Ronald A. Feinstein

Medical status of adolescents at time of admission to a juvenile detention center

PURPOSE To examine the medical status and history of health care utilization of adolescents at the time of their admission to a juvenile detention facility. METHODS Data were collected over an 18-month period on all detainees admitted for the first time to a juvenile detention facility in a major southeastern city in the United States. Information was gathered through a private, confidential interview completed by a medical social worker and a physical examination by a physician. Information was obtained regarding past medical history, complaints at the time of admission, health care utilization, and physical examination. RESULTS Approximately 10% of teenagers admitted to a detention facility have a significant medical problem (excluding drug/alcohol abuse, or uncomplicated sexually transmitted diseases) that requires medical follow-up. The majority of these conditions were known to the adolescent at the time of admission. Only a third of adolescents admitted to the detention facility reported a regular source of medical care, and only about 20% reported having a private physician. A majority of all the detainees had already fallen behind in or dropped out of school. More than half of the families of the adolescents with a medical problem appeared to be unable or unwilling to assist in ensuring proper medical follow-up. CONCLUSIONS A significant percentage of adolescents entering a detention facility have a medical problem requiring health care services. Detention facilities offer an opportunity to deliver and coordinate medical care to high-risk adolescents. Programs linking public and private health care providers with the correctional care system may provide juveniles with an acceptable option for obtaining needed health care services.

Risk for gonococcal and chlamydial cervicitis in adolescent females: Incidence and recurrence in a prospective cohort study

PURPOSE This study attempted to determine the incidence and risk for gonococcal and chlamydial cervicitis among sexually active urban adolescent females. METHODS The study design is a prospective cohort study. A cohort of 216 sexually active females were followed with repeat sexually transmitted diseases screening for 12-24 months. Subjects positive on any retest (FU) were compared with those who remained negative on all FU. Subjects were interviewed for history and screened for endocervical gonococcal and chlamydial infection. RESULTS The number of visits per patient ranged from 2 to 9 (median, 3). The initial Chlamydia trachomatis and Neisseria gonorrhoeae rates were 23.2 and 11.6%, respectively. The cumulative FU positive rates were 20.8% for C. trachomatis and 17.1% for N. gonorrhoeae. Although the initial gonococcal infection was a significant risk for a subsequent infection by C. trachomatis (p = .05) and N. gonorrhoeae (p = .001), the initial C. trachomatis status was not predictive of subsequent infections. The number of partners was not predictive of subsequent infections with either. In the entire study period, 86 patients had at least one episode of C. trachomatis and N. gonorrhoeae infection was confirmed in 52; 20 patients had recurrent cervicitis. During the study, 101 episodes of C. trachomatis and 68 episodes of N. gonorrhoeae infections were identified. Those with recurrent cervicitis (9.3%) were responsible for 33% of all cervicitis episodes identified during the study. CONCLUSIONS Adolescents in our study were at high risk for cervicitis, particularly as a result of C. trachomatis. Risk for subsequent C. trachomatis cervicitis was the same among initially positive and negative groups. Our data underscore the importance of repeat screening for sexually transmitted infections and treatment of contacts of adolescent females.

Sexual Behavior and Sexually Transmitted Diseases Among Male Adolescents in Detention

Background: Youth in detention represent a medically underserved population at risk for a variety of medical and emotional disorders. Goal of the study: To determine prevalence of STDs and high-risk sexual behaviors for HIV/STD among adolescent males admitted to a juvenile detention facility. Study Design: Cross-sectional study of behavioral risk factors and STD prevalence among detained males, 11 to 18 years of age. Study subjects were interviewed for behavioral history and screened for STD. Results: The median number of lifetime partners of the population was 8 (range 1–100), the number of partners in the preceding 4 months was 2 in median (range 0–30), 59% used a condom with their last sex, and consistent condom use in the past 4 months was reported by 37%. A history of sexual intercourse within the last one week was reported by 43%. Chlamydia trachomatis infection rate was 6.9% (66/957), Neisseria gonorrhoeae 4.5% (42/940) and syphilis 0.9% (8/930) including one who seroconverted while in detention. Overall, 12% (109/908) of subjects tested for all three infections were positive for at least one STD. Stepwise logistic regression analysis showed that greater than one partner in the previous 4 months (OR 1.53, 95% confidence interval [95%CI] 1.18–1.98), inconsistent or no condom use in the preceding 4 months (OR 1.77, 95%CI 1.37–2.28), a history of recent STD (OR 1.80, 95%CI 1.33–2.42) and greater than five lifetime partners (OR 2.03, 95%CI 1.41–2.92) were independent predictors of these STDs in this population. Conclusion: Detained juvenile males in our study were at a high-risk for STD/HIV infections and probably form a core group of STD transmitters. Vigorous attempt to reduce STD reservoir and change behavior of juveniles in detention, such as our study subjects, is urgently needed for the control of the STD/HIV infections.

