Pediatric Examination and Board Review (130 page)

12.
(C)
Alcohol is the most common substance of abuse in adolescence. In 2002, the monthly prevalence of any alcohol use in high school seniors was 48%; their annual prevalence of any use was 71%. There has been a modest decline in reported alcohol use during the past decade. Yet almost a third of 12th graders report drinking 5 or more drinks in a row in the previous 2 weeks. Motor vehicle accidents (MVAs) are the leading cause of death among young people of age 15 to 24 years. About 40% of these accidents are alcohol related. Alcohol is also a contributing factor in a substantial proportion of homicides and suicides, violence and injuries, impairment in school functioning, and deterioration in interpersonal relations. By age 15, a fifth of adolescent boys and a sixth of adolescent girls report they are problem drinkers. Fewer than 5% of adolescents can be categorized as alcoholics. Adolescents who drink daily, have a family history of alcoholism, have blackouts or withdrawal symptoms, and continue to drink despite experiencing damaging consequences in their family, school, and social life, fit into that category. The vast majority of teens who use alcohol but do not meet those criteria are considered problem drinkers. Problem drinkers have been drunk 6 or more times a year and at least twice a year have suffered negative consequences of alcohol use, including drunken driving and problems with family, friends, school, or police because of drinking. These teens are at especially high risk for MVAs and other unintentional injuries and for emotional, social, and academic difficulties. Alcohol use, particularly in early pregnancy, is responsible for fetal alcohol syndrome, a condition characterized by abnormal facies, microcephaly, thin upper lip, short palpebral fissures, hypoplastic maxilla, heart, kidney and skeletal defects, and mental retardation.

13.
(B)
Mild alcohol intoxication produces euphoria, slurred speech, and ataxia. Hypoglycemia may be present. With more severe intoxication, bradycardia, hypotension, hypothermia, stupor, coma, and death may occur.

14.
(C)
Marijuana is the most common illicit drug used by adolescents, ranking a close third after alcohol and cigarette smoking. During the 1990s the prevalence of use within the past month tripled for eighth graders (from 3.2% to 10.2%) and almost doubled for twelfth graders (from 13.8% to 23.7%). In the class of 2002, 48% of twelfth graders reported ever having used marijuana. D-9-tetrahydrocannabinol (THC) is primarily responsible for the neurophysiologic, biochemical, and behavioral changes induced by marijuana. Currently, most marijuana is obtained from a hybrid plant (
Cannabis sativa x indica
), and only the seedless buds of female plants (sinsemilla) are considered worth smoking. The concentration of THC has increased dramatically in the past 25 years from 2% to 10%. The dose delivered varies with the supplier. The drug may sometimes be adulterated by addition of PCP. The effects of marijuana start from seconds to minutes after inhalation and from 30 to 60 minutes after oral ingestion, peaking at 20 minutes and lasting for 3 hours. Marijuana induces feelings of well-being and relaxation and, at higher doses, it is a hallucinogen. Its serum half-life is 19 hours. It is primarily metabolized in the liver. Twothirds of the cannabinoid metabolites are excreted in the feces and one-third in the urine. After single use it can be detected in urine for up to 5 days and for up to 1-2 months in chronic users.

15.
(E)
At low doses, marijuana causes euphoria, relaxation, time distortion, vision and hearing distortion or enhancement, increased appetite, tachycardia, dry mouth, and sleepiness. At higher doses, it may cause dysphoric reactions including distortions in body image, disorientation, mood fluctuation, depersonalization, paranoia, and acute panic reactions. Although delirium and hallucinations may occur with high doses of THC, they may indicate the drug has been adulterated with PCP. Conjunctival hyperemia and increased appetite are common. The major effects of marijuana use are behavioral. Long-term use may impair memory, learning ability, and perception. Performance of tasks requiring coordination is significantly affected. The same is true for tracking ability, reaction time, and visualperceptive functioning, all important considerations when driving a car or operating complicated machinery. Attention and short-term memory are affected even in moderate doses. The existence of an “amotivational syndrome” secondary to marijuana remains controversial. Apathy, loss of energy, passivity, absence of drive, loss of effectiveness, impaired concentration and memory, and decreased interest in work and school performance and lack of concern about it have been described as characteristic of the amotivational syndrome, but it is difficult to discern whether marijuana use is the cause or a consequence of preexisting behavioral problems. Nausea is not among the symptoms of marijuana intoxication. THC has antiemetic properties. Adolescent boys that are heavy marijuana users may present with gynecomastia and decreased sperm counts.

16.
(D)
In 2002, the annual prevalence of use of any illicit drug during their lifetime among 12th graders was 53%. This percentage has been stable since 1997.Twenty-five percent of eighth graders reported ever having used an illicit drug. This includes use of marijuana, LSD, other hallucinogens, crack, other cocaine, heroin, amphetamines, barbiturates, or tranquilizers.

