Abstracts read by title only at the Annual Meeting of the Society for Adolescent Medicine October 1982

142

ABSTRACTS

JOURNAL OF ADOLESCENT HEALTH CARE Vol. 3, No. 2

CHLAI4YDIA TRACHOMATIS: INCIDENCE AND CLINICAL CORRELATES IN TEEN CLINICS. M.A.Shafer, B.Pelaquin, P.Dole, A.Beck, J.Shalwitz, J.Schaehter, R.Sweet, Dept. of Pediatrics, and Obstetrics/Gynecology, Univ.of California,San Francisco, California. Sexually active adolescent females (n=302) were screened for Chlamydla traehomatis(Ct), Neiserria gonorrhoea(GC), and cervical cytology in a general teen clinic and family planning clinic. The mean age was 17.0 yrs(r=12-21), and ethnic distribution was Black 40%; White 20%; Hispanic 22%; and other 8%. Reasons for visits were: 64%-birth control; 20%-infectlon related; 15%-other. Ct was isolated from 42(14%) subjects and GC was isolated from 15(5%) subjects. C t w a s associated wlthGC(p=.001): 8(53%) subjects with G C also had __Ct" Also, 22(54%)Ct subjects had inflammation on pap smears (p=.O02). In addition, the following data was concurrently collected on 169 subjects at time of visit: symptoms and signs of lower genital tract infection, vag. pH and wet mounts. 15(65%)C__tt subjects had a clinical Dx of vaginitis (p=.03). ii(46%)C_~t subjects complained of abdominal pain (p=.04). 4(2%) subjects had acute salpingitis: 1-C t; I-G__CC; 2-Ct+GC. Chlamydia was not significantly associated with race or type of contraceptive. These results show that Chlamydia trachomatis is a common sexually transmitted disease in adolescent females and should be routinely cultured and treated. Because of a high correlation between G_~Cand C t, all G C patients should be treated with tetracycline even where chlamydia cultures are unavailable, unless otherwise contraindicated.

Abstracts Read by Title Only at the Annual Meeting of the Society for Adolescent Medicine October 1982

ADOLESCENTS' SATISFACTION WITH PEDIATRIC NURSE PRACTITIONERS AS COMPARED TO PHYSICIANS FOR PRIMARY HEALTH CARE. L.A.Gerard & M.McGrath. Div. of Adolescent Medicine, Childrens Hospital Medical Center, Cincinnati, Ohio Adolescents' acceptance of nurse practitioners as health providers has not been previously assessed. A survey questionnaire was administered to determine adolescents' ability to differentiate between nurse practitioners and physicians, adolescents' satisfaction with nurse practitioners and physicians as health providers, and the characteristics viewed as desirable in these health care providers. The study consisted on thiry-two adolescents who had been seen for at least three previous visits at an adolescent clinic. The adolescent had to be seen at least once by a nurse practitioner and at least once by a physician as primary care provider. Only five of thirty-two adolescents correctly defined nurse practitioner, while twenty of thlrty-two adolescents correctly defined physician. This suggests that the role of the physician is more clearly understood by adolescents. The adolescents were satisfied with the care received from both nurse practitioners and physicians. Characteristics identified as desirable by the adolescents were similar for both physicians and nurse practitioners. The study suggests that nurse practitioners are not only acceptable to adolescents, but when functioning in a practitioner role are not differentiated from physicians by most adolescents.

AGE AND ATTITUDES IN TEEN PELVIC EXPI4S. D.N. C o l l i n s C.A. McDonald, Dpt. o f Adolescent Med.p C h l ! d r e n ' s Hosp. t Oakland s CA. The a p p r o p r i a t e time t o perform a p e l v i c exam in n o n - s e x u a l l y a c t i v e (NSA) adolescents Is problematic. This study assessed how adolescent women f e l t about p e l v i c exams. I t was performed from 11/81-5/82 on teens attending an adolescent clinic serving primarily C80%) low income inner clty youth, Two self-adminlstered questionnaires were used: Q1-patlents ,who had never had a pelvic; Q2-patientswho had. q2 was f l l l e a o u t a f t e r the exam. S l x t ¥ - f l v e aoolescents participated; 40 were s e x u a l l y a c t i v e (SA) and 25 were NSA. The SA group had a s l g n l f l c a ~ t l y h l g h e r _ c h r o n o l o g l c age CCA) X=16.2) and gynecolocloc age CGA) (X=4.1)t than the N ~ group (CA X = I 3 . 5 ; GA X=2.4~ (p=.00Z). F i f t y - s i x percent o f the teens were SA before t h e i r f i r s t p e l v i c exam. A l l o f these p a t i e n t s woulo nave been encouraged t o have a p e l v i c exam I f a G A o f 2 had been used as a guide. Of the 63 responses given on Q2 as t o what the p a t i e n t would t e l ] t h e i r f r i e n d s ~ o u t p e l v i c examsp 90~ were p o s i t i v e . P o s l t l v e o r negative f e e l l o g s about t h e exam were independent o f the nurrber o f exams the p a t i e n t had had o r whether they were SAo Only 6% o f the NSA teens who had had t h e i r f i r s t p e l v i c said t h a t i t would not be e a s i e r a f t e r a p e l v i c t o seek b i r t h c o n t r o l . Teens are often SA before t h e i r f i r s t p e l v i c . We recomuend f u r t h e r studies t o assess the CA and GAof onset o f sexual a c t i v i t y In various populations. Examscould then be encouraged as p a r t o f r o u t i n e care a t an age preceding onset o f SA. Our date suggests t h a t In t h i s pppulatlonp a n x i e t y about s u b j e c t i n g adolescents t o p e l v i c exams too e a r l y Is unwarranted,

September 1982

ALTERED BODY PERCEPTIONS OF OBESE ADOLESCENTS. R.H. DuRant, C.W. Linder, and S. Jay. Dept. of Pediatrics, Med. College of Georgia, Augusta, GA. Similar to anorexia nervosa, one symptom associated with obesity in some adolescents is an altered body perception. The objective of this investigation was to study altered body perceptions in a national representative sample of obese adolescents. Of 6722 adolescents in Cycle III of the Health Examination Survey, ii. 7% (N= 789) were classified as slightly obese (120%-139% relative weight), 3.9% (N=264) as moderately obese (149%-159% relative weight) and 1.8% (N=I21) as severely obese (> 160% relative weight) (90%-109% =normal). Of obese adolescents with > 120% relative weight, 1.8% viewed themselves as underweight or thinner than most other adolescents, suggesting severe altered body perceptions. Black males represented a significantly (p < 0.01) larger proportion of this group, followed by white females. Twenty-three percent viewed themselves as normal weight, having the same weight as most other adolescents; indicating slightly altered body perceptions. A higher (p < 0.01) proportion of this group were white males. Interestingly, two percent desired to gain more weight. Seventy-five percent had correct perceptions of their weight. Of parents who correctly viewed their obese children as overweight, 94.2% of their children also saw themselves as overweight. Of parents who viewed their obese children as underweight or normal weight, only 33.8% of their children had correct perceptions of their weight. These findings suggest that a phenomenon similar to anorexia nervosa, "obesity nervosa", may be found in up to one fourth of obese adolescents. This may also be reinforced by an altered perception of the adolescent's weight by their parent.

AMENORRHEA IN THE ADOLESCENT. G.P. G i d w a n i . Dept. of Ped. and Adolescent Gynecology, Cleveland C l i n i c Foundation, Cleveland, Ohio. Can the d i s t r e s s i n g symptoms of amenorrhea in the young g i r l be e a s i l y evaluated by the primary physician t a k i n g care of t h i s adolescent? F i f t y charts of non-pregnant p a t i e n t s coming to the adolescent g y n e c o l o g i s t ' s o f f i c e at the Cleveland C l i n i c in the year 1981 were reviewed. T h i r t y - s e v e n p a t i e n t s had secondary amenorrhea and 13 p a t i e n t s had primary amenorrhea. Of the primary amenorrhea group, about 69.0% (9 p a t i e n t s ) had chromosomal a b n o r m a l i t i e s or ov arian f a i l u r e with chromosomally competent ovaries, 15.4% (2 p a t i e n t s ) had m u l l e r i a n agenesis, and of the remaining 2 p a t i e n t s , the reasons were weight loss and anovulation. Twenty-one p a t i e n t s (57%) in the secondary amenorrhea group had symptoms r e l a t i n g to strenuous e x e r c i s e or e a t i n g d i s o r d e r s . Eight p a t i e n t s in t h i s group (21.4%) had a n o v u l a t i o n secondary to p o l y c y s t i c ovarian disease or i t s v a r i a n t s , 4 (10.8%) p a t i e n t s had premature ov arian f a i l u r e , and the remaining 4 p a t i e n t s had 2 o amenorrhea due to h y p o p i t u i t a r i s m , chromosome aberr a t i o n s , hypogonadism, and adrenal carcinoma. Amenorrhea can t h e r e f o r e be a symptom r e l a t e d to varied causes which m~y be r a r e l y l i f ~ t h r e a t e n i n g . A c l i n i c a l examination w i l l help d e l i n e a t e the p a t i e n t s t h a t need r e f e r r a l o u t s i d e the primary p h y s i c i a n ' s office. An A d o l e s c e n t H e a l t h S e r v l e e in S u b u r b i a : How is it U t i l i z e d ? M.Fisher, A.Marks. Depts. of Peds. C o r n e l l U n i v . M e d . C o l . . N e w Y o r k C i t y a n d N o r t h S h o r e Univ. H o s p . , M a n h a s s e t , Hew York The initial 2 yearsCMarch'80--Feb.'82)of utilization of a general Adolescent Health ServfceCAHSl in a m i d d l e class suburb were compared to t h e u n m e t h e a l t h n e e d s o f 649 un-seleeted adolescents in t h e s a m e c o m m u n i t y surveyed by questionnaire in F e b . ' 8 0 . A H S u t i l i z a t i o n ires: New Total %16-18 % %Referred Patients Visits Year Olds Female by Friend Ist y e a r 150 63~ 71% 77% 28% 2nd year 185 1023 65 84 66 Patients differed (p,(0.001) from respondents in a g e (mean 1 6 . 9 v s 1 5 . h ) , s e x ( 8 1 % , 5 2 % female), parents' education(29%,46% college grads),having a p r i v a t e M;D. (75%, 90%), and health-risk behaviors(for age 1 6 - 1 8 : s m o k i n g 7 0 % , 2 5 % ; d r i n k i n g 6 1 % , 3 ~ % ; d r u g u s e 7 3 % , 4 2 % ; s e x u a l intercourse 85%,33%). F u l l y 72% o f p a t i e n t s p r e s e n t e d for sexuality-related care, e n d o n l y 1 0 % for p r o b l e m s w i t h weight, depression or s u b s t a n c e a b u s e . Yet r e s p o n d e n t s c i t e d all 4 of t h e s e c o n c e r n s as t h e i r m a j o r u n m e t health needs. Common medical problems(eg.cheek-ups,infeetions) c o m p r i s e d 1 8 % of A H S i n i t i a l v i s i t s , y e t for s u c h m a t ters respondents readily utilized private physicians. These data indicate this new and experimental suburban A H S is m a i n l y u t i l i z e d b y a s u b - g r o u p of h i g h e r risk' f e m a l e s for s e x u a l i t y - r e l a t e d care, d e s p i t e o t h e r u n m e t n e e d s in t h e p o p u l a t i o n , a n d a c c e s s to p r i v a t e care.

