Seth Ammerman

Eating disorders in adolescents: A background paper

Although eating disorders primarily affect adolescents and young adults, much of the recent medical and psychiatric literature fails to consider the unique physiologic, psychologic, and developmental issues relevant to younger patients, more often describing older patients with more chronic and intractable disease. Pediatricians and adolescent medicine specialists see younger patients who have a shorter duration of illness and a different set of physiologic and psychologic responses to weight control. The Practice Guidelines for Eating Disorders, published in 1993 by the American Psychiatric Association (1), provide an excellent overview of the

Substance Use Screening, Brief Intervention, and Referral to Treatment for Pediatricians

As a component of comprehensive pediatric care, adolescents should receive appropriate guidance regarding substance use during routine clinical care. This statement addresses practitioner challenges posed by the spectrum of pediatric substance use and presents an algorithm-based approach to augment the pediatricians confidence and abilities related to substance use screening, brief intervention, and referral to treatment in the primary care setting. Adolescents with addictions should be managed collaboratively (or comanaged) with child and adolescent mental health or addiction specialists. This statement reviews recommended referral guidelines that are based on established patient-treatment–matching criteria and the risk level for substance abuse.

Randomized Clinical Trial of the Efficacy of Bupropion Combined With Nicotine Patch in the Treatment of Adolescent Smokers

Adolescent smokers (N = 211) were randomized to 1 of 2 groups: (a) nicotine patch plus bupropion SR (sustained release; 150 mg per day) or (b) nicotine patch plus placebo. Group skills training sessions were conducted each week by research staff. Abstinence rates at Weeks 10 and 26 were as follows: (a) patch plus bupropion, 23% and 8%, (b) patch plus placebo, 28% and 7%. Despite the lack of a treatment effect, a large majority of adolescents in both treatment groups reduced their consumption to a few cigarettes per day or less and maintained this reduction over time. Similarly, an examination of survival curves revealed that by the end of treatment many had managed to avoid a return to daily smoking. These findings are encouraging and suggest new avenues for research. For example, treatments of the kind examined in this report, augmented by extended maintenance therapies, may yield higher long-term success rates.

The Impact of Marijuana Policies on Youth: Clinical, Research, and Legal Update

This technical report updates the 2004 American Academy of Pediatrics technical report on the legalization of marijuana. Current epidemiology of marijuana use is presented, as are definitions and biology of marijuana compounds, side effects of marijuana use, and effects of use on adolescent brain development. Issues concerning medical marijuana specifically are also addressed. Concerning legalization of marijuana, 4 different approaches in the United States are discussed: legalization of marijuana solely for medical purposes, decriminalization of recreational use of marijuana, legalization of recreational use of marijuana, and criminal prosecution of recreational (and medical) use of marijuana. These approaches are compared, and the latest available data are presented to aid in forming public policy. The effects on youth of criminal penalties for marijuana use and possession are also addressed, as are the effects or potential effects of the other 3 policy approaches on adolescent marijuana use. Recommendations are included in the accompanying policy statement.

Do adolescent smokers experience withdrawal effects when deprived of nicotine

This is the first controlled prospective study of the effects of nicotine deprivation in adolescent smokers. Heart rate and subjective withdrawal symptoms were measured over an 8-hr period while participants smoked normally. Seven days later, participants were randomized to wear a 15-mg (16-hr) nicotine patch or a placebo patch for 8 hr, and they refrained from smoking during the session. Those wearing the placebo experienced a decrease in heart rate across sessions and an increase in subjective measures of nicotine withdrawal. Those wearing the active patch also reported significant increases for some subjective symptoms. Expectancy effects were also observed. The findings indicate that adolescent smokers experience subjective and objective changes when deprived of nicotine. As in previous research with adults, expectancies concerning the effects of nicotine replacement also influenced perceptions of withdrawal.

Efficacy and Tolerability of Pharmacotherapies to Aid Smoking Cessation in Adolescents

