adolescent health

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Persistent Stigma, Skepticism About Mental Illness Causes Real Harm

By Dr. Steve Scholzman
Guest Contributor

Profound misunderstanding about mental illness — its causes, its legitimacy and its treatment — permeate our culture. And the stigma that accompanies this lack of understanding hurts, a lot. Take this example — hardly original or rare.

Imagine a 15-year-old adolescent girl with fairly severe depression. She may be a classmate of your child, or the daughter of a friend. Let’s call her Sally.

Sally’s not so ill that she needs to be in the hospital, but she’s close. Her family and I — her psychiatrist — are doing our best to get her better as quickly as possible so she can get back to school. She’s been out now for about three days. Why? She literally lacks the capacity to think clearly. It’s all she can do to drag herself out of her bed and run a toothbrush across her teeth.

(Michael Summers/Flickr)

(Michael Summers/Flickr)

There’s a big family history of depression so Sally’s parents are both familiar with and frightened by her struggles.

“Can you call the school and ask them to give her more time on some work?” the parents ask.

“Sure,” I say, and I get in touch with the school administrator.

“Well,” I’m told by the very well-meaning administrator, “It IS a tough time of year. The other kids are getting through it somehow. I don’t see why she should get special treatment.”

“Because she has the equivalent of the flu,” I say. I like to use analogies at these crossroads.

“But the flu feels awful. Does she have a fever? Because if she does, she shouldn’t come to school…”

“No, she doesn’t have a fever,” I say. I try another analogy. “What if she had been in a car accident, God forbid?”

“Well, that’s pretty different, isn’t it?”

“How?” I ask.

“She’d be hurt,” I’m told. “This is an entirely different thing. You’ll need to get her pediatrician to call.”

I ask the pediatrician to call, and I can feel his discomfort over the phone. “I’m not very good at making this case,” he acknowledges. “It’s probably better if you just call them back.”

(I have to wonder whether he’d be so uncomfortable if I were a gastroenterologist asking him to call the school about a patient with ulcerative colitis?) Continue reading

New Pro-Circumcision Guidelines: Cutting Comments, Adolescent Choice

Preparing for a circumcision

Preparing for a circumcision (Cheskel Dovid/Wikimedia Commons)

Just days after the U.S. Centers for Disease Control and Prevention issued draft recommendations on male circumcision asserting that the health benefits outweigh the risks, more than 300 comments (and counting) have been posted on the agency’s website.

Surprise: The feedback overall reflects anger over mounting institutional support for what some call a “barbaric, outdated practice.” (The public comment period on the agency’s proposed recommendations ends on Jan. 16.)

Here are a few random comments:

When I was a little girl and discovered my little brothers had been cut, I was horrified for them and grateful I wasn’t born a boy.

The only benefit of infant circumcision is the fatter wallet of the circumciser. Wake up people! Condoms prevent sexually transmitted diseases, not circumcision. Males deserve the same protection from genital cuttings that females do. Shame on the CDC for condoning such a barbaric, outdated practice that nearly every other industrialized nation has refused to adopt!

Routine infant circumcision is morally wrong because it is non-essential cosmetic surgery performed on the body of a human being not yet old enough to give informed consent….

Your agenda clearly shows your primary purposes is for health insurance to pay for male genital mutilation. Please don’t continue to make the U.S. the continued laughing stock of the international medical community.

You get the picture.

The CDC stopped short of actually telling parents they must circumcise their baby boys; instead the agency offered guidelines — including a new recommendation that un-circumcised adolescent boys discuss the risks and benefits with their doctors — and laid out the latest research. Male circumcision, according to an AP report, can:

•Cut a man’s risk of getting HIV from an infected female partner by 50 to 60 percent.

•Reduce their risk of genital herpes and certain strains of human papillomavirus by 30 percent or more.

•Lower the risk of urinary tract infections during infancy, and cancer of the penis in adulthood.

Studies have not shown that circumcision will reduce an HIV-infected man’s chances of spreading the AIDS virus to women. And research has not found circumcision to be a help in stopping spread of HIV during gay sex.

The guidelines say circumcision is safer for newborns and infants than for older males, noting the complication rate rises from 0.5 percent in newborns to 9 percent in children ages 1 to 9, according to the CDC. Minor bleeding and pain are the most common problems, experts say.

CDC officials are recommending doctors tell parents of baby boys of the benefits and risks of circumcision…

These are the first federal guidelines on circumcision, a brief medical procedure that involves cutting away the foreskin around the tip of the penis. Germs can grow underneath the foreskin, and CDC officials say the procedure can lower a male’s risk of sexually-transmitted diseases, penile cancer and even urinary tract infections.