ABSTRACTS

143

ANOREXIA NERVOSA (AN) AS A COMPLICATING FEATURE OF INFLAMMATORY BOWEL DISEASE (IBD). D. Hardoff, M. Nussbaum, I.R. Shenker, A. Angelides, Dept of Pediatrics, Long Island Jewish-Hillside Medical Center, New Hyde Park, N.Y. 11042 !BD frequently has its onset during adolescence and is often preceded by or associated with an emotional or stressful event in the adolescent's life. Most patients respond to medical therapy consisting of a regime of Azulfidine and Steroids. Approximately 70-75% of patients do not respond to intensive medical therapy. These patients often have chronic courses of multiple exacerbatior~ of their disease. Poor responders to medical regimens may have more diffuse disease than others. We have, however, seen two patients with classic characteristics of AN complicating IBD. The patiehts appear to have exacerbations of their disease, including weight loss, diarrhea, anemia and amenorrhea. The patients can be differentiated by obtaining an appropriate history focusing on the patient's body image, by close observation of the patient either in hospital or by parents to ascertain the presence of self induced vomiting or laxative abuse. Physical examination and diagnostic tests may show minimal activity of the disease as is seen on barium studies, sigmoidoscopy, and erythrooyte sedimentation rate. Both patients were treated medically for IBD without satisfactory results. When specific psychotherapy and behavior modification was directed towards the anorexia a 20 lb. weight gain occurred in both patients without changes in the medical regimen. Patients with inflammatory bowel disease who are doing poorly should be evaluated for anorexia and treated appropriately. Persistent weight loss, body image disturbance and hyperactivity are clues to a concommitant diagnosis of AN with IBD.

ASSESSING AGE, A C R D ~ I C PE~FOI~NCE, SEXURL EXPERIENCE AND PARENTAL CONSENT ISSUE AMONG SOUTNEASTEENMICHIGAN ADOLESCENTS.

"A NEW pOPULATION." T.JA Caison-~orev. M.

~othr~d Div. of Adolescent Medicine, N e n r y F o r d Hospital, Detroit, Michigan. Southeast Michigan is the focus of a new thrust toward adolescent health care. A study was undertaken to assess age, academic performance, sexual experience and the parent consent issue regarding oral contraception. A questionnaire was administered to i00 adolescents age 12-20 yrs a t 3 Southeast Michigan clinics. The population was randomly selected, consisting of 82 females and 18 males. Age distribution was as follows: 65% age 15-17 yrs, 32% age 18-19 yrs, 6% age 14 yrs, others 2% or less. Statistics are as follows: Academic performance (100% response) 4/100 A students, 38/100 B students, 49/100 C students, 5/100 D students, 5/100 Drop outs. First Sexual Experience (99% response) Of 69/82 *SA females, average age of 13 yrs; Of 17/17 males, 13.6 yrs was average onset. Birth Control (85% response) Male: 10/16 no protection, 6/16 condoms. Females: 39/69 The Pill, 23/69 noprotection, 7/69 other. Pregnancy/Abortlon (69% female response) 33/ 6 9 1 pregnancy, 2/33)I preganacy, 21/89 1 abortion, 1/21~I abortion. Parental Consent for Oral Contraception (34% female response) 29/34 prefer parental knowledge, 3/34 would not. Conclusion: Our population consisted of average students. Despite our 3 yr effort, roughly 50% of our *SA females had a pregnancy prior to using birth control. We will therefore enhance our patient education and contraceptive efforts. It is hoped that this will effect a decrease in the initial pregnancy/abortion rate. A surprise was that females using oral contraception preferred parental Knowledge. *SA = sexually active.

AUDITORY FUSION IN LEARNING DISABLED AND NORMAL ADOLESCENTS. M.MeGrath, L.Isaacs, D.Horn, and R.Keith. Divs. of Adolescent Medicine, Univ. of Cincinnati and Children's Hospital Medical Center, Cincinnati, Ohio Although previous work suggests that an auditory fusion test may differentiate children with educational problems due to temporal impairments, no investigations have been done using an adollescent population. The auditory temporal integrity in a population of 15 adolescents with known language/learning disabilities was compared with a population of 15 normal adolescents matched for mental age and Tanner rating. Subjects who ranged in age from 9 to 18 years, had normal middle ear functioning as measured by acoustic impedance tests and normal sensitivity to pure tones. The learning disabled adolescents had undergone multidisciplinary diagnostic evaluation and were all receiving educational remediation. All subjects were assessed for height, weight and Tanner rating and were administered the WISC-R and the Columbia Test of Mental Maturity. Results indicated that normal adolescents exhibit auditory fusion at shorter time intervals than learning disabled adolescents and that signal intensity affects fusion for all groups. Since resuits suggested that several of the learning disabled adolescents exhibited a large number of inconsistent response zones, traditional fusion points were not judged to provide a valid basis for comparison. Further analysis using nontraditional psychophysical methods was required and will be discussed.

144

ABSTRACTS

BIFLIMIA IN COLLEGE WOMEN: PREVALENCE AND PSYCHOPATHOLOGY.M. Collins, J. Kreisberg, M. Pertsehuk, S. Fager. Student Health Service, Dept. of Psychiatry, University of Pennsylvania, Phila. Pa. A pilot project was designed to determine the prevalence of bulimia (B) in a sample of freshman college students and to compare their psychological profile with a normal control (NC) group. A four-part questionnaire was distributed to an entire freshman dormitory of 270 students. The first part requested medical history, the second part assessed eating and purging behavior, the third was the Eating Disorders Inventory (EDI), a standardized clinical evaluation tool, and the fourth part the SCL-90-R, a ninety item self report scale providing standardized measures of nine psychological symptom categories. Eighty-eight percent of the questionnaires were returned of which I00 were completed by female students. Nine (9%) bulimic women were identified by the criteria set forth in the DMS-III. Scores of the bulimics for the SCL-90-R subscales of depression, phobic anxiety and psyehoticism were significantly higher than the scores of normal controls (Chi-square; p < . 0 5 ) . Group means for each of the 8 EDI subscales for both bulimics and normal controls in our sample were comparable to respective group norms established in the standardization of the EDI. Other results from the survey revealed differences in history of individual psychiatric treatment (NC=I0%, B=22%) and history of family psychiatric treatment (NC=30%, B=11%) while current treatment was comparable (NC=8.9%, B=II%). The results of this survey suggest that bulimic women who are non-anerectic may have significant underlvin~ psychopathology despite their apparently normal functional s~atNs.

COMBINING RESEARCHAND TREATMENT OF ANOREXIA NERVOSA (AN) IN A CLINICAL RESEARCHCENTER (CRC). R.E. Kreipe, B. L i p i n s k i , C. Hodgman, Depts. of Peds. & Psychiatry, Univ. of Rochester, Strong Mem. Hosp. Med. C t r . , Rochester, N.Y. Behavior modification to induce weight gain in AN has been called "perilous" by Bruch. We report key findings of a successful behavioral regimen combining treatment and metabolic studies f o r I0 patients with AN (one with vomiting) in a CRC. All patients adjusted s a t i s f a c t o r i l y to the protocol and met the discharge weight goal in 26 to 64 days. The research team consisted of a pediatrician, a p s y c h i a t r i s t and the CRC s t a f f . Each patient received a prescribed, constant d i e t f o r 6-day periods, during which metabolic balance studies were performed. Intake was increased by 300 Cal/day at the end of each period i f weight gain was not at least 0.2 kg/day. The s t a f f accompanied the patient to other areas of the hospital; the bathroom door was locked; and complete bed rest was enforced f o r 24 hours i f any day's food was not completely eaten. We were encouraged to find that: I ) patients perceived the cont r o l l e d , consistent research protocol as supportive 2) p a t i e n t ' s were minimally "manipulative" due to the f i n e l y regulated environment of the CRC, that contrasted b e n e f i c i a l l y with t h e i r adverse home environments 3) the on-site metabolic kitchen added f l e x i b i l i t y and p a l a t a b i l i t y to the d i e t 4) the d i e t i t i a n ' s professional advice aided in the acceptance of the d i e t and 5) a nurturant research team could i n i t i a t e therapeutic changes in the patients and families while conducting c l i n i c a l studies. These findings suggest important treatment principles f o r patients with AN in other settings. DEVELOPING A PROGRAM TO PROMOTE COMPETENCY AND CONFIDENCE IN MENTALLY ABLE ADOLESCENT UNDERACHIEVERS. M.R. Crittenden, M.Kaplan, C.E.Irwin, Dept.of Pediatrics, University of California, San Francisco. The inability of potentially able youth to perform well in school or on jobs has received growing attention from the media, educators, employers, and parents. Review of our patients in a general adolescent clinic indicated that 33% in advanced classes had somatic, academic, behavioral or written language problems. To promote their development, we offered a program (1980-82) to improve study skills, written language and self confidence. Adolescents (n=16), grade 6-9, who scored above average on ability/ achievement tests but performed lower in school were chosen. The program consisted of 8 weekly sessions, 2 hrs.each, combining discussions of time-behavior management problems, structured lessons and individual help in making decisions about tasks. Pre-post tests given to the 16 subjects, 1980-81, improved significantly in study skills (Cornell Inventory:goal orientation p ~.05; activity structure, p~.005; scholarly skills, p ~005), written composition (Myklebust Picture Story: productivity, p<.005; syntax, p<.025), and self confidence (p<.O05). Areas not covered in the course (Cornell Inventory: lecture, text, exam mastery) or beyond the developmental level of the subjects (Myklebust abstract writing, grade 6-7) did not improve. Initial analyses of 22 subjects, 1981-82, show similar results. The project led 5 schools to request in-service workshops, increased clinic referrals, and expanded our services to youth with special and unidentified needs in most health settings.