Adolescent smoking remains a public health problem. Despite concerns regarding adolescent nicotine dependence, few well-designed smoking cessation studies have been conducted with teen smokers. This is particularly true regarding pharmacologic treatments for nicotine dependence. Currently, pharmacologic aids are not recommended for treating adolescent nicotine dependence, as efficacy has not been shown in this population.This review includes studies that have examined the efficacy of pharmacotherapy for smoking abstinence and/or reduction in cigarette consumption among adolescent smokers who want to quit smoking, laboratory-based adolescent studies that have examined the efficacy of these medications in reducing cravings and/or withdrawal symptoms, and/or studies that have assessed the tolerability of medications for smoking cessation in adolescent smokers. It provides information on the pharmacologic action of each medication, the efficacy of each medication for adolescent smoking cessation, the tolerability of each medication based on reported adverse events, and compliance with the medication protocols.Thirteen relevant articles were identified and included in the review. Nicotine patch (NP), nicotine gum, nicotine nasal spray, bupropion, and varenicline have been studied in adolescent smokers. The adverse events reported in the studies on pharmacology for adolescent smoking suggest that the side effect profiles for nicotine replacement therapy, bupropion, and varenicline are similar to those reported in adult studies. There is some evidence of efficacy of NP and bupropion at the end of treatment (efficacy of varenicline has not been assessed), but none of the medications included in this review were efficacious in promoting long-term smoking cessation among adolescent smokers. It is noted that many of the study protocols did not follow the recommended dose or length of pharmacotherapy for adults, rendering it difficult to determine the true efficacy of medication for adolescent smoking cessation. Future efficacy studies are warranted before recommending pharmacotherapy for adolescent smoking cessation.

Epidemiology of herpes simplex virus type 2 infections in a high-risk adolescent population.

The seroprevalence of infection with type 2 herpes simplex virus (HSV-2) was determined in 135 adolescents detained in a juvenile detention facility. A total of 16% of enrollees were seropositive for HSV-2. Age of onset of sexual intercourse, number of lifetime partners, frequency of condom use, and history of sexually transmitted diseases did not predict HSV-2 seropositivity.

Withdrawal symptoms over time among adolescents in a smoking cessation intervention: Do symptoms vary by level of nicotine dependence?

Nicotine dependence may be expressed differently in teens than in adults. Thus, it may not be sufficient to build diagnostic and cessation treatment strategies for teens based on adult-derived clinical and research data. This is the first study to prospectively examine the development of withdrawal symptoms by level of nicotine dependence among adolescent smokers. Forty-seven adolescent smokers completed nicotine withdrawal symptoms measures during 10 weeks of cessation treatment. Nicotine dependence was assessed at baseline using the mFTQ. Change in withdrawal symptoms over time by level of nicotine dependence was examined via mixed model ANOVA. Nicotine withdrawal in daily adolescent smokers was strongly and prospectively associated with the level of nicotine dependence. Craving was rated as the most problematic symptom at the baseline assessment. The results of this study may help guide the development of future research on diagnostic and cessation treatment strategies for teens.

The impact of marijuana policies on youth

This policy statement is an update of the American Academy of Pediatrics policy statement “Legalization of Marijuana: Potential Impact on Youth,” published in 2004. Pediatricians have special expertise in the care of children and adolescents and may be called on to advise legislators about the potential impact of changes in the legal status of marijuana on adolescents. Parents also may look to pediatricians for advice as they consider whether to support state-level initiatives that propose to legalize the use of marijuana for medical and nonmedical purposes or to decriminalize the possession of small amounts of marijuana. This policy statement provides the position of the American Academy of Pediatrics on the issue of marijuana legalization. The accompanying technical report reviews what is currently known about the relationships of marijuana use with health and the developing brain and the legal status of marijuana and adolescents’ use of marijuana to better understand how change in legal status might influence the degree of marijuana use by adolescents in the future.

The use of norplant and depo provera in adolescents

Although oral contraception is the fertility control method most frequently selected by US adolescents, factors such as inconsistent usage, payment inability, and cognitive-emotional immaturity lead half of these young women to discontinue pill use in the first year. Norplant and Depo-Provera--long-acting hormonal methods that do not require daily compliance--offer the potential to reduce the number of unintended pregnancies among adolescents; however, no data exist on the use of either method in this population. Before Norplant and Depo-Provera can be unconditionally recommended for use by adolescents, numerous research questions must be addressed. For example, it must be determined whether the pregnancy rates and side effects (especially on bone deposition) are the same in adolescents as in adult women. The possibility that adolescents who use long-acting contraception will abandon condom use due to the low risk of pregnancy--and thus place themselves at increased risk of sexually transmitted diseases--must be assessed. For Norplant, the medical-legal issues and responsibilities regarding insertion and removal must be clarified. More research is needed on the impact of partner perceptions on method continuation. It must be determined whether the role of health care providers in ongoing reproductive health promotion will be diminished by the need for fewer clinic visits. Also in need of attention are the demographic factors associated with use of these methods and the impact of their initial high expense on accessibility. If the continuation rates among adolescents of Norplant and Depo-Provera do not exceed that for the pill, the invasiveness and high cost of these methods may outweigh their benefits.