I asked circumcision expert Marvin Wang, co-director of the newborn nurseries at Massachusetts General Hospital (and someone who has performed thousands of circumcisions), about the new CDC draft recommendation, and he offered this thoughtful analysis:

First a little history:

For decades, the American Academy of Pediatrics (AAP) (which produces the majority of research-based policy for U.S. pediatric care) has led a relatively neutral stance on male neonatal circumcision, as the literature has shown that there is a relatively small health benefit by performing circumcision (there is huge debate on how one interprets the numbers on this, but overall, that conclusion is true). However, a game changer that tilted the balance towards claiming health benefits came in 2005-2007, when three separate World Health Organization clinical trials were performed in Africa demonstrating that circumcision among adult men in Sub-Saharan African settings reduced the acquisition of HIV by 50%.

With that, the AAP changed its recommendations in 2012 to reflect these studies. Their statement basically said that, yes, we know that there are health benefits now – enough to encourage parents to strongly consider circumcision for the newborn. However, the decision still lays with the parents, balanced by their beliefs (which may be influenced by religious, social or familial reasons). There are other tenets to the statement, but let’s just focus on this one topic, as this is most relevant to the recent CDC statement.

In light of the infectious disease issues involved, the medical community had been told that the CDC would make their recommendations regarding circumcision at about the same time as the AAP’s release. So, with this week’s statement, you are basically seeing a reaffirmation of the 2012 AAP statement. We don’t really see anything new. The health benefits touted in the CDC report have all been discussed before in the literature.

The only potentially new issue here is a topic that the 2012 AAP statement neglected: The idea of encouraging un-circumcised adolescents to discuss the option with their physician. Continue reading

When You’re Dealing With A Stressed-Out High School Junior: 5 Tips

By Steve Schlozman, MD
Guest Contributor

(Miguel Angel/Flickr)

(Miguel Angel/Flickr)

Sometimes things are so obvious we fail to take notice.

For example, if I tell you that high school students who plan on attending college are under a lot of pressure, your response might sound like, well, a 17-year-old:

“Duh,” you might say, “What else is new?”

This is not new, of course, but the pressure continues to get exponentially worse. Students from all walks of life are increasingly overscheduled, academically burdened and socially overwhelmed. We pile all this stuff on top of the already treacherous waters of adolescence, and it’s no wonder kids feel emotionally battered.

I started thinking more about this when a friend of mine from high school called about his 9th grade daughter.

“She’s 14,” my friend said, “And they’re telling her in the fifth week of school about college. Did we worry about college in 9th grade?”

No way.

I used to think that the pressure on high school teens was largely a regional issue. I was raised in the Midwest, so of course things weren’t quite so high-stress compared to here in Boston. But my friend was calling from Colorado, and this is therefore not a regional issue. What is clear, is that this pressure is not good for our kids.

Let’s look at some of the data:

•According to the Department of Education, there are around 2,675 nonprofit four-year undergraduate colleges in the United States.

•Although the number of students in high school continues to slowly decline, the number of students applying to college is steadily increasing. In 2011, there were about 20.4 million students enrolled in college, and that number is projected to reach about 23 million by 2020.

•One out of four teenagers submitted college applications in 2011, at an average of around $40 per application

•In 2001, the typical college admitted around 71 percent of its applicants. By 2011, this number dropped to around 65 percent. I could go on. The common application increases the overall number of applications that students complete, schools look to college acceptance rates as a means of measuring their success and they therefore pass this pressure onto their students, and students themselves are more and more led to view the junior year of high school as something akin to academic and extracurricular boot camp. I’ve seen students get freaked out even before the first week of 11th grade.

This this kind of systemic stress is not good for anyone. A 2008 study found that the increased rate of academic dishonesty on high school campuses stemmed, at least according to some students, from the increasingly high achievement bar that the students themselves experienced. This of course does not excuse cheating, but it is worth noting that both cheating and academic and social pressures seem to have grown in concert with one another. Continue reading

Study: Aerobics Plus Resistance Training May Be Best Against Teen Obesity

obese kid

A new study published online in JAMA Pediatrics finds that a combination of aerobic workouts plus resistance training offers the best hope for teenagers battling obesity.

From the abstract:

Aerobic, resistance, and combined training reduced total body fat and waist circumference in obese adolescents. In more adherent participants, combined training may cause greater decreases than aerobic or resistance training alone.