JOURNAL OF ADOLESCENT HEALTH CARE Vol. 3, No. 2

DRUG USE: NORFOLK DETENTION HOME VS. NORFOLK PUBLIC SCHOOLS. R.D. Rohn, J. Southall, Dept of Ped., Eastern Virginia Med Sch, Norfolk, Virginia. Objectives: (i) To compare the use of drugs in youth of the Norfolk Detention Home (NDH) with that of the youth in the Norfolk Public School System (NPSS) and (2) to compare these usage rates to those of other detention facilities or other studies. Methods: 874 subjects from NDH were interviewed during their stay, from 1977-1981, for any drug history and frequency of use. A random representative sample of 2471 NPSS students responded to a questionnaire on drug usage during the academic year 1977-78. A comparison of drug use frequencies was obtained between NDH and NPSS using chi square analysis. Similarly, comparisons between race and sex data at NDH were done. Results: Modal age (15.1 yrs) and racial mix (56% Black vs 44% White) were similar for NDH and NPSS. Male to female ratio was greater at NDN (70:30 vs 50:50 at NPSS). Cigarrette smoking (67% vs 50%)*, marijuana smoking (50% vs 36%)* and nonprescription drug use (11% vs 6.5%)* were significantly more frequent; yet alcohol use (53% vs 64%)* and no drug history (35% vs 64%)* were a significantly less frequent occurrence between NDH and NPSS youth respectively (*P<0.01). In general at N-OH, prevalence was greater White vs Black and female vs male. The NDH statistics show slightly greater use than the New York City detention facility data (1977) despite an overall decline in usage at NDH over the 5 year period. Conclusion: In this urban area, NDH drug usage data are not reflective of the "general" teenage population. Youth at a detention facility are more likely to be drug users than their school-going peers.

THE EFFECT OF AN ADOLESCENT ROTATION ON RESIDENTS' ATTITUDES. W.E.Bohannon, R.E.Harpin, S . P h i l l i p s & F.P. Heald. Dept. of Ped., Univ. Md. Sch. Med., Balto. Md. The impact of a required I-month adolescent rotation on residents' a t t i t u d e s regarding adolesce~t patients was assessed. The 42 residents completed a 46 item questionnaire pre- and postrotation. Residents rated themselves on: knowledge of developmenal stages and common disorders, comfort in managing and r e l a t i n g to, and i n t e r e s t and enjoyment w ~ w i t h teenage patients; and described the " t y p i c a l adolescent patient" with bipolar rating scales. Three groups were formed: those residents, who at postt e s t i n g , showed an Increase (n=13), a Decrease (n=9),or No Change (n=20) in the percentage of practice they would l i k e to devote to teenagers. These groups were found to d i f f e r on: (a) comfort in relating to teenage patients (F:3.47, 2<.05), (b) perceived competence in dealing with adolescent sexuality (F=6.40, 2<.005), (c) the degree to which they view adolescents as i n t e l l i g e n t (F= 3.73, ~.<05), and (d) the degree to which they view adolescen~ as self-assured (F=4.02, 2<.05). The Increase group became more comfortable in reTating to teenage patients (~<.02) and made greater gains in preceived competence in dealing with adolescent sexuality r e l a t i v e to the Decrease group(2,.05). The Increase group also viewed adolescents as more i n t e l l i g e n t and self-assured at the end of the r o t a t i o n , while both the No Change (~<.01) and Decrease (~<.001) groups viewed them as less i n t e l l i g e n t and, for the Decrease group, as less self-assured (2<.001). In Summary adolescent health care may be q u a l i t a t i v e l y and q u a n t i t a t i v e l y improved by placing greater training emphasis on these issues.

"ENTRANCE INTO ADOLESCENT PROSTITUTION (MALE & FEMALE)" D. Boyer, G. Robinson, R.W. Deisher Departments of Psychiatry and Pediatrics University of Washington, School of Medicine Seattle, Washington This research was generated from previous studies indicating that invovement in p r o s t i t u t i o n began during adolescence and from the s t a r t l i n g increase in adolescent p r o s t i t u t e s , both male and female. Data were obtained from I00 adolescent female prost i t u t e s , I00 non-sexually labeled female delinquents, 47 adolescent male prostitutes and 50 non-sexually labeled male delinquents. Ethnographic research, both empirical and descriptive provided information on the process of entrance into p r o s t i t u t i o n . Relationships were established between entrance into p r o s t i t u t i o n and early sexual experience, gender s o c i a l i z a t i o n , exposure to p r o s t i t u t i o n , and associated drug and crime involvement. The findings strongly support sexual labeling as i n f l u e n t i a l in the d r i f t towards sex role deviance.

September

1982

EVALUATION OF A PARAPROFESSIONAL TRAINING PROGRAM IN COUNSELING ADOLESCENTS. D.W.~affner,. #nd J . L . Katz, Planned Parenthooo of Metropotltan Wasnlngton, Washingt?n, D.C. In order to evaluate a federally funded program to improve counseling services to adolescents, a 57 item Likert scale questionnaire was developed. The questionnaire was administered to all staff counselors prior to the implementation of an intensive training and quality assurance program, and was repeated at the end of the first year. The training curriculum and the standards developed for counseling adolescents are presented. Dramatic improvements occurred in counselors' attitudes and behaviors as a result of the training, standardization, and quality assurance program. In 1981, only 2% of the staff explored with adolescent clients the decision to be sexually active. In 1982, 65% of the staff initiated discussions about sexual activity. In 1981, only 21% used role playing as a counseling technique. As a result of the program, 80% now rehearse problem situations with teen clients. In 1981, only one third of the counselors encouraged adolescents to talk with their families about sexuality issues; in 1982, 85% encouraged family involvement. In 1981, 46% of the counselors inappropriately assumed that teenage clients had already had intercourse; in 1982, only 15% made this assumption. An intensive training program and quality assurance system can improve the quality of counseling provided to adolescents by paraprofessionals.

ABSTRACTS

145

HIGH PROTEIN DIET IN THE TREATMENT OF ANOREXIA NERVOSA. G.B. Forbes, B. L i p i n s k i , R.E. Kreipe. Dept. of Peds., Univ. of Rochester, Strong Mem. Hosp. Med. C t r . , Rochester, New York. High protein diets have been advocated in the treatment of undernutrition. To assess t h e i r usefulness in the treatment of anorexia nervosa, we provided 4 patients with a high protein d i e t (20% protein cals) and 4 patients with a low protein d i e t (10% protein cals) on the Clinical Research Center; all had metabolic balances of N, Ca, K, P, sequential K-40 counts, BMRs and routine lab studies. The high protein d i e t produced higher values of BUN, urinary Ca, and a s l i g h t rise in serum albumin. The low protein d i e t did not result in a change in these values. No patients had any subnormal values at any time. Compared to the low protein d i e t , the high protein d i e t did not augment weight gain, % of weight gain due to lean body mass (av. 76%), N retention per unit weight gain, rise in BMR, or the sense of well-being. The high protein d i e t did not hasten the recovery from leukopenia, nor did i t prevent the s l i g h t drop in hematacrit seen during recovery. The caloric cost of weight gain was the same f o r both diets (av. 6.4 Cal/gm gain). Additional findings of i n t e r e s t were I ) the high % of weight gain a t t r i b u t a b l e to lean body mass; 2) K retention by balance exceeded K retention by K-40 counting by 2 to 16 meq/day. We conclude that high protein diets o f f e r no advantage in the r e n u t r i t i o n of patients with anorexia nervosa.

FACTORS EFFECTING ALTERED BODY PERCEPTIONS OF UNDERWEIGHT ADOLESCENTS. R.H. DuRant, S. Jay, and C.W. Linder. Dept. of Pediatrics, Medical College of GA, Augusta, Georgia. One of the symptoms that is often manifested by adolescents with anorexia nervosa is an altered body perception. The purpose of this study was to examine altered body perceptions of a national representative sample of underweight adolescents. Of 6722 adolescents in Cycle III of the Health Examination Survey, 3.8% (N=258) were classified as severely underweight (relative body weight J 79%) and 15.1% (N=I017) as underweight (relative body weight 80%-89%) (Normal=90%-109%). Of adolescents with < 89% relative weight, 1.4% viewed themselves as overweight or heavier than most adolescents, indicating severe altered body perceptions. A significant (p < 0.001) proportion (84.6%) of these were white females. Forty-two percent viewed themselves as normal weight, suggesting slightly altered body images. When controlling for the race and sex distribution of the sample, a greater (p < 0.01) proportion of this group were also white females. Four percent of the underweight adolescents desired to be thinner than they were. Fifty-seven percent had correct body perceptions. There was a significant (p < 0.05) association between an adolescent's body perception and their parent's perception of the adolescent's relative body weight. The findings suggested that altered body perceptions in underweight adolescents occur predominantly in white females and are related to and possibly reinforced by their parent's perception of the adolescent's weight.

