Mental Health and Psycheducational Functioning

Central nervous system (CNS) involvement with SLE is a common event for children and adolescents, reported to occur in 20 to 95 of patients (29). Table 2 Risk Factors for Accelerated Atherosclerosis in SLE Traditional risk factors Hypertension Hypercholesterolemia Diabetes Smoking Obesity Family history of CHD Potential disease-related risk factors Proteinuria related to nephrotic syndrome Although some CNS events, such as seizure or neuropathies, may be relatively isolated with few long-term...

Growing Up Looking After Yourself

It does get very embarrassing, especially if you're stuck in the bath and you can't get out. You just get embarrassed, especially if your parents are there, and you don't want your parents to pick you up out of the bath. You don't want your parents taking you to the toilet. It's embarrassing. Because I've got problems with my shoulder as well, so I have to choose tops which I can get on easily, and they're not always the ones I like, but I find the others hard to get on. I couldn't do simple...

Infectious

About 1 to 2 of children and adolescents with osteomyelitis have the infection localized to their spine. Within the spine, the lumbosacral area is the most common followed by the thoracolumbar region. There is a peak incidence in adolescence. Common presenting symptoms include back pain which can be severe, muscle spasm, vertebral tenderness, and fever (1). Patients may limp or refuse to walk, and usually appear quite ill, but may have had insidious symptoms for several weeks to months (63)....

Eating Disorders

Adolescents, especially females, may develop disordered eating behavior out of a desire to have a thin appearance (73-76). Western culture teaches youth that females must be very thin to be beautiful, a concept persistently advocated by movies and magazines glamorizing the ultrathin woman (73,74). Approximately 0.5 females in the United States, the United Kingdom, and other countries in Europe develop anorexia nervosa, often between 13 and 15 years of age (74). It is the third most common...

Other Secondary Forms Of Osteoporosis In Adolescents

Secondary forms of osteoporosis can be found in a variety of other illnesses (Table 1). Secondary osteoporoses are constantly increasing in the young for several reasons, such as the longer survival in many severe chronic diseases, the greater pediatric use of potentially bone-damaging drugs, and last but not least the greater attention now paid to the alterations of bone and mineral metabolism. In all forms of secondary osteoporosis in addition to the direct bone derangements caused by the...

Introduction

Adolescence is the critical process in which the child leaves childhood dependency and approaches a stage of human development in which dramatic changes develop leading to adulthood (1). It is a complex period with major physiologic, sociological, and psychological changes. The goal of adolescence is to allow the emergence of adults who are autonomous and ready to function at appropriate sexual, intellectual, and vocational levels and contribute to the society that hopefully nurtured them....

Low Bone Mineral Density Definition And Relevance

Low bone mineral density (BMD) can be defined as a reduction of bone mineral mass per volume unit of bone tissue, in the absence of mineralization defects. The last point is particularly important regarding infants and children, to avoid confusion with rickets. Clinically significant low BMD is increasingly observed in younger patients. While this condition in adults is normally referred to as osteoporosis (1), there is no consensus about the definition of osteoporosis in children before the...

Management Of Juvenile Slegeneral Concepts

Juvenile SLE is a chronic disease characterized by flares and remissions, often with long periods of active disease requiring intensive treatment. At times, the disease or its complications can result in severe problems needing urgent and aggressive care. Juvenile SLE can certainly be life threatening, particularly if there is inadequate treatment or poor compliance with treatments. The treatment of juvenile SLE should incorporate medical management with pharmacologic agents, and attention to...

Surgery

The inflammation related to juvenile arthritis is sufficient that in poorly controlled disease, it can cause such severe joint damage that patients require prosthetic joint replacement, often at a young age. In one long-term study group (3), prosthetic joint replacement was common, with 49 of the patient group having at least one major prosthetic joint replacement. The frequencies of joint replacement with JIA subset are shown in Table 6. The subgroups of systemic JIA, rheumatoid factor...

Social Functioning

Adolescence is also a time of social change when a young person has to establish self-identity and relationships outside the family (see Chapters 2 and 5) . Body image is important to all adolescents (36,37) and may be detrimentally affected in JIA. Generalized growth failure and pubertal retardation (38) are seen in severe JIA. Some local growth anomalies (e.g., a short digit) are often mild but may cause concern to the patient, while other anomalies, such as micrognathia, can profoundly...