Here’s more from The New York Times coverage of the study, which found that “diet without exercise accomplishes little:”

Canadian researchers put 304 obese teenagers on a diet with a daily energy deficit of 250 calories (measured from their resting energy expenditure). Then they assigned them randomly to one of four groups for 22 weeks: aerobic training on exercise machines like treadmills, resistance exercise using weight machines and free weights, combined aerobic and resistance training, and a diet-only group with no exercise… Continue reading

When Teens Talk Of Suicide: What You Need To Know

By Gene Beresin, MD and Steve Schlozman, MD
Guest Contributors

Here’s the kind of call we get all too frequently:

“Doctor, my son said he just doesn’t care about living anymore. He’s been really upset for a while, and when his girlfriend broke things off, he just shut down.”

Needless to say, situations like this are terribly frightening for parents. Kids break up with girlfriends and boyfriends all the time; how, parents wonder, could it be so bad that life might not be worth living? How could anything be so awful?

For clinicians like us who work with kids, these moments are at once common and anxiety-provoking. We know that teenagers suffer all sorts of challenges as they navigate the murky waters of growing up. We also know that rarely do these kids take their own lives. Nevertheless, some of them do, and parents and providers alike must share the burden of the inexact science of determining where the greatest risks lie.

Suicide has been in the news lately with a flurry of new research and reports and, of course, the high profile death earlier this summer of Robin Williams.

But suicidal behavior among teenagers and kids in their early 20s is different and unique.

So let’s look at a couple of fictional — yet highly representative — scenarios.

depressed

Charlie, a 16-year-old high school junior was not acting like himself. In fact, those were his parents’ very words. Previously a great student and popular kid, Charlie gradually started behaving like a different person. He became more irritable, more isolated and seemed to stop caring about or even completing his homework. Then one morning, just before before school, he told his mother that he wished he were dead.

Myths: Common But Distorted 

There are countless other examples. Sometimes kids say something. Sometimes they post a frightening array of hopeless lyrics on Facebook. And most of the time — and this is important — kids don’t do anything to hurt themselves. Morbid lyrics and even suicidal sentiments are surprisingly common in adolescence. Still, this does not mean for a second that we take these warning signs lightly. In fact, there is a common myth that asking about suicide perpetuates suicide. There is not a shred of evidence in support of this concern, and in the studies that have been done, the opposite appears to be true. Kids are glad to be asked.

We have to ask. It’s really that simple. But, we ask with some very basic facts in mind. Suicidal thinking, and even serious contemplation of suicide, is, as we mentioned, very common among high school students. In the Center for Disease Control Youth Risk Behavior Surveillance Survey distributed every two years to about 14,000 high school kids in grades 9-12, students are queried about a range of high-risk behaviors, including suicide.

The Underlying Mood Disorder

In 2013, 17% of teens reported seriously considering suicide, and 8% made actual attempts. Each year in the United States, about 15 in 100,000 kids will die by suicide, making suicide the third leading cause of death in this age group. Additionally, we have no idea how many deaths by accidents (the leading cause of death) were, in fact, the product of latent or active suicide.

The greatest risk factors for a teenager to die by suicide include the presence of some mood disorder (most commonly depression), coupled with the use of drugs, or other substances, and previous attempts.

Although research suggests that girls attempt suicide more often, boys more often die from suicide. Add these risk factors together, and it turns out that Caucasian boys are at highest risk.

Some of this is also driven by a still immature brain. Impulsive behavior is notoriously common in teens, and in many cases, it looks as if the act of suicide was the result of a rash and sudden decision. Continue reading

Pediatricians: Middle And High School Should Start No Earlier Than 8:30 AM

(eltpics/Flickr via Compfight)

(eltpics/Flickr via Compfight)

It’s one of the great joys of early parenthood: Finally being able to sleep until a reasonable hour — say, 6 a.m. Then, before you know it, you’re facing the opposite problem: Homeroom is just half an hour away, and your tween or teen remains an immovable lump beneath the covers.

As any parent who’s observed it would suspect, this is deep biology at work. Today, the American Academy of Pediatrics issues both an up-to-date explanation of research on adolescent sleep and a ringing call to the country’s schools to heed it and begin school later for “pathologically sleepy” older students. Sleep deprivation in youth is a common — “and easily fixable” — public health issue, the academy says in a policy statement.

From the press release, whose headline begins “Let Them Sleep:”

“The research is clear that adolescents who get enough sleep have a reduced risk of being overweight or suffering depression, are less likely to be involved in automobile accidents, and have better grades, higher standardized test scores and an overall better quality of life,” [statement lead author Dr. Judith] Owens said. “Studies have shown that delaying early school start times is one key factor that can help adolescents get the sleep they need to grow and learn.”