HOW DO PRACTICING PRIMARY CARE PHYSICIANS (PPCPs) VIEW THEIR ROLE IN PROVIDING SEX EDUCATION? T.M.Anglin and A.W.Wolf,Depts. of Ped. and Psyeh.,Cleveland Metro.Gen. Hosp./Case Western Reserve Univ. Sch. of Med., Cleveland, Ohio. Sex education is again becoming a controversial issue in this country. A random sample of 150 pediatricians (PED) and family practitioners (FP) was interviewed to determine physician attitudes toward inclusion of sex education as part of health care of young patients (PTS). It was found that 89% of PPCPs thought it at least somewhat appropriate for them to provide sex information to their PTS, and that 84% of PPCPs declared feeling at least somewhat comfortable when discussing sexual issues with their PTS. A 40-point index composed of i0 common topics in sex education was sorted into 5 components using factor analysis. The identified factors explained 79% of total index variance, and represented themes of sexuality,puberty,risks ~f sexual activity,moral values regarding sexuality,and sexual deviance. Analyses of variance demonstrated that PPCP sex and age did not influence their attitudes toward providing sex education. FP had a significantly lower overall mean index score than did PED (p<.Ol), although specialty certification did not influence PPCP attitudes. PPCPs who engaged in solo practice scored lower than did PPCPs practicing in either partnership (p~.05) or group (p~.01) settings. PPCPs born in Europe displayed more conservative attitudes toward providing sex education than did PPCPs born in the United States (p<.05). Although the majority of PPCPs consider sex education an appropriate part of their physician role in managing the health care of young PTS,s~gnificant attitudinal differences exist based on demographic predictors.

GARDNERELLA VAGINALIS IN ADOLESCENT FEMALES.J.Shalwltz, P.Dole,M.Shafer,C.E.Irwin,R.Sweet,M.Ohm-Smith,J.Wood, A.Beek,Dept. of Pediatrics and Obstetrics/Gynecology, University of California, San Francisco, California. To assess the association of Gardnerella vaginalis(Gd) and non specific vaginitis(NSV) in adolescent females,93 subjeets(Ss) in a General and Gynecology Adolescent Clinic were cultured vaglnally for G d d u r i n g routine pelvic exams. Mean age was 17(range = 13-21). 82(87%) Ss were sexually active(SA). Reason for visit: 44(47%)-symptoms of lower genital tract infection(LGTl);26(28%)birth control;23(25%)-other. Information recorded at time of visit included: chief complaint, sexual history, symptoms/signs of LGTI, vaginal pH, and wet mounts. Gd positivity(Gd+)was defined semiquantitatively as moderate/many colony growth and Gd- had no/few colonies. NSV was diagnosed with i sign or symptom of LGTI and 25% clue cells per high power field x3 on wet mount. Results: 42(45%)of Ss had Gd+. Associated with Gd+ were: sexual activity in 41(98%)(p=.01);vaginal pH>5.0 in 20(48%)(p=.04); complaints of vaginal odor in 14(33%)(p=.03). Of 16(20%)SA Ss complaining of vaginal odor, 5 were diagnosed with NSV, 1 with trichomonas, i with candida, and 9 had no etiology for vaginitis on wet mounts~15(94%) had Gd+. Gd+ was not associated with the presence of clue cells. Associated with the 15(18%)SA Ss diagnosed with NSV were: vaginal pHi5.0 in 12(80%)(p=.003);complaint of vaginal odor in 5(33%) (p=.02); vaginal odor noted by clinician in 7(47%)(p=.002).We conelude that vaginal pH and subjective complaint of vaginal odor are associated with Gd+ and NSV in adolescent females.

HYPNOTHERAPY WITH POORLY-CONTROLLED ADOLESCENT ASTHMATICS. S.B. Fitzpatrick, W.E. Bohannon & S.B. Friedman, 3ohns Hopkins 5ch. Med. & Univ. Md. Sch. Med., Baltimore, Md. Investigators have reported that emotions trigger asthma in some individuals. While hypnotherapy has been used to decrease attacks in adults, little data exists for teenagers. Poorly-controlled adolescent asthmatics were selected for study a f t e r a trial of adequate medical management, and a f t e r documenting serum bronchodilator levels & frequency of ER visits. Response to combined medical & hypnotherapy was assessed in terms of frequency of ER visits. Sample characteristics: 6 males & 4 females (X=l#.g yrs; Tanner stage ~=B.9); they had a mean FEVI of 80% predicted value; 80% had received prior steroid &/or immunotherapy; 30% had family history of asthma; 100% had normal growth & development, though only 30% had age appropriate school placement. Patient assessment: PE, CBC, IgE, allergy skin testing (20% positive) & exercise tolerance tests (10% positive). Medications: 100% theophyllin preparations and, 50% beta-2 agents. Psychological interviewing revealed: 30% were experiencing an adolescent adjustment reaction & the remaining 70% were judged to have significant "secondary gain" from asthma. Despite adequate serum bronchodilator levels, subjects remained poorly-controlled. Weekly l-hr. individual hypnotherapy with mental & muscular relaxation was started. During the 6 month study period, ER visits were reduced from 9.#7/month to 0.17/month (_t=/~.38; E<0.005). This combined treatment approach was shown to be cost-effective in reducing ER visits in a selected group of adolescent asthmatics.

146

ABSTRACTS

THE IMPACT OF COMPREHENSIVECARE ON CONTRACEPTIVE COMPLIANCE. J.W. Greene and B.W. Evans, Division of Adolescent Medicine, Vanderbilt Univ., Nashville, TN. Poor contraceptive compliance is often encountered in family planning clinics providing services to teenagers. This study examines the e f f e c t of offering comprehensive health care in a setting which had previously provided only family planning services. Included in the study were 208 females aged 12-19 who made t h e i r i n i t i a l v i s i t a f t e r the addition of a comprehensive care option. Chart review i d e n t i f i e d 115 patients u t i l i z i n g both comprehensive and family planning services, and 93 u t i l i z i n g only family planning. The l a t t e r group chose to continue obtaining t h e i r general health care from other sources. Contraceptive compliance as measured by pregnancy avoidance, appointment adherence, and either p i l l count, presence of IUD string, or reported diaphragm use was s i g n i f i c a n t l y greater among those using both services (p < .05). Additional analyses were performed to determine whether other factors contributed to this difference. Variables examined included age, race, source of funding, age at menarche, duration of sexual a c t i v i t y , sexual partners, perceived a b i l i t y to make decisions, parental knowledge, written parental consent for services, contraceptive type, and type p r a c t i t i o n e r seen. Of these, only written parental consent showed a positive correlation (p < .05). These findings suggest that adding comprehensive health services to family planning c l i n i c s may enhance contraceptive compliance. Parental acceptance of c l i n i c attendance appears to be a contributing factor.

MEDICATION COMPLIANCE BY ADOLESCENTS: FILLING THE PRESCRIPTION. L.R. Jaffe, R.N. Wortman, and J. Cohl. Depts. of Pediatrics, Psychiatry, and Pharmacy, Mount Sinai Sch. of Med. of the City Univ. of N.Y., New York, N.Y. An essential component in the delivery of health care is the maximizing of patient compliance. We undertook to determine the degree of compliance in the filling of medication prescriptions in our patient population, in addition to elucidating some of the variables which might influence this behavior. From Jan. 4-28, 1982, prescriptions were given to 298 adolescents receiving medical, gynecologic and psychiatric care at a free-standing, comprehensive adolescent health center. All prescriptions written were compared with the hospital pharmacy's record of prescriptions filled (the prescriptions can only be filled at that pharmacy). Ten practitioners recorded the level of importance they attributed to each medication prescribed. Two hundred twenty-eight (76.5%) of the patients had their prescriptions filled. NO significant difference existed by prescribing practitioner, except for the psychiatrist, whose patients' 56% rate of compliance was significantly lower than the other health care specialties (F 4.05). Only one practitioner demonstrated a significant association between his perceived importance of the prescription and the patient's filling of it. The particularly poor compliance of the patients receiving psychotropic medications probably results from multiple factors, which include the high incidence of uncomfortable side effects, as well as the need for denial of emotional illness. The high overall non-compliance (23.5%) represents a serious obstacle in health care delivery.

MENSTRUAL MANAGEMENT IN ADOLESCENTS AFTER TOXIC SHOCK SYNDROME-J.L.Rauh, C.C.Linneman, A.Beiting, C.D.Waldrop, C.R.Buncher, S.Hornstein, and T.P.Barden. Divs. of Adol. Med. & Inf. Dis.,Univ. of Cincinnati and Childrens Hosp. Med. Ctrs.,Cincinnati, Ohio As part of a surveillance study of colonization of staphloeoccus aureus in the genital area, 430 menstruating women were questioned about current menstrual management. The purpose of this study was to look for menstrual management differences between adults and teenagers 6 to 12 months following toxic shock syndrome (TSS) media coverage. At the time of interview 30% of teenagers (N=II6) and 31% of adults (N=314) used tampons only. Napkin and combination use were comparable for both groups. For white and blacks there was no difference by age, but white adults and teenagers used tampons significantly more than blacks of comparable age (p<.O01). Questions specifically about knowledge of TSS and subsequent change in management were asked of 240 subjects. Seventy-two percent of teenagers (N=65) had knowledge of TSS compared to 95% of adults (N=175). There was no significant difference between black and white teenagers with respect to knowledge of TSS, but white adults knew of TSS more often than black adults (p(.01). Thirty-eight percent of teenagers and 48% of adults with knowledge of TSS made a management change. The major change in teenagers was in product brands used. In conclusion, there was no significant difference between teenagers and adults in menstrual management, but there was a difference between races.

