Clinical Updates in Adolescent Medicine

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Drs. Abigail Harrison & Asha Pemberton

Objectives

Case 1

• Jana is 16y (“almost 17”) and about to start 6^th form at a new school
• She has come for a school medical
• Mom comments she has been spending more time in her room and seems to never be hungry since she has started this new fitness regime she is on
• Jana has no concerns but hopes she doesn’t need any shots

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But…..

• You meet with her alone and ask a few more questions
• She has been unhappy with her weight
• She has been dieting past 5 months; jogging 3 times/week to “look good by the time I start my new school”. “I’m tired of being the cute chubby one” “now my guy friends are really looking at me”
• LMP was 2 months ago and “it was the best one I ever had, it was so light I had no cramps”
• “I’m not sure how come I missed my last period…but I’m not complaining….and ....NO I am not having sex …. I’m not pregnant”
• Appetite less just doesn’t feel like eating much now but feels fine

Physical Examination

• Essentially normal

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http://www.cdc.gov/nchs/about/major/nhanes/growthcharts/clinical_charts.htm

http://www.cdc.gov/nchs/about/major/nhanes/growthcharts/clinical_charts.htm

Caught it relatively early !!

Disordered eating behaviours

Disordered eating behaviours(DEB’s)

• Wide range of unwarranted weight control measures in someone with an altered perception of their weight

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• Includes:
• severe caloric restriction
• abnormal eating patterns such as skipping meals, consumption of unusually large quantities of food (binges)
• compensatory behaviours - excessive exercise, use of laxatives, diet pills, self-induced vomiting

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Why are adolescents at risk?

DEBs in Jamaican adolescents

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• 22% adolescents (11-19y) screened were identified as ‘at risk’ for developing an eating disorder (females 28% > males 16%; p<0.001)

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• 8% self-induced vomiting

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• 3% chemical methods

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Harrison et al JAH 2015

Eating Disorders

Anorexia Nervosa (AN): DSM-V

• Restriction of energy intake → significantly low body weight

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• Intense fear of gaining weight or becoming fat, even if at a significantly low weight

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• Disturbance about body weight or shape, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of current low body weight

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• Sub-Types
• Restrictive(AN-R)
• Binge/Purge (AN-BP)

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Atypical Anorexia Nervosa: DSM-V

All criteria for anorexia nervosa are met:

• except despite significant weight loss, the individual’s weight is within or above the normal range

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Bulimia Nervosa(BN): DSM-V

• Recurrent episodes of bingeing
• Recurrent inappropriate compensatory behaviors
• Binge eating and compensatory behaviors occur at least once a week for 3 months
• Self-evaluation is unduly influenced by body shape and weight

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Binge Eating Disorder: DSM-V

• Recurring episodes of binge eating :
• 1 time per week for 3 months

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• Binge eating associated with 3 or more:
• Eating  rapidly 
• Eating until uncomfortably full
• Eating large amounts when not hungry
• Eating alone because of being embarrassed by how much one is eating
• Feeling disgusted /depressed/ guilty after overeating

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• Marked distress regarding binge eating

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• Absence of regular compensatory behaviors

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AVOIDANT RESTRICTIVE FOOD INTAKE DISORDER (ARFID) - DSM-V

• Eating or feeding disturbance manifested by persistent failure to meet appropriate nutritional or energy needs leading to one or more of the following:
• Significant weight loss (or failure to achieve expected weight gain or faltering growth )
• Significant nutritional deficiency
• Dependence on enteral feeding or oral nutritional supplements
• Marked interference with psychosocial functioning

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• not attributable to a concurrent medical condition or not better explained by another mental disorder

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Etiology

Assessment - History

Carefully take a developmentally appropriate history 

• Weight History 
• Body (dis)satisfaction
• Nutritional History
• Bingeing/Purging
• Exercise History
• Menstrual History
• Family History
• Review of Systems
• Psychosocial History (HEADS)

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Physical Examination

• Weight loss / Failure to gain weight and height
• Emaciated
• Flat affect
• Hypothermia
• Bradycardia/ arrythmias
• Orthostatic changes in pulse and blood pressure
• Cold extremities, acrocyanosis
• Dull, thinning scalp hair
• Lanugo hair

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• May be no apparent physical signs
• Palatal scratches
• Swelling of the parotid glands
• Frequent and unusual dental problems
• Calluses on the dorsum of hand - Russell’s sign
• Menstrual irregularities

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Unique medical

complications

Cardiovascular

Metabolic

Gastrointestinal

Pubertal delay/interruption

Osteoporosis

Growth Impairment

Structural brain changes

General treatment guidelines

Management of Eating Disorders

Outcomes

• Traditional treatments: 
• 1/3 full remission in 2-5 years 
• 1/3 partially recover 
• 1/3 chronic illness
• Family Based Therapy: 
• 50% - 60% full remission in 1 year  
• 25% to 35% partially recover 
• 15% are nonresponsive to treatment

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• Recovery from anorexia nervosa much less likely the longer the illness has persisted 

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Questions?

