Adolescent Preventative Care

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Preventive care includes advice and information concerning physical growth and development as well as social and academic issues. Topics include a balanced diet as well as the importance of physical exercise and ongoing health maintenance activities including immunizations. School and after school activities are also important as are discussions about violence and injury prevention. Specific risk reduction topics include the use of tobacco, alcohol or other drugs as well as sexual practices.

One of the easiest ways to reduce risk in adolescents is through appropriate immunizations.

The HPV (Gardasil) vaccine prevents certain HPV types (HPV types 16 and 18) that have been associated with cervical/ vaginal cancer in women, penile cancer in men and anal and oropharyngeal cancer in men and women. It is a three dose series that is given at age 11 or 12 years and then a booster is given 2 and 6 months later. There must be at least 2 months between the first dose and the first booster and 4 months between the first booster and the second booster. A longer period can occur between doses but the adolescent is not adequately immunized until all three immunizations have been given. It is recommended for males and females.

The MCV4(Menactra) vaccine is a meningococcal conjugate vaccine that protects against 4 of the 5 serotypes that affect humans.

The Tdap (Boostrix) vaccine is a combined tetanus, diphtheria and pertussis vaccine that includes a pertussis component to prevent whooping cough.

The last vaccine is influenza vaccine and should be administered to everyone over 6 months every year.

If any immunizations have been missed they need to be administered to allow the adolescent to “catch-up”. This includes a three shot hepatitis B (HBV) series as well as inactivated polio series for those younger than age 18 years. Two doses of MMR and Varicella vaccine should also be verified. A two dose hepatitis A vaccine series (HAV) is also recommended for all adolescents.

If the adolescent is immunocompromised a pneumococcal vaccine is also recommended to prevent invasive pneumococcal disease. A booster dose of MCV4 (Menactra) is recommended 5 years after the initial dose at age 11 or 12 years.

In 2010 the HPV initial dose compliance for females was 40% and only 32% completed the three dose series. The compliance rate for Tdap and MCV4 were both under 70%. The rate for a second dose of varicella vaccine was only 58%. The best way to improve immunization compliance is through a top to bottom awareness of the benefits of immunizations and a review of immunization status every time an adolescent is seen in the office. All adolescents should have an annual healthcare visit and if a teen is seen who has a minor illness and they are behind in their immunizations catch-up immunizations should be given at the illness visit.

In terms of safety concerns the HPV vaccines are extremely safe. Almost 50 million doses have been given in the US and there have not been any serious safety concerns raised. The HPV vaccines are given at age 11 or 12 years so they are received and the child is immunized before there is a risk for exposure to the virus (HPV). Since teens are engaging in sexual activities at younger ages it is imperative they are protected early or the vaccine is not effective.

We believe every adolescent should receive these immunizations. We are confident they are safe and provide vital protection for your child from illness and cancer. We want to reassure you the risks for any of the immunizations are minimal when compared to the actual benefits. You are doing the right thing when you immunize your adolescent.

Influenza Vaccination Rates

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Although influenza vaccination works and prevents minor and severe illness due to influenza almost half of all children and teens from 6 months to 17 years do not receive influenza vaccine in 2010. This was at the height of influenza concerns due to H1N1 influenza. The highest unimmunized groups are adolescents and black children. School aged children and teens are at the greatest risk of contracting and spreading influenza yet their immunizations rates are low. The reasons are multiple for the low adherence with the American Academy of Pediatrics (AAP) recommendation that annual influenza vaccine be given to all children and teens from 6 months to 18 years.

Barriers to immunization include cost and insurance coverage as well as infrequent visits to doctors. Reminder systems are inadequate and outreach programs to provide low cost and affordable immunizations at accessible and visible locations are inadequate. School based immunization programs and the use of social media, including text messaging directed towards encouraging adolescents to take on the responsibility of obtaining a flu shot to maintain their own health improve immunization rates. Ownership is associated with improved outcomes and immunization compliance for adolescents. Education and availability go hand in hand with success.

The Boston Marathon

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Have you ever wondered why one person helps and another turns away?   Although there will never be one answer to this question I do believe the power to choose is within each of us.