Many studies have documented that the average adolescent in the U.S. is chronically sleep-deprived and pathologically sleepy. A National Sleep Foundation poll found 59 percent of 6th through 8th graders and 87 percent of high school students in the U.S. were getting less than the recommended 8.5 to 9.5 hours of sleep on school nights.

This medical stance on sleep deprivation is not new; the research has been accumulating for many years. But the academy reports that about 40 percent of American high schools still start before 8 a.m., and only 15 percent launch the school-day at or after 8:30. Among middle schools, it says, more than one-fifth begin at 7:45 or earlier.

If schools are not shifting later as fast as pediatricians might like, that could be because, like virtually everything in education, it’s not as simple as it might seem.

‘Life is going on right now in hyperspeed for most of our young people.’

“Once you go deeper into the lives of kids today, things become more complex,” says Dr. Bob Weintraub, who was the headmaster of Brookline High School from 1992 to 2011 and is now a professor of educational leadership at Boston University. Based on the research, Brookline High shifted start times for most students to 8:30 during his tenure, he said, but such shifts do raise issues.

“One of the practical problems has always been for high school athletics and school activities,” he said; if school ends later, sports and other activities must start later, and outdoor sports are hindered when darkness descends. Continue reading

A Bittersweet Graduation For Patients At The Mass. Hospital School

Brian Devin, CEO of The Massachusetts Hospital School, speaks with student Miguel M. in the cafeteria after lunch. (Jesse Costa/WBUR)

Brian Devin, CEO of The Massachusetts Hospital School, speaks with student Miguel M. in the cafeteria after lunch. (Jesse Costa/WBUR)

By Gabrielle Emanuel

CANTON, Mass. — It’s lunch break and there’s a wheelchair traffic jam in the school hallway.

Friendly shouts of “Beep! Beep!” and “You’re blocking traffic” interrupt chatter about one kid’s new backpack and another guy’s birthday plans.

It’s a typical school scene, except a bunch of the kids are using computers to talk and others breathe through ventilators.

Like students across the country, many of these kids are getting ready for graduation. It’s a bittersweet time for graduates of all stripes, but perhaps nowhere is it more bittersweet than here.

All of the 91 students in these hallways are also patients. When they graduate – as about a dozen will this year – they’re not only leaving their friends and teachers, they’re leaving the hospital they’ve called home for years, and in some cases, a decade or more.

The campus’ main entrance is on a rural road in Canton, where a flashing sign reads: The Massachusetts Hospital School.

Brian Devin, the CEO, says that when cars zip past drivers often “think it’s a school where they teach people to work in hospitals.”

Devin says it’s a fair assumption, but completely wrong. This facility is part pediatric hospital, part elementary and secondary school. It serves children with severe disabilities — muscular dystrophy, cerebral palsy, brain injuries — and is run jointly by the state Department of Public Health and the Department of Education.

Children as young as 6 or 7 can be admitted to the hospital and they often stay at this lakefront campus until the kid’s clock strikes 22 years old, when it’s time to graduate and it’s time to go, regardless of whether there is another alternative place to go.

A Non-Institutional Hospital

As the hallway traffic starts moving, the students wheel themselves out into the brisk spring air. They race down covered ramps toward horseback riding lessons, speech therapy sessions and wheelchair hockey practice.

Those white ramps create a web that connects all the brick buildings on this idyllic, 160-acre facility.

“The kids are all over the place. They are not always with staff — we don’t want them to always be with staff,” Devin says. “We want them to be with themselves and with other kids as much as possible. There is no real institutional flavor.”

The Massachusetts Hospital School’s ultimate goal is to cultivate as much independence as possible for these children. Continue reading

Navigating The Senior Prom: Tips To Help Parents Cope

From left: Zack Beresin, Sophie Manning and Glennon Beresin (Zack's twin sister) before their senior prom (Courtesy of Gene Beresin)

From left: Zack Beresin, Sophie Manning and Glennon Beresin (Zack’s twin sister) before their senior prom (Courtesy of Gene Beresin)

By Drs. Steve Schlozman and Eugene Beresin
Guest contributors

The recent fatal stabbing of a 16-year-old girl in Connecticut have understandably cast a dark shadow over prom night.

Attacks like the one in Connecticut are rare, but these events receive massive attention and can thus obscure the more common tribulations characteristic of the spring dance.

In no way do we want to make light of the seriousness of recent events, but we also do not want to miss the opportunity to explore the more common hand-wringing of this yearly ritual.

