Tomas J. Silber

Confidential health care for adolescents: Position paper of the Society for Adolescent Medicine

• Confidentiality protection is an essential component of health care for adolescents because it is consistent with their development of maturity and autonomy and without it, some adolescents will forgo care. • Confidential health care should be available, especially to encourage adolescents to seek health care for sensitive concerns and to ensure that they provide complete and candid information to their health care providers. • Health care professionals should educate adolescent patients and their families about the meaning and importance of confidentiality, the scope of confidentiality protection, and the limits to confidentiality. • Health care professionals should support effective communication between adolescents and their parents or other caretakers. Participation of parents in the health care of their adolescents should usually be encouraged, but should not be mandated. • Health care professionals and delivery systems should review and, if necessary, revise their procedures (including scheduling, billing, and recordkeeping) to ensure that adolescents’ privacy and the confidentiality of their health information are protected to the extent possible. • Health care professionals should receive education and ongoing training to ensure that they know and understand the state and federal consent and confidentiality laws relevant to the delivery of health services to adolescents and have the skills to apply these laws when delivering clinical care. • Laws that allow minors to give their own consent for all or some types of health care and that protect the confidentiality of adolescents’ health care information are fundamentally necessary to allow health care professionals to provide appropriate health care to adolescents and should be maintained. • Research related to confidentiality and adolescent health care should be placed within a broad research agenda focused on finding ways to increase the numbers of adolescents who receive high quality health care for the wide range of health issues important in this age group. Future research should investigate the impact of providing or limiting confidential adolescent health services on specific health outcomes, inform strategies to address system-level barriers to provision of confidential adolescent services, and define ways that health care professionals can encourage parentteen communication without losing the trust of adolescent patients.

Clinical spectrum of anorexia nervosa in children

A retrospective review of 21 patients ages 12 years and younger (age of onset range 7 to 12 years) with anorexia nervosa showed diagnostic delay in the youngest ones, high incidence of family psychiatric history, a remarkable severity of illness, and positive response to intensive treatment. Additional findings included significant comorbidity, a distinct subgroup with personality disorder and another with features of the “vulnerable child syndrome.” This broad clinical spectrum of anorexia nervosa in children may explain the great variability in outcome. The development of anorexia nervosa in children relates to a complex combination of etiological and trigger factors. Precipitants identified in this study were physical maturation, entry into junior high, loss, or some combination thereof. J Dev Behav Pediatr 14:211–216, 1993. Index terms: childhood anorexia nervosa, comorbidity of anorexia nervosa, vulnerable child syndrome.

American academy of pediatrics policy statements on bioethics: summaries and commentaries: part 3.

1. Mark R. Mercurio, MD, MA* 2. Edwin N. Forman, MD* 3. Rosalind Ekman Ladd, PhD* 4. Marilyn A. Maxwell, MD* 5. Lainie Friedman Ross, MD, PhD* 6. Tomas J. Silber, MD, MAAS* 1. *On behalf of the American Academy of Pediatrics Section on Bioethics The American Academy of Pediatrics (AAP) has a strong and longstanding interest in the field of bioethics and periodically publishes policy statements pertaining to specific ethical questions relevant to pediatrics. The subjects addressed cover a wide range of topics, from parental refusal of immunization to the care of critically ill children. These policies initially are authored by the AAPs Committee on Bioethics and undergo extensive internal review by other committees prior to publication. This article is the third in a series of three intended to familiarize the reader with many of the AAP policies currently in place that address issues in bioethics. In this series, 16 policies published by the AAP are summarized, each followed by a brief commentary. The commentaries are intended to address, at least on a cursory level, some of the ethical principles underlying the policies. Some briefly point out possible alternative viewpoints. The policies referenced in this article represent the efforts of various committees and committee members over the years. Each of the summaries presented here, as well as the commentaries that follow, represent the work of an individual serving on the Executive Committee of the Section on Bioethics, as indicated at the beginning of each summary. Understandably, some of the wording of these summaries is taken directly from the published policies. When quotations are used within a summary and not referenced, it can be assumed that the quote is taken directly from the policy being summarized. For ease of use, the references for each policy are provided with each individual summary and commentary. Part 1 of this series reviews: (1) 1. Informed Consent, Parental Permission, and Assent in Pediatric Practice 2. Religious Objections to Medical Care 3. Responding to Parental Refusals of Immunization of Children 4. Sterilization of Minors With Developmental Disabilities 5. Human Embryo …