This past week I was called during the night to admit a child having trouble breathing due to asthma. She was two years old and was responding well to medication but needed to be hospitalized.  After finishing the admission I returned to bed thinking about treatment options and as frequently happens could not fall asleep.  I went downstairs for a cup of tea to allow my mind to settle. I usually sit in the dark at the kitchen table for a few minutes and then head upstairs; but something told me to turn on the television. I clicked the remote and the Boston Marathon bombing flashed across the screen. Split screen views and a ticker tape narrative instantly described the insanity of this life-ending event.  A finish line forever linked to the carnage of so many by so few.

Yet, watching the screen, I was overcome not by the bombing itself  but rather, by the brave responses of so many who chose to act in the face of destruction.

I saw police lines fray but never break as officers turned towards and not away from the blast. As runners stopped, swayed or fell, a wave of responders swept to the billowing smoke. I saw two soldiers tearing away wooden barriers clearing a path to allow rescuers to pass.  Volunteers, police and firemen ran to the blast that now shrouded their lives. Medics, doctors and nurses labored to save lives while bystanders and responders cradled those who could not move and guided or carried those who could.

Watching these acts of love I felt pride for each responder who freely chose the care of another over their own safety.  I thought about the parents of each responder who chose to act. I realized such actions bounded by giving rather than receiving are the hope of every parent.

Heading up to bed I thought about the power of love which was so visible in this unfinished marathon. As I climbed into bed I realized we are more same than different and no matter what age, occupation or station each of us through our power to choose has the ability to reach out and help another.

Sunburn Protection

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Ultraviolet light exposure is dangerous. UV light radiation (UVR) exposure is the most important risk factor you can manage to decrease your risk of melanoma. Melanoma cases are increasing. In the year 2011 it is estimated almost 9,000 people died from melanoma. Studies have shown that recurrent sunburns and sunburns at a young age place you at highest risk for developing melanoma. The risk for melanoma later in life doubles if there is a history of a single sun burn during childhood.

There have been numerous education programs in schools, in doctor’s office and in the media but children and adolescents have not changed their habits. Children and adolescents continue to report sun burn episodes and are not wary of the proven life threatening risks. Most adults are much more aware of the risks and willing to curtail UVR exposure to decrease their risk. The younger age groups do not look at the long terms risks. Due to their age they feel immortal and are preferentially influenced by short term social, behavioral and brain mediated benefits. Many adolescents seek a “tan”. They are not interested in spray on tan options. They seek the social benefits and enjoy the sensation of well-being they feel from a tanning session or lying in the sun. New studies support the activation of centers in the brain that are normally activated by addictive substances including cigarettes and alcohol.

It is imperative that all children and adolescent, not just those with fair skin be protected. Try to avoid the highest periods of midday sun exposure and avoid behaviors, such as tanning beds that further increase UVR exposure. Parents need to emphasize the importance of safe skin care. The routine use of products that block both kinds of cancer causing rays is essential. UVA and UVB protection both are needed. SPF numbers in the past only reflected UVB protection. The FDA has recently released new rules for sunscreen. The new rules list “broad spectrum” coverage as applying to both UVA and UVB protection. UVA penetrates the skin deeply and causes wrinkles. UVB is the type that causes sunburn. Both cause cancer. The FDA has also replaced the word waterproof with water resistant (40 minutes) or water resistant (80 minutes). This supports the need to reapply protection frequently.

Always apply enough sunscreen to cover all exposed areas of skin. Try to apply 1-2 ounces of sunscreen every 2 hours and wear clothes that provide high SPF protection. All clothing screens out some sun but darker colors and a tighter weave protect you more than others. You can increase the UV-blocking capability of any washable garment by using a laundry aid like SunGaurd that can boost a clothing items protection manifold. Sunglasses that block 99-100% of UVA and UVB are also a must and should be worn all day even though light hits the eyes more directly in the morning and the afternoon.

HPV Vaccine

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Human Papillomavirus (HPV) is a common virus that is easily spread from skin to skin during contact. It causes various types of cancer including cervical, vaginal, penile, vulvar and certain mouth and throat cancers. HPV also causes genital warts in men and women.

HPV is a silent virus. Most of the times when you have HPV you have no symptoms. This means HPV can be spread without you knowing it. There is a vaccine to help stop the spread of HPV in both girls and boys. It is safe and effective and can protect males and females against some of the most common HPV types and the health problems that the virus can cause.