JOURNAL OF ADOLESCENT HEALTH CARE Vol. 3, No. 2

NEISSERIA MENINGITIDIS AS A SEXUALLY TRANSMITTED ORGANISM. L.R. Jaffe, and J.A.S. Stavis. Depts. of Pediatrics and Obstetrics & Gynecology, Mount Sinai Sch. of Med. of the City Univ. of N.Y., New York, N.Y. Neisseria meningitidis is increasingly being isolated from the urethra, cervix and anal canal of sexually active adults. The objective of this study was to determine if a similar phenomenon existed with sexually active adolescents and to assess the health implications. From January 1 through December 30, 1981, 92 isolates of Neisseria were cultured from the anogenital site of sexually active Black and Hispanic adolescents attending a comprehensive adolescent health care facility. Of the isolates, 88% (N=81) were N. gonorrhoeae, 8.7% (N=8) were N. meningitidis, and 3.2% (N=3) could not be speciated. The clinical associations are suggestive that N. meningitidis causes sexually transmitted disease; one boy presented with a urethral discharge and two girls were diagnosed as having acute pelvic inflammatory disease. As it may be a causative agent of urethritis and pelvic inflarmnatory disease, N. meningitidis should be considered a pathogen when identified in the urethra or cervix and treated with appropriate antibiotics. The health implications of isolating N. meningitidis from the anal canal are less clear, although it may be associated with proctitis. N. meningitidis can be initially spread to anogenital sites via oral-genital sexual contact with a pharyngeal carrier. Therefore, while sexually spread, N. meningitidis does not imply third-person involvement in a relationship; this has psychosoeial and epidemiologic implications.

ORAL CONTRACEPTIVE USER RESPONSE TO FEDERAL PARENTAL NOTIFICATION REGULATION N.Goldfield and F. Tenant Jr., Dept of Med, Univ of Southern California Sch of Med~and Dept of Epidemiology~ Univ of California at Los Angeles. This study of i00 Female oral contraceptive users who live at home with their parents examines the effect of the new proposed parental notification on future contraceptive use. The study uses a prospective nonrandomized design. Sociodamographically the sample consists of patients who were caucasian,unmarried,Medicaid eligible with a median age of 16.9 yrs. Most had used oral contraceptives for less than one yr. Both parents lived at home in the majority of eases with father only households accounting for five% of cases. The study revealed that a substanti~l percentage of parents are aware of adolescent contraceptive use. This subgroup consists almost exclusively of mother s. Adolescent contraceptive user s who parents were unaware of their daughters activity almost universally reported that they would not be permitted to stay] at home if their parents knew of their oral contraceptive user Almost the enfire population of this study group was willing to pay 20-255 to avoid parental notification of birth control use This study reveals that though a substantial parental~largely maternal knowledge of offspring contraceptive use is present~ adolescents would prefer to be the bearer of good tidings.

PATIENT UNDERSTANDING OF ORAL CONTRACEPTIVE SIDE EFFECTS N. Goldfield, L. Neinstein, F. Tenant J r . , Univ. of Southern C a l i f . , Los Angeles, C a l i f . , Childrens Hospital of Los Angeles, Los Angeles, C a l i f . , and Sch. of Public Health, UCLA Sch. of Med., Los Angeles, Calif. This study of lOO female oral contraceptive users examines the sources o f contraceptive information, patient compliance with oral contraceptives and the importance to the adolescent of slde effects. The study u t i l i z e s a prospective non-randomized design. Sociodemographically, the sample consisted of patients who were predominantly Caucasian (80%), unmarried (84%), and Medicaid e l i gible(75%), with a median age of 19.5 years. In 65% of patients, the source of information about side effects came from information provided at the c l i n i c prescribing the contraceptives or other printed information. Information came from friends in 13~, from school in 8%, from family in 7%, from TV in 4% while the adolescent's partner provided information in only one situation. 18% of the study group consider weight gain and 9% acne to be important. In comparison, 45% consider blood clots and 33% cancer to be important side effects. Only a small number(22%) agreed with the statement that oral contraceptives had changed t h e i r body figure. Compliance wlth oral contraceptives was extremely high with 85% of patients missing no p i l l s , IO% no more than one p i l l per month and 5% no more than two p i l l s per month. This study substantiates the view that contraception is typically not discussed between partners. The hypothesis that adolescent females consider body image issues more importantly than other serious contraceptive slde effects is refuted in this study. Compliance for oral contraceptives is high.

September 1982

ABSTRACTS

147

PEDIATRICIANS, TE~AGF/~$, AND THE LAW V.C. $traeburger, J.M. Eisner, and R.A. Kramer. The Committee on A d o l e s c e n c e , Connecticut Chapter of the American Academy o f P e d i a t r i c s , BridEeport, Connecticut. How much do p r a c t i c i n g p e d i a t r i c i a n s know a b o u t the legal a s p e c t s o f t r e a t i n g t e e n a g e r s and d o e s i t i n f l u e n c e t h e i r mode of practice? In F e b r u a r y , 1981, we c i r c u l a t e d a q u e s t i o n n a i r e and l e g a l q u i z t o a l l 400 C o n n e c t i c u t AAP members. A t o t a l o f 79 were c o m p l e t e d (response rate 20~). N e a r l y t w o - t h i r d s o f the r e s p o n d e n t s expressed concern about the legal aspects of treating teenagers, yet o n l y one p h y s i c i a n answered the l e g a l q u i z c o r r e c t l y . Of 17 q u i z q u e s t i o n s , an a v e r a g e o f 4 were m i s s e d (mean s c o r e 7 3 . 8 ) . Most f r e q u e n t l y m i s s e d were q u e s t i o n s a b o u t t r e a t m e n t o f drug a b u s e r s , t r e a t m e n t o f mature m i n o r s , and c o n s e n t for a b o r t i o n s . However, a s u r p r i s i n g 22% of r e s p o n d e n t s t h o u g h t t h a t the m a j o r i t y of 14-15 year-old girls are sexually active, more physicians knew the correct drinking age (97~) than the correct voting age (87%), 17% of physicians would not treat a teenager for gonorrhea without parental consent, and an alarming 13% would n o t approve of an emergency appendectomy being done on a teenager if parental consent could not be obtained. The majority of physicians surveyed said that they felt uncomfortable doing pelvic exams (58%) and prescribing birth control (66~). 61% replied that they would favor a law specifyie E age 15 as the age at which a teenager should be allowed tO c o n s e n t for hls/her own medical care. It is possible that the spread of adolescent medicine is being hampered by pediatricians' fear of legal repercussions in seeing minors and their inadequate knowledge of the law.

I~%ELIMINARY DATA ON ~ EFFECTS OF ~ NOtIFICATION ON ADOLESCENT FAMILY PLANNING BE~VIOR. A. T. Nowlan, G. O. Goldsmith, J. Morrissey, M. P. White, The Door - A Center of Alternatives, New York, N.Y. Most service providers consider oonfidentiality of vital ~ p o r tance to adolescents seeking health care. Proposed regulatory changes make this an acute and crucial issue. A survey is being conductad at a multiservice center for teens in order to determine how minors would be affected if parental notification were required for the provision of contraceptives. Women under eighteen years of age are asked to oomplete a questionnaire which asks how they would be affected if the clinic were required to notify their parents of their birth control use. Responses are analyzed by age, ethnic background, current sexual experience and parental awareness of sexual activity. To date, 48 women have responded (total sa~ole to equal 200); mean age is 16.1; 40% are white, 30% black, 19% hispanic and 10% other; 73% are currently sexually active, 34% of whom reported their parents are aware of this. 56% of all respondants said they would stop using the clinic if parents were to be notified. Of those teens whose parents are not aware of their sexual activity, 32% would risk having sex without using birth control, 27% would use a non-prescription method and 36% would either seek services from a private physician or use a non-prescription method. Preliminary data suggests that if parental notification were required, more adolescents would engage in risk-taking behaviors. It also suggests that further efforts be made to determine oonsequences and that such regulations be considered cautiously.

POLYCYSTIC OVARY SYNDROME PRESENTING IN THE ADOLESCENT PERIOD. K. Woodward, M. Lappin. Dept. of Adol. Med., Children's Hos. Nat. Med. Ctr. Polycystic Ovarian Syndrome (PCOS) is well-described in adult women, and most often is diagnosed with the chief complaint of infertility. Our population of adolescent women, diagnosed with PCOS presented with a variety of chief complaints: menstrual disturbances (oligomenorrhea, amenorrhea and menorrhagia), worry about possible pregnancy, hirsutism, and severe amenia. Twelve adolescent women with PCOS were compared to 12 regularly menstruating, nulligravida, non-oral coutracepting women, matched for gynecologic age (years post menarche). As there were significant differences in the gynecologic history, physical examination, and ovarian size on pelvic sonography, it is our conclusion that the diagnostic clues of menstrual disturbances should not be ignored in adolescents. The objective is to identify, educate and treat these young women so as to improve their medical and psychological management. Early detection of PCOS will permit the practitioner to utilize preventive measures (prevent dysfunctional uterine bleeding, severe anemia, increased hirsutism, etc.) and anticipatory guidance (contraceptive issues, infertility, risk of endometrial carcinoma) to aid the patient in the development of a sound selfbody image and ego. Concerns about body image are at their peak in the adolescent period. We reaffirm that careful, sensitive explanations and care can he given, consistent with their cognitive and ~evelop~ent.al stage.