So, consider the following scenario:

It’s late afternoon on the day of the prom. Your son ambles downstairs in his tuxedo, silently seeking approval. Your younger daughter giggles: “What’s that thing he’s wearing?” she asks.

“That’s a tuxedo,” you say.

“I know what that is, Daddy, but what’s that big black belt?”

“It’s a cummerbund,” you reply.

But you are wrong, according to your daughter’s analysis. “It’s morantic,” she says. “I think he looks morantic.”

That’s how she says romantic. It usually cracks up your son when she says this, but not today.

“No,” you respond. “You look very distinguished.”

He’s still not pleased. He’s 18, after all, and not ready to be distinguished.

And as his date arrives, you have this sinking recollection: they are preparing themselves for a night that can’t possibly live up to expectations.

Then you start to worry about the sharp turn that can separate the glamour of the dance itself from the potential debauchery of the post-prom festivities. No dress-up clothes then, no contrived formalities…just hanging out with friends and staying up all night, with possible cut-loose celebrations (read: sex) or unfettered over-indulgence (read: drugs).

For all those parents out there who are planning to launch their own kids into this great Western tradition, we would like to opine from our vantage points as child and adolescent psychiatrists, and as former prom attendees, and, for at least one of us, as someone who has seen four kids attend proms. Here are a few tips:

1. Don’t use the “S” word

When your daughter emerges in her prom dress, don’t fuss. Tell her that she looks great, or that she looks beautiful, but don’t say sexy. Continue reading

What Teens Say Teens Should Know About Sexually Transmitted Diseases

(Planned Parenthood)

(Planned Parenthood League of Massachusetts)

By Joey Boots-Ebenfield
Guest contributor

I’ve gotten used to hearing myths and misinformation when I talk about sex with fellow teens.

And I talk about sex often in my role as an 17-year-old peer educator with the Planned Parenthood Get Real Teen Council (GRTC) — a year-long high school sexual health program for 10th-12th graders who are trained to facilitate sex education workshops and serve as resources for peers, families and communities.

If teens are uncomfortable talking about topics related to sex and sexuality, or don’t have a trusted source of information about their health, it’s easy for all kinds of misinformation to spread. And of course, there’s the Internet, where bad information is often rampant, so it’s not always a reliable place to find accurate health information.

The subject of sexually transmitted diseases (STDs) is no exception. I’ve heard some pretty interesting misconceptions about what STDs are and what it’s like to get tested. One myth is that STDs have obvious symptoms, like localized pain or some other physical sign.

In fact, this is quite the opposite! STDs often show NO symptoms. This myth is especially dangerous because it means that someone can have an STD and not even know it. As a result, many STDs go untreated, which can cause cause some pretty nasty complications. Continue reading

Coerced Sex Common For Teen Boys And Young Men, Study Finds

A few nights ago, unable to wind down, I was searching for something to watch and stumbled across the film “Adore.” It’s about a pair of lifelong friends (grown women) who end up having affairs with each other’s young, hunky, 19- or 20-year-old sons. My first reaction was the same as one Netflix commenter:

“…if this had been two pals and each other’s teen daughter; well, you get the point. The movie would not have been made, or if so, it would have had an entirely different hue-to say the least. DOUBLE STANDARDS.”

Or, as A.O Scott wrote in his New York Times review:

“It is worth noting that the same movie about a couple of dads sleeping with each other’s 20-year-old daughters would need, at a minimum, to confront the ickiness of the situation. Really, such a movie would be unlikely to make it into theaters, in spite of the commonness of real-life relationships between older men and younger women.”

(Dustin Hoffman, Anne Bancoft in "The Graduate"; Movie-Fan/flickr)

(Dustin Hoffman, Anne Bancoft in “The Graduate”; Movie-Fan/flickr)

The film isn’t about sexually coercion; but it is about boundary breaking, and I thought of it again reading this new study on the pervasive, but largely unexamined problem of sexual coercion among boys and young men.

The study, published in the journal Psychology of Men and Masculinity, found that coerced sex is fairly common for teenage boys and college-age men and can lead to psychological distress and risky behavior, such as sexual risk-taking and alcohol use.

From the American Psychological Association news release:

A total of 43 percent of high school boys and young college men reported they had an unwanted sexual experience and of those, 95 percent said a female acquaintance was the aggressor…

“Sexual victimization continues to be a pervasive problem in the United States, but the victimization of men is rarely explored,” said lead author Bryana H. French, PhD, of the University of Missouri. “Our findings can help lead to better prevention by identifying the various types of coercion that men face and by acknowledging women as perpetrators against men.” Continue reading