CASE 2

• 15 yo male adolescent
• Fall off in grades for past 2 years at prominent high school
• Challenges from grade 3-4 but grades always been maintained
• No history of disrupting class, talking a lot but would day dream
• Would forget his pencil case or homework at home regularly; frequently lost his bag or books

• Met with him alone
• He thinks he has ADHD (Tik Tok) but mom is not having it – tells him ‘stop the foolishness you’re perfectly fine’
• Loses track of time – keeps being told he is procrastinating
• Having difficulty with friends
• Getting frustrated by these challenges sometimes feels overwhelmed by it

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Factors to increase suspicion of diagnosis

Differential diagnoses to consider

• Developmental variations - intellectual disability, giftedness; learning, language, visual-motor, or auditory processing problems
• Emotional and behavioral disorders –anxiety disorder, mood disorders, oppositional defiant disorder, conduct disorder, obsessive-compulsive disorder, substance use disorder, posttraumatic stress disorder, and adjustment disorder
• Environmental factors - stressful home environment, inappropriate educational setting, less structure/ rules at home, high-frequency digital media use

Differential diagnoses to consider

• Medical - hearing or visual impairment, lead poisoning, thyroid abnormalities, sleep disorders (eg, obstructive sleep apnea, restless leg/periodic limb movement disorder), tics, and medication effects 

Assessment Scales

• Connors rating scale (6-17y)
• good sensitivity and specificity
• Self-report scale

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• Vanderbilt (6-12)

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• Child Behaviour Checklist

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Sharing the news with adolescent and parent

Treatment

Questions?

TRAUMA-INFORMED CARE FOR ADOLESCENTS AND YOUNG ADULTS�IN A TIME OF COVID-19: �

Dr. Asha Pemberton

MBBS (Hons) DM (Paediatrics)

Clinical Fellowship: Adolescent Medicine

PG Dip. Loss, Grief and Trauma Management (Distinction)

GOALS FOR TODAY

• Recognition that we ALL, (but especially our adolescents and young adults) have experienced losses and grief during and continuing in the pandemic

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• Specific losses and trauma relate to the A/YA age group

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• Effects ARE impacting their ongoing lives and clinical presentations

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• Understanding of grief, loss and trauma to apply to trauma informed approaches and widen our lens as regards these concepts in our population

A CHANGED WORLD

The COVID-19 Pandemic changed the entire world

Adolescents/Young Adults experienced many forms of grief and loss

-Death of parents, siblings, wider family, friends

-Stymied grief processes (funeral, last rites, viewing of deceased)

-Community disruption and stigma

-Impact of social disruption, academic overhaul, disconnection

-Missed major milestones of adolescence

-School entrance (Secondary, University)

-Graduation

-Milestone Birthdays (10,13,16,19,21,25)

Exposure to domestic and intimate partner violence, parental substance use

NEW AND UNANTICIPATED STRESSORS

• Social anxiety
• School anxiety
• Information/Misinformation overload
• Vaccine hesitancy
• Disrupted sleep-wake cycles
• Impact of excessive screen time
• Disrupted eating routines
• Body dysmorphia

RESPONSES IN A/YA ARE MULTIDIMENSIONAL

• Pre-pandemic exposure and resources
• Prior exposure to adversity
• Physical and mental health vulnerabilities
• Economic and social supports
• Exposures encountered since the pandemic:
• Illness of a family member
• Loss of family security
• Job status – essential health care workers
• Time immersed in social media, news, over-exposure to information
• Community-level stressors – e.g., “Hot spots”

GRIEF AND LOSS ARE UNIVERSAL, YET UNIQUE

A loss occurs when an event is perceived to be negative

and it results in long-term changes in one's social situations, relationships, or way of viewing the world and oneself. Life will never be the same.