PRESENTATION OF SYPHILIS IN ADOLESENCE: A REVIEW OF 40 CASES, TJ Silber, - N. Niland, - Children's Hosp. National Medical Center, Washington, D.C. Syphilis, due to the spontaneous healing of its initial lesion, is often overlooked by the adolescent patient. If undetected and untreated, the condition may bring disastrous consequences. To detect how syphilis presents when first seen, the authors studied the medical histories of 40 patients diagnosed at their program from 1976 to 1982. 5 Presented with typical chancre (prlmary syphilis) 3 Presented with atypical chancre (primary syphilis) 5 Presented with lymphadenopathy (secondary syphilis) II Presented with latent syphilis. 16 Presented with rash (secondary syphilis) All cases had a positive RPR and were confirmed by FTA-ABS. Most of the patients whom we detected with latent syphilis belonged to a high risk group including homosexuals, pregnant teenagers, patients with hepatitis, patients with concomitant veneral disease or a past history of veneral disease and victims of sex abuse. We conclude that syphilis is not a rare disease in adolesence. Contrary to general belief, m o s t patients do not consult for a primary chancre. Instead, they either have an atypical presentation or are discovered to be in the latency stage by physicians who maintain a high index of suspicion.

PREGNANCY INDUCED HYPERTENSION IN AN ADOLESCENT PROGRAM UTILIZING STRICT DIAGNOSTIC CRITERIA. P.C. Leppert and D. Barker. Dept. of Ob/Gyn and Pediatrics, College of Physicians & Surgeons, Columbia University New York, New York. Pregnancy Induced Hypertension (PIH) is most frequently seen among young nulliparous women. Although the usual stated incidence is 5% (Pritchard and MacDonald 1976) figures as low as 2% and as high as 30% are reported among adolescent pregnant populations. Diagnostic criteria utilized for PIH in reported studies are unclear, often follow adult blood pressure norms and vary from center to center. Preeclampsla was defined in this study utilizing strict criteria of increase in diastolic of 15 mg. Hg.; 30 mg. Hg. systolic -- failure of normal midtrimester drop in BP; significant proteinuria and comparison of BP to age appropriate BP. The incidence of PIH among 564 high risk, low socio-economic pregnant girls ii to 19 years seen in a comprehensive pregnancy program was 4.7% (27) in antenatal period, 0.9% (8) is intraparrum and 2.4% (14) in postpartum period. All offspring were healthy. It is concluded that adherence to strict obstetrical criteria provide an incidence of PIH among a high-risk pregnant group slightly above the usually cited incidence of this obstetrical problem. A strict diagnostic criteria for PIR aids in providing optimum care and facilitates comparisons of statistics among comprehensive programs.

PRESENTING SIGNS AND SYMPTOMS OF SYSTEMIC LUPUS ERYTHEMATOSUS (SLE) DURING ADOLESCENCE. D. Saunders, W. Rosenfeld, and M. Boeck. Div. of Adol. Mad., Dept. of Peds., Albert Einstein Coll. Med., Bronx, N. Y. SLE is among the more conm~n chronic illnesses that first manifest during adolescence. Early symptoms of this disease are frequently non-specific and delays in diagnosis may lead to anxiety, prolonged illness, and unnecessary laboratory testing. This study was conducted to determine the nature of early signs and symptoms of SLE during adolescence. A retrospective analysis was undertaken on the records of all patients admitted to an adolescent unit between 1971 and 1981. Within the 15,750 admissions, 25 patients were newly diagnosed as having SLE. They ranged in age from Ii to 20 (mean 15.~ yrs., with 96% being female. The most common initial signs and symptoms included arthritis (62%), fever (52%), malar rash (48%), and fatigue and/or weakness (44%). Less commonly encountered were adenopathy (20%), bleeding (16%), and alopecia (16%). 6 patients (24%) presented with symptoms not ordinarily associated with SLE (bullous skin lesions, flank pain, bruising, edema and fever, and weight loss with dyspnea). These less characteristic initial findings were more common in the 16-20 yr. old patients (5 of 13) than in those 15 and below (1 of 12). This may account for the longer interval between presentation and diagnosis encountered in the older vs. the younger adolescents (3.7 mos. vs. 2.5 mos.). In all patients, antinuclear antibodies were present the first time that the test was performed. This study suggests that many adolescents with SLE present with initial findings not often associated with the disease and that such atypical presenting signs and symptoms are more frequent with advancing age.

148

ABSTRACTS

PROLACTINOMAS CAUSING PRIMARY AND SECONDARYAMENORRHEA IN ADOLESCENTS. Ridgway EW, Emans SJ, Fisher EG, and Crigler JF. Division of Adolescent Medicine, Children~ Hospital Medical Center, Boston. Prolactinomas are a well recognized cause of amenorrhea in adults, but less known in adoleseent~ In 6 years, 6 adolescent females were found to have prolactin-secreting tumors. 3 had primary amenorrhea (P.A.); 3 had secondary amenorrhea (S.A.). Only one of the l a t t e r had galactorrhea. The ages of P.A. and S.A. were similar. 5/6 were below the 50% f o r height; those with P.A. were shorter (4162 cm). The 3 cases of P.A. had incomplete puberty, (breasts Tanner stages i - 3 ) . Those with S.A. were a l l Tanner 5. 5/6 had positive x-ray and/or CT scan evidence of p i t u i t a r y tumor. Endocrine evaluation revealed elevated prolactin l e v e l s , 37 to 1450 ng./ml, which f a i l e d to respond to TRF stimulation. All patients had normal basal LH & FSH levels and responded to LHRH stimulation, however, estrogen levels were low in P.A. and normal in S.A. Growth hormone (GH) secretory responses to e i t h e r sleep or insulin-induced hypoglycemia were normal in a l l . Treatment: Two P.A. patients had surgery, then bromocriptine f o r normal prolactin levels: The 3rd P.A. patient had bromocriptine and has normal prolactin. One has normal mense~ Radiation alone in S.A. pt. caused normal prolactin but no menses. One S.A. patient had surgery with normal menses next month. One patient refused treatment. Conclusion: i . prolactinomas can cause both P.A. and S.A. 2. P.A. patients are shorter and may have arrested pubertal development. 3. Short stature is secondary to low estrogen as GH reserves were normal. Currently emphasis is on menstral dysfunction 2° to exercise and eating disorders. Underlying prolactinomas must be ruled out in these patients.

PSYCHOLOGICAL ADJUSTMENT OF ADOLESCENT PHYSICAL ABUSE VICTIMS. R.D. Marble and D.P. Orr. Child Protection Te~ma, University of California, Irvine, Irvine, CA While physical abuse of children and adolescents is a well recognized problem, little is known concerning the psychological correlates of abuse in the adolescent. TO assess adolescent psychosocial adjustment, 23 female and ii male physical abuse victims eval0ated in a pediatric physical abuse clinic completed the Offer Self-Image Questionnaire (OSIQ) . The mean age of the victims was 14.0 years (range 11.0 - 17.4). Physical abuse, as defined by the California State Penal Code, was confirmed in all 34 cases. Results of the OSIQ demonstrated group mean scores in the poorly adjusted range on five scales indicating serious problems with emotional tone (p<0.001), sexual attitudes (p<0.0l), family relationships (p<0.001) , feelings of inability to master the external enviror~nent (p<0.01) and poor psychologic adjustment (p<0.001) , as well as poor overall adjustment (p<0.001) . Group mean scores for the scales relating to impulse control, social relations and morality were within noz~nal limits. Adolescent physical abuse victims report experiencing many prdole~s. While they appear to be seriously psychologically disturbed and d ~ o n s t r a t e poor adjustment in dealing with external problems and family relationships, cc~pared to the general adolescent pepulation, we find no evidence t o support the suggestion that these victims are more impulsive. Causality for the apparent deviancy is only speculative at present.

THE PSYCHOSOCIAL EFFECT OF SURGERY FOR THE CORRECTION OF DENTO-FACIAL DEFORMITIES. H.Oliver, S.Sachs, l~.Drucker and J.Kane,Depts. of Psychiatry and Oral Surgery,Long Island Jewish-Hillside Med.Ctr.,New Hyde Park, N.Y. this study evaluated the commonly-held belief that surgical correction of disharmonies in facial form and function helps to improve morale and results in better psychological functioning.A pilot group of twelve patients (all adolescents or young adults) were evaluated both before and after surgery. Each patient received a full-length psychiatric interview by an experienced staff psychiatrist and a written battery of tests which included the MMPI, the SCL-90, the Katz Relative Rating Scale and a Social Adjustment Scale. The patients were again interviewed and the tests repeated following the surgery and a significant healing period: approximately one year later. Following surgery, the clinical interviews showed a definite decrease in anxiety, bodily preoccupation and paranoid feelings. This was also reflected in the psychological tests which showed decreases in the anxiety, somatization, and paranoia subscales of the SCL-90, lowering of the social introversion scores on the ~ P l and increase of self esteem on the Social Adjustment Scale. All of these changes were statistically significant (p~05). Our findings indicate that adolescents with dento-facial deformities are liable to anxiety, low self esteem, preoccupation with somatic problems and a mild paranoid trend which primarily takes the form of referential thinking. These nuclear problems can easily lead to social withdrawal and vocational underachievement. These pathological personality reactions are not yet fixed in the adolescent:corrective surgery results in improvement in all areas.

JOURNAL OF ADOLESCENT HEALTH CARE Vol. 3, No. 2

RACIAL DIFFERENCES IN LEVELS OF STRESS: IMPACT ON SCHOOL AND HEALTH FUNCTIONING. B.A.Cromer, M.Petchers. Dept. of Pediatrics, Cleveland Metropolitan Gen. Hosp., Case Western Reserve Univ., Cleveland, Ohio. There has been increasing public awareness in recent years of the sociologic problems of our adolescents and their impact on physical and mental health issues. This study was designed to examine the effects of stress on different racial groups of teenagers: their levels of anxiety, school adjustment, and personal health concerns. One hundred seventy-one inner city high school students completed questionnaires covering the above issues. To examine the relationship among these variables and to compare their impact, correlations and ANOVA were performed, respectively. Data obtained from the questionnaires revealed the following: Black White Hispanic Stress 2.7x 1.8x 3.5x sig p < .01 Anxiety .44x .44x .46x (1)Stress levels differed significantly by race, whereas, (2) anxiety levels showed no concomitant variation. (3)Furthermore, upon examining the relationship between stress and anxiety for each racial group, the black sample alone showed a significant correlation (r=0.3l). Other factors that were examined included the relationship between stress and school absenteeism and number of doctor visits. Each were found to have a significant correlation among the black students only (eta=.44,p<.OO6,eta=.43,p<.03, respectively). These findings suggest that stress has a significant impact on black, but not white or hispanic, teenagers' level of anxiety along w i t ~ e l e c t e d sociomedical attitudes and behavior.