Health care for incarcerated youth: Position paper of the society for adolescent medicine

Each year, increasing numbers of juveniles are incarcerated (1,2). In 1991, 823,449 youths were detained in longand short-term facilities in the United States (3). As the federal and state governments move to mandate harsher penalties for delinquent youth, this population is likely to increase (4). Systems that are already taxed will find their resources diminishing relative to demand. Many youth entering detention lack comprehensive health care and have long-term neglected health needs (5,6), whereas the scope of the care offered by detention facilities varies widely. Juvenile detainees have been identified as a group that participates in high-risk behaviors including substance abuse (7–10), early sexual activity (10–13), violence (10), weapon use (10), murder (14), and gang involvement (10). This group also has a high prevalence of medical conditions including seizure disorders, respiratory disease, nutritional deficiencies, and orthopedic, skin, and dental problems (5,11,15–18). In addition, juvenile detainees often have physical or psychological disorders that contribute to behavior problems (15,19–23). For example, a high rate of depression has been reported among detained youth (10,18,24). Moreover, during detention, youth may be at risk for accidental or self-inflicted injuries (6,25) as well as stress-related symptoms (17). The time in custody presents a unique opportunity to address the basic health concerns of this population and provide health education. However, a number of factors tend to impede the provision of excellent health care to detained adolescents. Currently, under federal regulations, incarcerated populations, even detainees under 18 years of age, are ineligible for Medicaid benefits. This prohibition postpones fulfillment of the health care needs of incarcerated youth. The provision of health care in detention settings is complex and multifaceted, and has the potential for conflicts of interest. The health care professional’s primary responsibility is to ensure the welfare of individual detainees. When youth already under psychiatric care are admitted to detention facilities, their care may be interrupted because of poor coordination between mental health providers within and outside the detention system. When juveniles are released from detention, follow-up of medical and psychological needs is often neglected. Incarcerated youth depend on others for their medical, psychiatric, and dental care, and lack outside oversight. Unfortunately, this situation can lead to a decline in accountability. The Society of Adolescent Medicine believes that health care providers in correctional settings should take an active role in ensuring the unimpeded access to health care for all juvenile detainees as well as the ongoing health and safety of the young people within their purview, and endorses the following positions:

Procreative experiences and orientations toward paternity held by incarcerated adolescent males

PURPOSE To describe the procreative experiences and the attitudes related to paternity held by a sample of incarcerated adolescent males. METHODS All adolescent males who were admitted to a long-term correctional facility between July 1994 and October 1994 were asked to participate in a confidential, face-to-face interview. RESULTS One hundred twenty-five incarcerated adolescents agreed to participate in the study. Over one-quarter (25.6%) of the respondents reported having ever gotten a girl pregnant; 40.6% of fathers reported having caused more than one pregnancy. A majority of respondents believed that fathering a child would be desirable, that they would be capable of being a father to a child, and that they could be responsible for the baby and mother. Fathers were more likely than nonfathers and black respondents were more likely than white respondents to report that they, their parents, and their friends would be pleased were they to get girls pregnant. Black respondents were more likely than white respondents to believe that they could be a good father to a child. CONCLUSIONS The general perceptions that fathering a child as a teenager is desirable and that they could be good fathers to their children will make the prevention of pregnancy and parenting difficult in this population. Incarcerated adolescents should be educated about parenting prevention using interventions that take into consideration their attitudes and perceptions of teenage parenting.

Sexually transmitted diseases and sexual behavior in urban adolescent females attending a family planning clinic.

