a meaning-
ful assessment of the presenting problem or issue, and intervene in a helpful and sup-
portive way. Confidentiality is extremely important and, in regard to legal concerns
generally, common sense must prevail—“no physician has ever been successfully sued for
prescribing birth control to a minor” (also true in Australia). Whether an experienced
adolescent health physician, a family physician or fellow in training, all will benefit from
having this concise, comprehensive and highly accessible resource close at hand.
David Bennett,AO,MBBS,FRACP,FSAM
Clinical Associate Professor and Senior Staff Specialist
Department of Adolescent Medicine and Head,
NSW Centre for the Advancement of Adolescent Health
The Children’s Hospital at Westmead
Sydney, Australia
vii
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Preface
“I see no hope for the future of our people if they are dependent on the frivolous youth of
today, for certainly all youth are reckless beyond words….When I was a boy, we were
taught to be discreet and respectful of elders, but the present youth are exceedingly wise
and impatient of restraint.”
Hesiod, 8thcentury Egyptian historian
Adolescents have always been a challenge. From Hesiod’s complaint that they disrespect
their elders to Aristotle’s observation that they lack “sexual restraint” to Shakespeare’s
suggestion that they be put into suspended animation until age 23, the history of West-
ern civilization is replete with a litany of complaints about teenagers. Yet we sometimes
forget how adolescents have changed the world. Many of the signers of the Declaration
of Independence were still in their teens. In the 1960s, student unrest on college cam-
puses catalyzed public opinion against the Vietnam War. Many of today’s most gifted
athletes whom adults spend hours watching on TV are, in fact, adolescents.
Adolescents sometimes make challenging patients as well. Not just “sex, drugs, rock
‘n’roll,” but acne, eating disorders, and depression may complicate adolescence. In the
movie “One-Eyed Jacks,” Brando’s character is asked, “What are you rebelling against?”
He answers: “What’ve you got?” But while the image of a motorcycle-jacketed Marlon
Brando or a James Dean rebel-without-a-cause may represent parents’(or clinicians’)
worst fears, most teenagers get through adolescence with little or no difficulty (80%, ac-
cording to the psychiatric literature).
Physicians, nurse practitioners, and others who treat teenagers need to be vigilant
about the pitfalls encountered during adolescence but also need to be nonjudgmental
and tolerant as well. Clinicians also need to enjoy seeing teenagers. Adolescents are
unique creatures and deserve special care. This small handbook is designed to be a prac-
tical and quick guide to diagnosing and treating common adolescent problems. It is not
intended to be a comprehensive academic tome but rather, since “brevity is the soul of
wit” according to Polonius in “Hamlet,” this book is meant to be useful above all else.
Take it to clinic with you, keep it at your desk in your consulting room, refer to it often.
We hope that you will find it indispensable in treating your adolescent patients.
viii
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Acknowledgments
We would like to thank Carole Clark for her technical assistance, as well as Lisa S.
Blackwell, Serials/Reference Librarian at the Children’s Hospital Library of Columbus,
Ohio.
Many thanks also to the Department Chair of the School of Medicine at the Univer-
sity of New Mexico, Dr. Robert Katz, who allowed Dr. Strasburger time to write, and to
his colleague, Dr. Karen Campbell, who allowed him time to think.
ix
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