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Grief is a strong, sometimes overwhelming emotion that occurs due to the actual pain felt after a loss

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Mourning is the acting of social behaviours and rituals performed during times of grief

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GRIEF AND LOSS ARE UNIVERSAL, YET UNIQUE

Losses that are real or tangible (death, separation)

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Losses that are symbolic or intangible (graduation, milestones)

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Losses that are stigmatized (death due to COVID in early pandemic)

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Losses that are disenfranchised (A/YA unable to discuss the actual loss)

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Different Types of Losses: Different Types of Grief

GRIEF AND LOSS MODELS

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• Each model explains responses to grief (in stages, or through tasks or in phases) and provides some useful guidance on how to move forward

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• The models can be seen as complementary to each other; we can choose what we like from each one and apply it to our own lives and grieving process

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• Knowing that grief is a universal, natural response to loss, helps us understand that experiencing negative feelings is normal and that these feelings will go away or become less painful with time

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THE KÜBLER-ROSS MODEL

One of the most well-known models on how to deal with grief is the Kübler-Ross Model

According to it, people go through five emotional stages when they are grieving:

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1. Denial- This can’t be happening to me!
2. Anger- Why is this happening? Who is to blame?
3. Bargaining- Make this not happen, and in return I will...
4. Depression- I’m too sad to do anything.
5. Acceptance- I’m at peace with what happened.

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1. Accept the reality of the Loss
2. Process the pain of grief
3. Adjust to a new world
4. Find a way to connect

THE DUAL PROCESS MODEL

• According to this model, grief is a dialogue between pain and hope:

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• There is oscillation between focus on our loss and other times we focus on restoring our lives back to normal

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• Very applicable model when we consider grief/loss in A/YA

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• Aligns with adolescent cognitive processes

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PERSONAL RESPONSE �GRIEF AND LOSS ARE UNIVERSAL, YET UNIQUE

• While models help us understand grief and our general responses to loss, we must remember that grieving is a personal process
• Only the individual knows how they feel and how much time we need to recover from a loss

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• Approaches to Adolescent and Young adults in pandemic world must include:

-Understanding of types of losses they all endured

-Grief responses and variations

-How grief is impacting their clinical presentations

-Loss, Grief and TRAUMA definitions

-Trauma informed approaches

WHAT IS TRAUMA?

Individual trauma results from an event, series of events, or set of circumstances experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being

TRAUMA INFORMED CARE ELEMENTS

Understanding the prevalence of trauma

Recognizing how trauma impacts individuals

Putting this knowledge into practice

to actively resist re-traumatization

POTENTIAL TRAUMATIC EVENTS

Abuse

• Emotional
• Sexual
• Physical
• Domestic violence
• Witnessing violence
• Bullying
• Cyberbullying
• Institutional

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Loss

• Death
• Abandonment
• Neglect
• Separation
• Pandemic
• Natural disaster
• Accidents
• Terrorism
• War

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Chronic Stressors

• Poverty
• Racism
• Invasive medical procedure
• Community trauma
• Historical trauma
• Family member with substance use disorder

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IMPACT OF TRAUMA: �ADVERSE CHILDHOOD EXPERIENCES

CDC

IMPACT OF TRAUMA ON THE BRAIN

• The brain has a bottom-up organization
• Experiences build brain architecture
• Fear activates the amygdala and shuts down the frontal lobes of the cortex.
• Toxic stress and trauma derail healthy development, and interferes with normal functioning

IMPACT OF TRAUMA

The effect of trauma on an individual can be conceptualized as a normal response to an abnormal situation

IMPACT OF TRAUMA:�PROBLEMS OR ADAPTATIONS?

“Passive, unmotivated”

OR

Giving in to those in power

Fight

“Non-compliant, combative”

OR

Struggling to regain or hold onto personal power

Flight

“Treatment resistant, uncooperative”

OR

Disengaging, withdrawing

Freeze

IMPACT OF TRAUMA:�SIGNS OF TRAUMA RESPONSES

Fight, Flight, Freeze responses occur immediately in traumatic situations

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Can also be chronic and lead to similar patterns of behaviour following long term, severe or ongoing trauma

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This impact on the developing teen/YA brain can lead to long lasting

Behavioural and other outcomes

APPROACH IS KEY

PRACTICE OF �TRAUMA INFORMED CARE FOR ADOLESCENTS AND YOUNG ADULTS COVID-19

IT STARTS WITH APPROACH…..NOT THESE!�

1. What you have to feel sad about?
2. You should be grateful
3. People out there dying and you studying party?
4. What do you want me to do about it?
5. Calm down.
6. What’s your problem?
7. You never (or) you always….
8. Just get over it
9. Why don’t you be reasonable?