HPV is the main cause of cervical cancer in women with over 12,000 new cervical cancer cases each year in the United States. 4,000 women die each year from cervical cancer in the United States. Over 15,000 HPV associated cancers in the United States may be prevented each year by vaccination.

There are two HPV vaccines licensed by the FDA and both are effective against diseases caused by HPV types 16 and 18. These are the types of HPV that cause the most cervical cancers and other associated cancers. One of the vaccines, Gardasil, also protects against HPV types 6 and 11 and is licensed for use in males.

Girls and boys should receive the vaccine at age 11 or 12 years and if they did not receive all three doses then they should be immunized with three doses through age 26 years. The recommendation for boys is more recent than for girls and hence many boys over age 10 have not been immunized. It is important for preteens to get all three doses long before any sexual activity with another person begins. When immunized at a younger age higher protective antibody levels are produced. HPV infection can occur after a single contact with HPV during intimate body contact. This vaccine is an important tool to protect against cancer and genital warts.

HPV vaccine can be given safely with the other vaccines given at age 11 years. These are the meningitis vaccine (Menactra) and the diphtheria-pertussis-tetanus (Boostrix) vaccine. Three vaccine doses are given over six months. The second dose is given 1-2 months after the first and the third dose 6 months after the first. An easy way to remember is 0-2-6 months.

HPV vaccines do not treat or get rid of existing HPV infections and cervical cancer screening (PAP Tests) are still needed even if the HPV series has been completed.

Most health insurance plans cover HPV vaccine. Don’t wait. Protect your child now.

Sudden Cardiac Arrest in Children

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Identifying children at risk for sudden cardiac arrest (SCA) is vital to prevent the death of a child and a tragedy for a family. Causes include structural and functional abnormalities, cardiomyopathy, coronary abnormalities and electrical abnormalities are causes for SCA.

Warning signs associated with SCA include fainting or syncope with exercise, chest pain with exercise, shortness of breath not associated with asthma in response to exercise, a family history of sudden cardiac arrest in someone younger than 50 years of age or having a family member who is affected with a condition that can cause sudden cardiac arrest.

It is very important you talk to family members to learn about your family history.

Many parents are not aware of their family history of SCA. You must ask and investigate any history of a relative who died from a sudden cardiac problem and discuss this information with your pediatrician. Obtaining a comprehensive and accurate family history and pedigree can help prevent a death due to an inherited cardiac genetic disorder.

Consider encouraging your child’s school to have an emergency response plan that includes cardiopulmonary resuscitation and automated external defibrillator (AED) use. With this preparation survival rates increase from 10% to 64%. Symptoms, as discussed above, are present in fewer than 50% of all children who have a SCA. Options to improve outcome for these children include obtaining an electrocardiogram (EKG) for all children involved in athletics. This type of testing can identify 70-90% of all children at risk. Remember to support education programs for effective bystander cardiopulmonary resuscitation (CPR) and appropriate AED use. Such intervention can save the life of your child.

Adolescents and Influenza Vaccine

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Although influenza vaccination works and prevents minor and severe illness due to influenza almost half of all children and teens from 6 months to 17 years do not receive influenza vaccine in 2010. This was at the height of influenza concerns due to H1N1 influenza. The highest unimmunized groups are adolescents and black children. School aged children and teens are at the greatest risk of contracting and spreading influenza yet their immunizations rates are low. The reasons are multiple for the low adherence with the American Academy of Pediatrics (AAP) recommendation that annual influenza vaccine be given to all children and teens from 6 months to 18 years.

Barriers to immunization include cost and insurance coverage as well as infrequent visits to doctors. Reminder systems are inadequate and outreach programs to provide low cost and affordable immunizations at accessible and visible locations are inadequate. School based immunization programs and the use of social media, including text messaging directed towards encouraging adolescents to take on the responsibility of obtaining a flu shot to maintain their own health improve immunization rates. Ownership is associated with improved outcomes and immunization compliance for adolescents. Education and availability go hand in hand with success.