Specimens from the lower genital tract of 102 sexually active urban adolescent females were tested for the common sexually transmitted diseases (STDs). The results were correlated with concomitant clinical, demographic, and historic data. Forty-one percent (42/102) were infected with one or more of the following organisms: Chlamydia trachomatis (26/102), Trichomonas vaginalis (13/102), Neisseria gonorrhoeae (10/102), yeast (6/102), condyloma (5/102), and herpes simplex virus (1/44). Mixed infections were found in 13%. Fifty-nine percent were negative for any infectious agents. The presence of genitourinary symptoms were of no value in predicting an STD. The rate of positive physical findings was significantly higher in the STD-positive group than in the negative group (p = 0.03), but 28% of the STD-negative group had positive physical findings, and 50% of the STD-positive group had normal physical findings. A history of genitourinary complaints or presence of physical findings was not predictive of a positive STD culture. Oral contraceptive use of more than six months appears to be a risk factor for an STD. No other factors, including the number of sexual partners, were significantly correlated with the presence of an STD. This study supports the need for routine screening of sexually active urban adolescent girls for an STD.

Chlamydia trachomatis cervical infection and oral contraceptive use among adolescent girls

This study examines the relationship between oral contraceptive use and Chlamydia trachomatis cervical infection in women less than 19 years of age. The clinical and epidemiologic data of 73 (19.4% prevalence rate) girls with chlamydial infection were analyzed, with special attention given to contraceptive use. The findings were compared with data from 303 girls who were chlamydia negative to assess the relationship between oral contraceptive use and C. trachomatis infection. Use of an oral contraceptive for 6 months or longer was associated with chlamydial infection (p = 0.005; odds ratio = 2.41; 95% confidence interval 1.53-3.29). Oral contraceptive use was not associated with an increased rate of Neisseria gonorrhoeae or Trichomonas vaginalis infection. Association of oral contraceptive use with chlamydial infection remained significant after adjustments were made for confounding variables in a logistic regression process (p = 0.013). This study suggests that oral contraceptive use may promote chlamydial infection of the cervix or enhance the detection of the C. trachomatis from the cervix in this population.

A National Survey of Preparticipation Physical Examination Requirements.

In brief: A mail survey of the 50 states and the District of Columbia was conducted to assess the requirements for scholastic preparticipation physical examinations (PPEs). Forty-five replies were received. The results showed that 35 states require a yearly examination and 36 states provide an official state form. Twenty-five states have a medical history questionnaire, but only three states supply a list of contraindications for participation. Several states allow examination by someone other than a physician. Only one of the forms contains a statement of the purpose and/or limitations of the PPE. The requirements and intent of the PPE differ considerably from state to state, indicating that national guidelines for PPEs are needed.

Detection of asymptomatic Chlamydia trachomatis infection in adolescents

Abstract Endocervical swabs from 137 asymptomatic girls 12–18 years of age (mean 16.1 years) were tested for Chlamydia trachomatis using a direct fluorescent antibody (DFA) slide test (MicroTrak, Syva Co., Palo Alto, CA) and compared with the tissue culture isolation of the organism. The DFA slides were examined for quality of the specimen as well as for the presence of elementary bodies. Of 137 slides, 5 (3.6%) were “poor” (less than 50 epithelial cells per well) and were excluded from the analysis. The DFA test identified 26 (89.7%) of 29 culture-positive specimens and 102 (99.0%) of 103 culture-negative specimens. The DFA test is a valuable screening tool (positive predictive value 96.30%, negative predictive value 97.14%) for identification of asymptomatic chlamydial cervical infection in adolescents when slides are interpreted for adequacy of the specimen as well as the presence of elementary bodies.

Enzyme immunoassay for detection of asymptomatic chlamydia cervical infection in pregnant adolescents

To determine validity of enzyme immunoassay (EIA) as a screening tool for asymptomatic chlamydia cervical infection in pregnant teenagers, 164 endocervical specimens from 103 pregnant teenagers (12–16 years of age; mean 14.9 years) were screened for Chlamydia trachomatis by EIA and compared with tissue culture isolation. The EIA identified 23/25 culture-positive specimens (92.0% sensitivity) and 136/138 culture-negative specimens (98.6% specificity). The concordance rate of EIA with the culture method was 97.0%. The positive predictive value of EIA was 92.0% and the negative predictive value was 98.6%. Our study indicates that the EIA is an acceptable alternative screening tool for detection of asymptomatic chlamydia cervical infection in teenagers.