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USE THESE STATEMENTS:�REFLECTION, EMPATHY, VALIDATION

• Opening statements: “What happened to you? How did it make you feel?

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• Verbally reflect another’s emotional state:
• “It sounds like you feel very angry about this.”

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• Offer the ultimate empathic statement:
• “Let me be sure what I heard is what you just said.”

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• Validate the person’s emotions:
• “I understand why you feel this way about this.”

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USE ACTIVE LISTENING

• Convey through verbal acknowledgement, conversation, and body language that you are really paying attention to the individual, and what they are saying and feeling.
• Use clarifying statements such as, “Tell me if I have this right…”
• This does not mean you agree with the individual,
• but that you understanding what he/she is saying.

TIME AND REPETITION ARE ESSENTIAL

• A/YA often will not be able to understand or contextualize their own feelings
• Patience and time are required by practitioners
• Allow them to repeat and restate their feelings
• When offering support, strategies and solutions, we too need to repeat and restate

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• Recognize that ongoing exposures and resettling are still in process

CASE PRESENTATIONS�

15 Year female

Affluent Trinidadian family

Noted over past several weeks, prior to return to FTF classes to be anxious and finding reasons to avoid going to school

Parents noted in particular a refusal to take off her mask anywhere…they only noticed during a dental appointment

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Further inquiry:

-Losses of friendships during social restrictions

-Marked anxiety regarding body image and return to FTF school

-Repetitive and intrusive thoughts that her “nose was big” and “face was ugly”

-Significant anxiety and panic at the thought of removing mask

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-Normal appearing adolescent female

-Intense and intrusive features of body dysmorphia emerging

-All commenced during lockdown and emerged with return to social interaction

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CASE PRESENTATIONS�

17 Year male presented with cycles of binge and purge behaviour

Noted during lockdown to stay up late gaming with friends

Resides in home with single mother, who is a nurse and worked long hours as a front-line worker

He admitted to late night eating, all day sleeping

Approximates that he gained over 20 lbs (unsure) but definite weight gain

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Upon return to FTF classes was teased by friends (although he denies calling it outright bullying)

Commenced strict daily fasting, followed by uncontrolled binging and purging

Calls himself “obsessed” with losing weight and getting fit

Activity unknown to mother

Came into Teen Clinic for advise regarding acne treatment and upon enquiry this emerged

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Diagnostically: Bulimia Nervosa

CASE PRESENTATIONS�

22 Year old Young Adult

Identifies as Non-Binary

Came in for general check up prior to commencing UWI

During consultation, on enquiry about general recent life, disclosed that during pandemic became clearly on gender

Joined a local online community of LGBTQ youth some of whom also due to commence UWI

Forged a relationship during the time, unknown to parents/family: all online

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Now about to commence in-person interactions, relationship, openness, has experienced significant anxiety.

Does not feel able to discuss with anyone

Recently started drinking more at home (a few Smirnoff Ice drinks daily) to ease anxiety

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Aware that things are spiralling but unsure how to process

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May not fit a diagnostic category

Stymized social development in a vulnerable/stigmatized group

BE AWARE

Disrupted peer relationships

Anxiety about conducting in person connections, relationships, sexual exploration

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Academic readjustment and related anxiety

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Body image concerns and identity (delayed navigation of this domain, as indoors for a long time)

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Altered sleep-wake; daytime-nighttime eating cycling

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Stigmatized losses: due to COVID, hidden relationships

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Exposure to violence/abuse

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Escalating alcohol/substance use

CASE PRESENTATIONS�

What is the common link?: Trauma informed approach: Basic Steps

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Create Safety

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Are you willing to share anything/any experience that happened to you over the past year/2 years?

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How has that experience affected you/affecting you today?

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How might you use your story to positively help other teens/young adults?

TRAUMA INFORMED CARE:�FURTHER READING

Judith Herman (2015) Trauma and Recovery

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Linda Sanford (1991) Strong at the Broken Places

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Robert Sapolsky (2004) Why Zebras Don’t Get Ulcers

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Bessel Van Der Kolk (2014). The Body Keeps the Score

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