17.
(C)
In 2002, almost a third of 12th graders reported ever having used an illicit drug other than marijuana. The most commonly used illicit drugs in this category include hallucinogens, amphetamines, MDMA, narcotics (including oxycodone and oxycodone/ acetaminophen), and tranquilizers. Of note, 9.6% of 12th graders reported having used oxycodone plus acetaminophen during the previous year.

18.
(C)
In 2002, a nationwide survey of the lifetime prevalence of use of various drugs by eighth graders indicated that 25% of them had ever used an illicit drug. If inhalants are included, that percentage climbs to 31%. Nineteen percent of eighth graders reported having used marijuana. After marijuana, inhalants are the most frequent drug of abuse with a lifetime prevalence of 15% and an annual prevalence of 7.7%. Inhalants are more likely to be used by younger than older adolescents. Frequently used inhalants include model glue, gasoline, aerosols used as propellants for cleaning fluids, fabric guard, correction fiuid, deodorants, and spray paint. Toluene is the most common hydrocarbon found in paints and model glues. Inhalation of toluene may result in renal and hepatic damage, neuropathy, seizures, and encephalopathy. Sudden death attributable to cardiac arrhythmias has been reported. Amphetamines rank third with a lifetime prevalence of 8.7%. Almost half of all eighth graders reported they had ever used alcohol, and 1 in 5 report ever having been drunk. About 31% of teens have tried cigarettes and 11.2% have tried smokeless tobacco.

19.
(D)
All of the above will be necessary except for a pregnancy test, which may remain positive for up to 4 weeks after a pregnancy termination. Complications of first-trimester abortion may include excess blood loss, infection, and failed abortion. Pelvic infection should be excluded. Fever and bleeding 3-7 days postabortion and uterine or adnexal tenderness suggest that diagnosis. Contraception is usually initiated at the time of the procedure. It will be important to reexamine the several psychosocial risk factors discussed on the previous visit (alcohol and marijuana use, poor school performance, anger issues) and to refer for appropriate counseling.

20.
(C)
With a typical failure rate of 0.3%, depomedroxyprogesterone is one of the most effective hormonal contraceptive available to teens. This failure rate compares very favorably with the one of combined oral contraceptives, which has a failure rate of about 2% in typical adult users and up to 6-7% in teens. It is an excellent method for teens who have difficulties with medication compliance, those who have significant dysmenorrhea or dysfunctional uterine bleeding, those that cannot tolerate estrogens, and particularly those with seizures undergoing anticonvulsant therapy. Irregular bleeding is a common occurrence during the first 3-9 months of use after which most patients will develop amenorrhea for as long as they remain on the medication. Weight gain is a common complaint, particularly in those teens who are overweight when the treatment is started. Osteoporosis may result from long-term use, and a daily calcium supplement should be taken to help prevent this adverse effect. Depomedroxyprogesterone can be started immediately after pregnancy termination.

S
UGGESTED
R
EADING

Emans SJ. Teenage pregnancy. In: Emans SJ, Laufer MR, Goldstein DP, eds.
Pediatric and Adolescent Gynecology.
5th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2005.

Hatcher RA, Trussell J, Nelson AL, Cates W, Steward FH, Kowal, D.
Contraceptive Technology.
19th rev. ed. New York, NY: Ardent Media; 2007.

Joffe A, Blythe MJ. Handbook of adolescent medicine.
Adolesc Med.
2003;14:2.

Johnson BE, Johnson CA, Murray JL, Apgar BS.
Women’s Health Care Handbook.
2nd ed. Philadelphia, PA: Hanley & Belfus, 2000.

Neinstein LS.
Adolescent Health Care: A Practical Guide.
5th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2007.

Schydlower M, ed.
Substance Abuse: A Guide for Health Professionals.
2nd ed. Elk Grove Village, IL: American Academy of Pediatrics; 2001.

CASE 78: A 15-YEAR-OLD GIRL WITH OBESITY, ACNE, NO MENSES IN 3 MONTHS, AND POSSIBLE DEPRESSION

A 15-year-old adolescent girl comes to the clinic with a history of deteriorating school performance. Her past medical history indicates that she was a full-term 8-lb 10-oz baby born by cesarean delivery after a pregnancy complicated by gestational diabetes. She attained all her developmental milestones on time. She was never hospitalized and has no chronic illnesses except for seasonal bouts of allergic rhinitis. She is always congested and has been told that her tonsils are “too big.” She started her menses at age 11 years. They have been irregular, with no excessive cramping. Her last menstrual period was 3 months ago. She has a few friends but spends most of her free time at home watching TV. Her family history reveals that her maternal grandmother died 6 months ago at age 56 years, of complications of diabetes and hypertension. Both parents are obese. While interviewing the patient alone and after being assured confidentiality, she tells you she has never been sexually active but wants to start birth control “just to be on the safe side.” She denies smoking cigarettes or using alcohol or other drugs. She has been sleepy lately and sometimes she may even fall asleep in class. She feels tired and quite irritable most of the time. She is unhappy about her appearance and frustrated about her lack of success with several of the diets she tried in the past. She admits to being a “loner” and feels hopeless at times. When asked about suicidal ideation she states that the thought has crossed her mind in the past but she never devised a plan.