The 4 C’s of Successful Parenting

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Parenting is a scary topic. Most parents want to do the right thing, but busy schedules and complex issues make it difficult to know what is the right response to their child’s inappropriate behavior. The general rule is to always anticipate negative behaviors and head them off before they occur. You also want to seek a relationship with your child that encourages your child wanting to please you. By interacting with your child in a supportive and ongoing fashion you will develop a relationship built on trust. Your child sees you are attentive, responsive, attuned and sensitive to his needs and this will encourage good behavior and discourage bad behavior.  At the same time, however, always be aware of a negative behavior due to your child being tired, hungry or feeling alone. In these situations the best thing you can do is to respond to the basic needs of food, safety, warmth and security and allow the behavior issue to resolve itself.

If you are successful in these general rules your next step is to move up to the four C’s: competent, committed, consistent and confident parenting. In order to become a competent parent you should reach out to those you admire and ask for advice and suggestions about parenting tips and techniques. Read parenting books, blogs and articles or take a parenting course. Read about child development and always remember to look inside yourself to understand the choices and decisions you make. Learning how to manage your own emotions, deal with disappointment or frustration and examine your ability to have full and meaningful relationships with others. These are the initial steps to become a competent parent.

To become a committed and consistent parent you must evaluate your expectations about parenting and then determine your ability to follow through with your desires. What are your core parenting beliefs? What behaviors do you support? What actions are you willing to take? When are you willing to take them? How willing are you to pursue the actions and results you desire? Are you ready and able to follow through with your goals and objectives? Most parents have difficulty with limit setting even though they know the setting of age appropriate limits is associated with positive behavioral outcomes for children. Limit setting builds trust and a respect for consequences. Children raised by parents who are committed to consistent limits are better able to delay gratification and wait for something they want. They get along better with peers and are more confident in social situations.

To become a confident parent you must believe in yourself. You must become empowered by your knowledge and actions to believe you are the best parent you can be. This knowledge will allow you to project assertiveness to your child with your facial expression, gestures, tone and rate of speech and eye contact. Before you redirect your child go through a set routine to practice what you are about to do. This allows you to be prepared for what you are about to do and allows you to find a comfortable rhythm and mind set. Always consider enlisting the support of others concerning your actions. When doing something new or difficult it is helpful to have the support of someone you trust and love. Have a weekly parenting review with your spouse to support each other. Be available to receive a phone call or text message from a spouse who needs your immediate support. The simple act of hearing someone tell you they believe in you builds confidence. Another tip is to stop what you are doing and maintain eye contact with your child during a parenting interaction. Your body position and gaze will show him you are engaged and this interaction is important to you. Stop moving or fidgeting. When parents redirect children they often are uneasy with the interaction and their body movements show it. Talk in a smooth and controlled fashion. Avoid signs of excess emotion including talking too fast, too slow or too loud. Stand or sit upright with your shoulders back, head up and your arms uncrossed. You will look and feel more confident.

As a parent if you follow these general rules much of the fear of parenting will dissolve and be replaced with the confidence that consistent, committed and competent parents feel every day. So start now. You can turn these C’s into A’s.

Adult ADHD

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As most parents know ADHD does not “go away” in the majority of children. ADHD persists into adulthood in up to 65% of children with ADHD. It is felt that 4-5% of adults in the US meet criteria for ADHD yet only 25% have been diagnosed and only 10% have been treated. Many adults with ADHD have associated mood, anxiety, sleep and substance misuse issues that complicate diagnosis and intervention.

In adults the primary symptom is inattention rather than hyperactivity. All adults who meet the diagnosis criteria must have a history of ADHD onset in childhood and must meet the established childhood criteria. These criteria include the following: onset of symptoms prior to age 7 years; the presence of at least 6 of 9 possible symptoms in 1 or both of the 2 diagnostic clusters of inattentiveness and hyperactivity; impairment in 2 or more settings (such as home, school and work).

The diagnosis is made by using screening tools in conjunction with a comprehensive patient history and physical examination to evaluate any associated psychiatric disorder. The cognitive and affective symptoms of ADHD are similar to symptoms seen in mood and anxiety disorders. Chronic anxiety issues compounded by stressful events can produce cognitive symptoms that appear similar to ADHD.