THE RELATIONSHIP BETWEEN COPING STRATEGIES AND METABO~ IC CONTROL IN ADOLESCENTS WITH IDDM. D.G. Marrero and D.P. Orr. Dept. of Pediatrics, University of California, Irvine, Irvine, CA Achieving metabolic control of insulin-dependent diabetes mellitus(IDDM) requires the patient cope with a broad range of social, psychological, and emotional factors. Little is known about types of coping strategies or the relative effectiveness of different strategies in achieving and maintaining effective metabolic control. Coping responses of two groups of adolescents with IDDM 17 in good eontrol(GC) and 23 in poor control(PC) - were compared using the Ways of Coping Checklist(WCC). WCC measures 12 types of coping responses: palliative, instrumental, wishful thinking, advice seeking or avoidance, growth, minimize threat, seeking social support, self blame, cognitive control, fatalism, active mastery, and emotive action. PC subjects indicated a greater total number of coping responses(p < .05). More PC's used instrumental(p<.O001~ growth(p <.03), fatalism(p <.01), wishful thinking(p (.04), and active mastery(p ~.006). Contrary to common beliefs, there was no difference between PC and GC in using self blame, advice seeking and avoidance. Higher total use of coping strategies in general, and specifically instrumental and active mastery strategies, suggest that PC subjects have not yet found but continue to search for effective coping strategies to gain metabolic control. Clinical interventions should not only focus on educating the patient or conducting psychotherapy, but also on developing more effective coping skills including coping with psycho social factors.

THE RELATIONSHIP OF MENSTRUAL CYCLES TO BODY FAT COMPOSITION AND SPORTS PARTICIPATION. Emans SJ, Podolsky C, Wilson, C. Division of Adolescent Medicine, Children's Hospital Medical Center, Boston, and Harvard Medical School. Previous studies have suggested that low body f a t composition and a t h l e t i c competition may delay the onset of menses and the establishment o f regular cycles. This study was undertaken to reexamine these possible relationships in a healthy adolescent popul a t i o n , 327 adolescent g i r l s from an independent secondary school in the Northeast were surveyed. Mean age was 15.45 years; 306 g i r l s had had menarche, 21 were premenarcheal. The age at which a g i r l had had her menarche was s t a t i s t i c a l l y correlated with calculated body f a t composition %fat = 40 - 1.06 (age at menarche). Body f a t composition was lower in those who had not experienced menarche (27.3% v. 22.4%; p4.0001). The data was also examined in terms of hours/day of exercise and by sport. Gymnastics was the only sport shown to be associated with delayed menarche, dancing was associated with i r r e g u l a r menses, and swimming with abnormal duration of flow. Although there was no c o r r e l a t i o n f o r dysmenorrhea with type of exercise, hours/day, or body f a t , premenstrual symptoms were s t a t i s t i c a l l y associated with higher body f a t %. Competitive sports p a r t i c i p a t i o n f o r I - 3 hours/day had minimal impact on menstrual function. The data also supports the Frisch hypothesis that delayed menarche may be associated with low body f a t composition.

September 1982

ABSTRACTS

SEXUALITY EDUCATIONGROUPSIN JUVENILE DETENTION. J. A. Farrow, E. Schroeder. Div. of Adolescent Med., University of Washington Sch. of Med., Seattle, WA. Objectives of this study include development of a sexuality education program administered in a juvenile detention setting appropriate to this unique population of adolescents and further to effect positive change in attitudes and knowledge about sexua l i t y , venereal disease control and contraception and to increase self-esteem. 15 detained youth, 10 females and 5 males, with a background of criminal behavior, running away, prostitution and substance abuse were studied and a five session group format was developed for application in a detention environment. Development of the five session program was based on an eight month experience by the investigators in leading sexuality groups in detention and a review of the literature. Pre and post tests were administered and included a knowledge/attitude test developed by the investigators based s t r i c t l y on program content; Hudson's Index of Self-Esteem and a participant program evaluation. The program consisted of individual sessions on the medical aspects of sexuality, sexual exploitation, positive sexual relations, normal sexual behavior and sex and drugs. Results of completing the sexuality education curriculum shQwed i) a s t a t i s t i c a l l y s i g n i f i c a n t (p .004) improvement in knowledge/attitude scores, 2) higher (not s t a t i s t i c a l l y s i g n i f i c a n t ) self-esteem scores, and 3) overall high p a r t i c i p a n t evaluations of the program. Other benefits gained by participants and the detention center were delineated. Similar programs are recommended. SEXUALLY TRANSMITTED DISEASES IN A JUVENILE DETENTION FACILITY. J.A. Farrow, T.A. Bell, W.E. Stamm, and K.K. Holmes. Departments of Pediatrics, Epidemiology and Medicine, University of Weshimgton, Seattle, Washington. In 1981, 27 male and 77 female adolescents in an urban shortterm detention facility who had received no antimicroblals in the previous month were examined for infection with Neisseria $oq0rrhoeae (N.g.), Chlamydia trachomatis (C.t.), Trichomonas va$inalis (T.v.), and Treponema 2allidum (VDRL), and for non-specific vaginitis (NSV), abnormal cervical cytology (ABN PAP), tender uterine adnexae (TEN ADN) with the following results: Detainee

N'g"

Percent with infection/disorder c.t. T.v. VDRL NSV ABN PAP

TEN ADN

Female, prostitute

30

29

24

0

27

24

21

Female, nonprostitute

16

22

27

0

25

16

32

Male, symptomatic

27

14

Not done

0

--

--

--

Rates for prostitutes and non-prostitutes were not significantly different. Self-obtained vaginal cultures for N.g. were 63% sensitive and 100% specific relative to endocervical cultures (p<.O01). Nine of Ii females with ABN PAPs -- all Class II -- had N.g. and/or C.t. and another had T.v. Eight of 17 with TEN ADN had N.g. and/or C.tt These two agents, which are more common in females in this facility than in the local sexually transmitted disease (STD) clinic, deserve greatest emphasis in examinations of adolescent detainees for STDs.

The Sodit=n PotassiLun Pump Activity in Patients with Anorexia Nervosa. Grace,E., Deluise,M., ~nans,S.J., Children's Hosp., }Larvard ~d.Sch. Boston, MA. Sodium and potassium dependent adenosine triphosphatase(NaK-ATPase) is the enzymatic expression of the NaK-pur~o. The effects of selfinflicted starvation as seen in anorexia nervosa on the NaK-pump is unknown. Determining the activity of the NaK-punlp in patients with anorexia nervosa would provide an enzymatic measurement of energy cons~ption and further elucidation of the pathophysiology of the condition. 13 patients with anorexia and 14 normal weird]ted age n~tched controls followed in the Adolescent Unit of Children's Hosp. participated in the study. Following a i0 hour fast 10cc's of heparinizedblood was collected and the erythrocyte NaK-ATPase pump units were measured by the modified ouabain binding method. Despite the prolonged reduction in caloric intake by the anorectics (mean 22 ~Dnths) there was no significant difference in the ouabain binding capacity of erythrocytes co~0ared to normal weighted controls. The mean val~es were 0.509_+0.024 in the anorectics and 0.551_+0.027 ~n01es/10 ~ cells in the controls. Neither the total nor the ouabain resistant uptake differed in either groups (83.5+2.3, 86.3+3.5 nmole/109 cell/hr in controls and anorectics respectively). The intrinsic activity of the pu~ was the same in the controls (45_+9 ions/sec) and the asorectics (44_+8 ions per sec). By utilizing the NaK-pump as an enzymatic measurement of energy consumption no alteration ~] pt~0 function was demonstrated in the patients with anorexia nervosa when compared to normal weighted controls.

149

SPIRITUAL/RELIGIOUS CONCERNS OF THE HOSPITALIZED ADOLESCENT. T. Silber and M. Reilly, Children's Hospital National Medical Center, Wash., D.C. There is universal agreement on the fact that one of the tasks of adolescence is the development of a value system. Yet, the relationship of values to the experience of hospitalization in adolescence has not been researched. A social science survey was conducted by the authors in order to study the spiritua~ concerns of adolescents as they express themselves in the situation of hospitalization. One hundred hospitalized adolescents ranging in age from 13 to 19 were interviewed and compared with a control group attending the outpatient department. A Likert Scale questionnaire was administered and a statistical analysis was done with a Kendal Tau correlation based on ordered data. The study demonstrated that a subgroup of hospitalized adolescents had experienced Intensified spiritual and religious concerns as compared to their values and preoccupations before hospitalization and by comparison with their controls. In response to the questionnaire over 10% of the patients requested further help. These findings suggest that training in adolescent health care and the provision of services to teenagers ought to include teaching and collaboration in the area of spiritual and religious values of teenagers, with emphasis on the hospitalized adolescent.