Primary Forms Of Osteoporosis Idiopathic Juvenile Osteoporosis

Idiopathic juvenile osteoporosis (IJO) is a rare, self-limited disease, first described in 1965 by Dent and Friedman (20). IJO reveals itself in otherwise healthy children, more often 2 to 3 years before puberty, even if more precocious cases are observed (21). It does not appear to be hereditary and is equally distributed among genders. Affected children have pain in the back, pelvis, knees, feet, and sometimes have difficulties in walking. Compression vertebral fractures are frequent and may...

Treatment Related Factors

The development of a positive self-concept and body image in adolescents with chronic rheumatic diseases is challenged by the experience of side effects of the medications. NSAIDs and DMARDs are associated with a number of adverse effects, of which gastrointestinal complaints (e.g., nausea, vomiting, diarrhoea, dyspepsia) are most common. Pseudoporphyria or linear facial scarring was estimated to affect 11 of children taking chronic NSAIDs (68). Hepatotoxicity, bone marrow suppression, lung...

Substance Abuse

Alcohol and illegal drug use among adolescents in the world are major health problems facing society in the 21st century (3,29,37). Young adolescents tend to start their drug experimentation with inhalants (aersols, glue, petrol, or volatile solvents). However, the most chemicals widely used Immature cervix (cervical ectropion) Use of needles for use of substance abuse Other patterns of needle injury (self-mutilation, body piercing, tattoos) Magical thinking (feeling that high-risk behavior...

Obesity

Surveys note a prevalence of over 20 in the United States, England, other European countries, China, and other areas (55-57). Obesity is one of the most important health problems of children, adolescents, and adults in the world, with major negative health implications on physical and psychological health (58). Obesity prevalence among Americans aged 18 to 29 is 14 and increases to 21 if they have spent time in a college or university perhaps 25 of American college students are overweight...

The Current Situation in Health Care The Quality Chasm

Much has been written lately about the inadequate quality and safety in health care. A very strong whistleblower on safety issues was the report, To Err Is Human Building a Safer Health System, published by Institute of Medicine (IOM) in 2000. According to an estimate in that report, 7 of all hospitalized patients experience a serious medication error, and 44,000 to 98,000 Americans die in hospitals each year from care injuries (6). Similar figures from all parts of the western world have been...

References

The incidence of pediatric rheumatic diseases results from the Canadian Pediatric Rheumatology Association Disease Registry. J Rheumatol 1996 23(11) 1981-7. 2. Fujikawa S, Okuni M. A nationwide surveillance study of rheumatic diseases among Japanese children. Japonica 1997 39(242) 244. 3. Kaipiainen-Sappanen O, Savolainen A. Incidence of chronic juvenile rheumatic diseases in Finland during 1980-1990. Clin Exp Rheumatol 1996 14 441-4. 4. Cassidy JT, Sullivan...

What Is Quality Improvement

Batalden and Davidoff recently proposed to define quality improvement as the combined and unceasing efforts of everyone health care professionals, patients and their families, leaders, researchers, payers, planners, educa-tors to make changes that will lead to better patient outcomes (health), better system performance (care), and better professional development (learning) (Fig. 1) (9). This means that quality improvement is not tools and methods. The tools and methods help us to work on the...

Trigger Questions

Finally, the use of trigger questions is particularly useful for exploring the more sensitive areas of enquiry. Several have been already used as examples in the preceding text. Table 5 lists some further examples of these useful Table 5 Trigger Questions in Adolescent Rheumatology Can you explain your condition in your own words How would you tell someone about your condition What information have you found on your disease in books, the internet, on TV, and from experts Do you know other...

Why Should Professionals Be Interested

A U.K. study involving national focus groups of young people with JIA highlighted the need to consider social aspects of the young person's life alongside their physical and psychological needs (1). Young people reported an overwhelming need to meet similar others with JIA and the need for health professionals to pay increased attention to issues such as bullying, social isolation, and the loss of valued social activities. In a health care setting discussion of such topics can help develop...

Arthritis Is Mean

Arthritis is mean Arthritis is cruel I didn't like it But I got to miss school How long you are in for you do not know You need to drink and eat to keep you on the go You may not want to but you have to The doctors and nurses will help you. They ask questions, it's really boring Soon they'll have you snoring and snoring When they take blood it seems mean But doctors are really keen. When you feel better And can take off your own sweater Avoid the cannula, it's not nice It busts your hopes by a...