Almost 10 million adults in the US have ADHD. It is the second most prevalent disorder behind major depressive disorder which affects almost 7% of the population and generalized anxiety disorder (3%), bipolar disorder (2%) and schizophrenia (1%). 75% of adults with ADHD were not diagnosed as having ADHD during childhood. Adults have fewer symptoms than children and the signs of inattention and hyperactivity in adulthood are somewhat different from those in childhood. In adulthood the inattention symptoms include: difficulty sustaining attention at meeting, with paperwork or with work reading requirements; making careless errors; being forgetful and easily distracted; poor concentration; difficulty finishing tasks; disorganized work habits and frequently misplaced items. Hyperactivity patterns include: inefficiencies at work; internal restlessness; difficulty sitting through meetings; working more than one job; working long hours; very active jobs; feeling of being overwhelmed and talking excessively.

Many adults who are not diagnosed in childhood have developed compensatory strategies to allow them to function in and out of the home and at work. Family members are often able to provide information that is different or not available from the adult who is being evaluated for ADHD.

The treatment of adult ADHD follows the guidelines for the treatment of ADHD in children. A multimodal approach is recommended. Psycho-educational interventions are first and followed by pharmacotherapy for ADHD and any associated psychiatric disorders. Available pharmacologic treatments include short and long acting stimulants and non-stimulant medications. Stimulants are associated with mild elevations in both blood pressure and pulse and need to be monitored in an ongoing basis throughout treatment. Studies have not supported an increased risk for serious cardiovascular risks such as sudden death, myocardial infarction or stroke in children, young adults or middle aged adults.

Although information is limited there is some support for the benefits of using stimulant and non-stimulant therapy to improve executive function impairments that can limit job performance. Executive function involves the ability to organize, sequence, prioritize and maintain information in your working memory while you make decisions. If the executive function disturbance is related to ADHD symptoms including difficulty with selective, shifting and sustained attention then executive function usually improves with medication.

Only about 5% of children diagnosed as having ADHD in childhood continue medication into adulthood. This is felt to be primarily due to the misconception that ADHD symptoms resolve in childhood.

Cognitive behavior therapy approaches that focus on organizational skill development and self-talk/management strategies can also be helpful to develop the compensatory strategies to improve remaining functional impairments. Supportive counseling can also provide motivational support as well as family based mediation and communication benefits.

Attention Deficit/Hyperactivity Disorder (ADHD)

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Attention Deficit/Hyperactivity Disorder (ADHD) is a chronic condition and frequently coexists with other emotional, behavioral, developmental and physical conditions. This problem causes major academic and social issues for your child and stress for your family. Children who are having difficulty with attention span, distractibility, impulsivity, motor restlessness and work completion need to be evaluated for ADHD.

Children, teens and adults can all have ADHD. No one is certain what causes ADHD. It likely comes from a combination of things including genes, exposure to lead, smoking and alcohol, certain brain injuries and other environmental exposures.

Children with ADHD get distracted easily and have difficulty listening to and following directions. They move from one activity to another too quickly and seem to fidget and squirm. They are often easily distracted and unable to finish tasks. They tend to be active and prefer to run around a lot. They climb on furniture and in or out of cabinets. They have trouble keeping their hands to themselves. They may be very impatient and have trouble controlling their emotions. Some children with ADHD have the inattentive type. In this type of ADHD the child is not hyperactive. Their primary issue is with attention and being easily distracted. These children are more often girls than boys and can be easily missed because they do not stand out due to not having a high activity level.

Most evaluations occur between the ages of 4 and 18 years. Your first discussion of your concerns will be with your child’s pediatrician. Depending on your child’s age and symptoms, initial interventions including parent and teacher directed behavior therapy and medication intervention. The primary focus must always be on appropriate social, emotional, educational and behavioral accommodations as well as a physical examination to make certain there is no underlying medical condition causing the ADHD symptoms. If symptoms warrant a referral to a specialist who deals with ADHD may be arranged.

When seeking a specialty evaluation for your child with possible ADHD it is important you seek a professional trained in the diagnosis and management of ADHD. A thorough history will be obtained and a comprehensive physical and neurological examination will be performed. The evaluation may also include psychological and educational assessments and a review of prior evaluations and teacher reports. Further information including classroom observations and parent/teacher questionnaires may also be required.

Intervention options are targeted to your specific needs and the needs of your child. A collaborative multimodal treatment plan tailored to the short and long term behavioral and academic needs of your child is the goal. Children, teens and adults with ADHD do get better with the right treatment, guidance and understanding.