Clinical Trials in Pediatric Traumatic Brain Injury: Unique Challenges and Potential Responses

In order to optimize pediatric traumatic brain injury translational and clinical research, scientific and ethical challenges need to be recognized and addressed. Having recently conducted a multisite phase II safety/feasibility trial of magnesium sulfate as a neuroprotective agent, we supplement our own experience by a mini review of similar studies, identifying challenges and possible responses from the perspective of families, investigators, funding agencies and society.

Somatization disorders: diagnosis, treatment, and prognosis.

1. Tomas Jose Silber, MD* 1. *Professor, Department of Pediatrics, The George Washington University School of Medicine and Health Sciences; Director, Adolescent Medicine Fellowship Program, Childrens National Medical Center, Washington, DC. After completing this article, readers should be able to: 1. Identify the various manifestations of somatization disorders in children and adolescents. 2. Understand the association of psychosomatic disorders with personality traits and stressors such as physical and sexual abuse, bullying, parental anxiety, and pressure for a child to perform. 3. Recognize secondary gains of somatization disorders. 4. Explain why it is necessary to focus on school attendance and the management of school avoidance. 5. Develop a partnership with patients and their parents to address the symptoms of a somatization disorder. 6. Plan the treatment and management of somatization disorders Children and adolescents suspected of having somatization disorders present a challenge to pediatricians. Clinicians are often concerned about “missing something,” while also worrying about alienating both the patient and the family when explaining the condition. Many clinicians are baffled by the onslaught of symptoms, feel frustrated by the never-ending recurrent complaints, or become annoyed by the time consumed in caring for patients who might be perceived as “not really being sick.” The research on somatization disorders is neither easily available nor conclusive. Moreover, paradoxically, although somatoform disorders in children have been defined as psychiatric disorders, psychiatrists seldom see these patients. By default, most children and adolescents who have symptoms are seen by primary care physicians. (1)(2)(3)(4) This review focuses on understanding, assessing, and developing strategies for managing somatization disorders. Somatization is “the tendency to experience and communicate somatic distress and symptoms unaccounted by pathological findings.” (5) However, it must be stressed that somatization can coincide with another illness. Somatization is deemed to exist in conjunction with a physical illness whenever the physical …

Eating disorders in adolescents and young women with spina bifida

This is the first report of the association of spina bifida and eating disorders. Five patients were diagnosed rather late in the course of their illness. They all had been overweight premorbidly and had been urged to lose weight for years in order to improve their mobility. As they dieted, they experienced their weight loss as a source of power that could somehow compensate for their losses and neurologic limitations. They responded to a multidisciplinary intervention. Clinicians taking care of patients with spina bifida need to be cognizant that they may be at risk of developing an eating disorder. Such awareness should influence the quality of nutritional counseling (prevention aspect) and the clinical assessment of sudden weight loss (early intervention).

Process, Promise, and Pitfalls of Collaborative Treatment of Anorexia Nervosa in an Adolescent Patient

This case study illustrates the process and challenges of multidisciplinary treatment of an adolescent with anorexia nervosa. A biopsychosocial model of anorexia nervosa is presented. This case study demonstrates the need for a multidisciplinary approach in which a physician, psychotherapist, and dietician with training in the treatment of eating disorders collaborated in an outpatient setting. This case was complicated by comorbid obsessive-compulsive personality features and limited adherence with treatment recommendations. A 1-month hospitalization on an inpatient unit is described to illustrate the importance of maintaining communication among all health care providers during the transition into and out of the hospital. This case demonstrates the importance of avoiding the pitfalls of splitting or scapegoating among the treatment team.

Informed consent and the implications for statutory rape reporting in research with adolescents

Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content.

Researchers Have an Ethical Obligation to Disclose the Availability of Off-Label Marketed Drugs

Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content.