STUDENT-HEALTH SERVICE POLICIES REGARDING CHEST RADIOGRAPHS AND TUBERCULIN-SKIN TESTS. G.Slap, S. Fager, D. Kitz, J. Eisenberg. Dept. Med., Univ. Pa., Phila., Pa. Although tuberculous infection has declined dramatically and the efficacy of screening chest x-rays (CXR) has been questioned, many student-health services (SHS) continue to require or recommend (R/R) CXR and tubercuiin-skin tests (TST). This study was designed to: 1) determine the policies of SHS regarding CXR and TST; and 2) estimate the economic and health impact of these screening CXR. Comp]ete questionnaires were returned by 408 of 624 (65%) SHS directors and abbreviated postcard questionnaires by 123 (20%). The %of SHS which R/R screening tests for all incoming students, health students (H), foreign students (F) and intercollegiate athletes (A) are: All H F A Enrollment CXR ~ 2~% 3T% 1~% Periodic CXR 7 21 17 I0 Enrollment TST 52 49 54 39 Periodic TST 27 50 32 25 An estimated 724,000 incoming college students in the U.S, received screening CXR in 1980 with resultant expenditures of $7-27 million (estimated from Blue Shield reimbursement rates and hospital charges). The millirad dose to each cancer site from one CXR and the incidence of each type of cancer were used to predict the number of cases of radiation-induced cancer among these students over 20 years: 0.33 cases of lung cancer, 0.09 cases of breast cancer, 0.07 cases of leukemia and 0.05 cases of thyroid cancer. We conclude that many students are receiving screening CXR at considerable cost with questionable benefits.

TEENAGE PREGNANCY: IS SEXUAL RESTRAINT AN EFFECTIVE SOLUTION? B. Hart, I. Hilton, C. Kunkes. Pace Univ., Yeshiva Univ., The Door. New York, New York. Public policy directed toward increased emphasis on family responsibility in the control of sexual behavior has lead to decreased federal spending and retrenching of services aimed at preventing untimely pregnancy and motherhood. This study examined the personality of the sexually inactive glrl in order to determine the reasons for her sexual status and the degree of risk she presents for unwanted pregnancy once she becomes sexually active. One hundred and sixty-one adolescents were studied; 60 sexually inactive; 35 sexually active using birth control reliably; 34 sexually active not using birth control; 32 pregnant girls who decided to carry their pregnancy to term. All responded to a structured clinical interview and battery of psychological tests used in our concurrent investigation into the causes and effects of teenage pregnancy. Analyses of covariance indicated that sexually inactive adolescents had significantly lower levels of ego development than adolescents using birth control and were at the same level of ego development as the pregnant sample (p~.001). Sexually inactive adolescents were lesm able to establish warm personal ties with peers and non-family members (p,.01) and their self-perceptions, standards and values ware determined primarily by the external constraints imposed by the family (p~.001). Avoidance was their most frequently used defense (p,.0001). It was concluded that the sexually inactive adolescent with her susceptibility to an external value system, is a high risk candidate for adolescent pregnancy once defensive avoidance and barriers to intimacy are overcome by her repeated exposure to the predominant standard of sexual expression.

150

ABSTRACTS

TRUST D I S T U R B A N C E S A M O N G V I C T I M S OF RAPE AND INCEST. D. Brothers, I. Hilton, and C. Kunkes, Y e s h i v a U n i v e r s i t y and The Door, New York, NY This study e v a l u s t e d the clinical b e n e f i t s of viewing the crisis following s e x u a l t r a u m a in terms of disturbed trust in s e l f ~ i n others. F i f t y - s e v e n a d o l e s cents b e t w e e n 14 and 21 were d i v i d e d into four groups: incest victims, v i c t i m s of s t r a n g e r rapes, v i c t i m s of k n o w n assailants, and controls. Trust d i s t u r b a n c e was m e a s u r e d by three scales d e v i s e d by the s e n i o r author. S t r u c t u r e d interviews, a s y m p t o m checklist, and m e a s u r e s of ego d e v e l o p m e n t , s e l f - e s t e e m , a t t i t u d e s toward women, g e n d e r identity, locus of control and d e f e n s e m e c h a n i s m s were also used. S u b j e c t s were r e c r u i t e d as they w a i t e d for m e d i c a l a p p o i n t m e n t s at The Door. The results of ANOVAS and P e a r s o n p r o d u c t m o m e n t corr e l a t i o n s showed s i g n i f i c a n t l y g r e a t e r trust d i s t u r b a n ces among v i c t i m s than n o n - v l c t i m s . S e v e r i t y of the t r a u m a v a r i e d a c c o r d i n g to the p a t t e r n of d i s t u r b a n c e ; v i c t i m s low in s e l f - t r u s t and high in trust in others were most s e v e r e l y t r a u m a t i z e d . Subjects w i t h a high p r e d i s p o s i t i o n for trust d i s t u r b a n c e b a s e d on n u m b e r s of t r a u m a t i c llfe events and p o o r early r e l a t i o n s h i p s were m o r e s e v e r e l y t r a u m a t i z e d . The o r d e r of s e v e r i t y of t r a u m a by group was: incest victims, v i c t i m s of s t r a n g e r s and v i c t i m s of k n o w n a s s a i l a n t s . An u n d e r s t a n d i n g of trust d i s t u r b a n c e allows c l i n i c i a n s to deal more sensitively w i t h the coping s t r a t e g i e s of a d o l e s c e n t victims.

USE OF CONIKN~AMONG SEXUALLY ACTIVE ADOLESCEN7 MALES. J.M. Lovett, I.F. Litt, and C.A. McDonald. Stanford Univ. School of Medicine, Stanford, CA and Children's Hospital Medical Center, Oakland, CA. Efforts to prevent unplanned teen pregnancy have focused mainly on educating sexually active adolescent females. Relatively little is known about the teenage male partners' role in encouraging or preventing conception. The purpose of this study is to describe the attitudes of teenage males toward contraception and fatherhood and to determine whether free condoms or a prescription for condoms are effective adjuncts to contraceptive counseling. The study population consists of 76 black, sexually active adolescent males attending a medical clinic for teens. The subjects completed a questionnaire detailing their attitudes, knowledge, and behavior about family planning. All except one subject wanted to postpone fatherhood. 60% had used condoms sometime in the previous 2 months. Nevertheless, 65% of the subjects had also had unprotected intercourse during those 2 months. A randomized controlled trial was undertaken to determine the relative efficacy of provision of free condoms or a prescription for condoms in promoting condom use. Of the 56 subjects who returned for follow-up 2 months after the intervention, 18 indicated that they hsd used condoms. 25 of the 36 returning subjects (66%) reported unprotecte~ intercourse sometime in the interval between intervention and follow-up. II of 12 receiving prescriptions obtained condoms, suggesting that this intervention may be an effective adjunct to reproduction counseling among teenaged males.

USE OF CONTINUOUS SUBCUTANEOUS INFUSION OF INSULIN (CSII) IN THE TREATMENT OF EMOTIONALLY DISTURBED DIABETICS. M. Nussbaum, I.R. Shenker, C. Abrams, Dept of Pediatrics, Long Island Jewlsh-Hillside Medical Center, New Hyde Park, N.Y. 11042 The insulin pump for CSII is generally regarded as contraindicated in patients with severe psychological manifestations of diabetes mellitus. Patients are often poor compliers and patient cooperation is considered essential for successful CSII therapy. We believe most patients with poorly controlled diabetes mellitus are in poor control for psychological reasons. Diabetics do not have external or visible evidence of their disease and are thus able to use denial as a prime coping mechanism. This denial leads to continued anxiety in daily management. The insulin pump, effective in the control of unstable diabetics reverses many of the biochemical abnormalities. In wearing an insulin pump the diabetic is also no longer able to deny disease. The handicap becomes visible. The promise of good control with a new "invention" may also relieve anxiety about long range complications. We postulate that the coping mechanism is changed from denial to intellectualization. Our experience with utilization of CSII in four emotionally disturbed diabetic adolescents in conjunction with comprehensive care has reduced hospitalization and objectively improved control. Mean Hgb AIC prior to CSII was 17.1 and at last follow up was 13.0. Mean cholesterol dropped from 209 to 155. Total hospital admissions was markedly reduced. Significant psychopathology as a contraindication to CSII therapy in diabetic adolescents is not supported by our data.

JOURNAL OF ADOLESCENT HEALTH CARE Vol. 3, No. 2

USE OF MICROCOMPUTERS FOR AN ADOLESCENT BIBLIOGRAPHY FOR HOUSE STAFF AND RESIDENT TEACHING B.S. Lachman, Dept. of Pad., Med. College of Wisconsin and Milwaukee Children's Hospital, Milwaukee, Wisconsin Reference bibliographies are useful providing house staff and students with up to date educational information. However, bibliographies are hard to keep current and difficult to adequately cross-reference. An Apple II computer and Visidex, a commercial software program, were used to compile a crossreference and adolescent medical bibliography. A hard copy manual containing instructions and cross-referenced lists was compiled. The bibliography items have been photocopied and placed in binders in a clinic area for resident and student use.

VARICOCELE AND TESTICULAR GROWTHIN ADOLESCENCE W.L.Risser and L.I. Lipshultz, Depts. of Pediatrics and Urology, Univ. of Texas Medical School-Houston Houston, Texas Because of the paucity of available information concerning the e f f e c t o f varicocele on t e s t i c u l a r growth in adolescents, we measured t e s t i c u l a r size in a group of 201 adolescents with and without varicocele. Calipers were used to determine t e s t i c u l a r length. Varicoceles were graded for size. Fifteen of 201 adolescents (7.5%) had l e f t varicoceles. Decreased t e s t i c u l a r size on the side of the varicocele ( i p s i l a t e r a l side) was noted in 13/15 (87%). Only 1/201 has a small t e s t i c u l e not associated with a varicocele. In 11/15 of the patients with varicocele, the l e f t t e s t i c u l a r length was 80-85% of the r i g h t ; in 2/15, the l e f t t e s t i c u l a r length was 20-25% of the right;and in 2/15, the t e s t i c u l a r lengths were equal. Decreased t e s t i c u l a r size was found with small varicoceles as often as with large ones. Hence many adolescents with varicocele have decreased size of the i p s i l a t e r a l t e s t i c l e . A s i g n i f i c a n t number of men with varicocele become i n f e r t i l e , but no information currently a v a i l able c l a r i f i e s who is at r i s k f o r this complication. We believe that adolescents with varicocele and decreased t e s t i c u l a r size should have t h e i r varicoceles repaired, since decreased t e s t i c u l a r size may indicate incipient decrease in function.