Bone Health Promotion

As a general measure, in order to create the most favorable environment for bone growth and development, the correct intake of nutrients, especially calcium, according to the patient's age, sex, and physical characteristics should be actively promoted. Physical activity has also a major role in the full attainment of an individual's genetically determined potential peak of bone mass. This is extremely important, since it has been estimated that a 10 increase of peak bone mass reduces by 50 the...

Growing Up Meeting Someone Special

It's hard, especially, like, as you get older and you start getting into relationships. That's always hard because you're like shall I tell the person straightaway because what happens I'm good now, but what happens in a few months, I might have a little bit of a bang, I might fall over will it come back and then having to try and explain that. When you are at the hospital, the boyfriend does get shoved out the way. But it's like now. I want him here. He's in my life. He looks after me. He...

Chronic Rheumatic Diseases And Their Effect On Bone Density During Adolescence And On Peak Bone Mass

The effects of chronic illnesses such as the rheumatic disorders on bone density are well known. Failure to develop adequate bone mineralization is common in children with chronic arthritis. (For a comprehensive review, see Reference 24). Juxta-articular osteopenia can be evident in plain radiographs even in early disease, whereas diffuse osteopenia or osteoporosis can develop later and lead to the risk of vertebral collapse and long-bone fractures after minimal trauma. Multiple risk factors...

Bone Health in SLE

The use of long-term corticosteroids to control SLE activity has detrimental effects on bone health, leading to decreased bone mass (24). This is of particular concern in the adolescent, as adolescence and young adulthood are an important time to develop optimal peak bone mass (25). In adults, a low bone mineral density (BMD) is associated with an increase in risk for osteoporotic fractures. Although the magnitude of the fracture risk for adolescents with low BMD due to SLE and steroid...

Health and Disease Related Knowledge

As adolescents transition to adult-oriented care, it is also essential that they understand both their past medical history and current health care needs. It has been demonstrated that many young people with JIA score poorly on arthritis related knowledge (62), even long-term clinic attendees (63). Effective transitional care has shown to improve such knowledge (55). Thus, assisting the young person to be able to communicate their health care disease and needs is essential. Creating a health...

Developmental Issues And Chronic Illness

Most discussions of developmental aspects during adolescence refer to the widely accepted concept of developmental tasks (7), which has a focus on the psychosocial dimension (8). However, there are also profound transformations on a more basic level, that is, the adolescent's information processing. The following section summarizes typical ways in which adolescents perceive their world differently from children. This is then followed by a discussion on divergent conceptualizations of...

Conclusion

Sports foster many lifelong essential skills and qualities including independence, teamwork, socialization, coordination, determination, self-worth, and a healthy lifestyle and should be enjoyed by all. Unfortunately, injury has become a common problem due to overuse and intense sport participation in many adolescent athletes. Recognition and education regarding youth injuries are important to prevent further and future injury. The National Institutes of Health web site carries multiple patient...

Homicide

In Latin America, homicide is the leading cause of death for young males (3,99). In the United States, homicide is the second leading cause of death for adolescent males 15 to 19 years living in inner cities (100). Homicide becomes more likely to occur in the city and suicide in suburban America. The relative easy access to guns is a contributing factor in both types of deaths for American youth. Each year, four to five thousand 15- to 24-year-olds are murdered in the United States, for a death...

Model for improvement

How will we know that a change is an improvement What changes can we make that will result in an How will we know that a change is an improvement What changes can we make that will result in an Figure 7 The improvement model The Plan-Do-Study-Act (PDSA) cycle. Figure 8 Evidence-based improvement equation. Source Courtesy of Batalden PB, 2006. Figure 8 Evidence-based improvement equation. Source Courtesy of Batalden PB, 2006.

Nonspecific Back Pain

The majority of back pain found during adolescence does not have an identifiable etiology and falls into the category of nonspecific back pain. Most studies have found that the prevalence of back pain rises during adolescence (6,14-18), reaching adult levels in late adolescence. Generally, there is a 10 or lower lifetime prevalence of back pain in children 10 years or younger (4,15,16,19). The prevalence starts to rise in the next 1 to 2 years, with some studies reporting a lifetime prevalence...

Sexually Transmitted Diseases

There are many types of STDs which can affect youth and over half of STDs occur to adolescents (1,3,29-31). The majority of STDs involve individuals aged 15 to 29 years. Each year, 1 in 20 adolescents in the world obtains a curable STD (3). STDs can be asymptomatic and youth often do not seek treatment even if symptomatic. Adolescents are less likely than adults to use protection (i.e., condoms). The most common STDs among youth are infections due to human papillomavirus (HPV), herpes simplex...

Multidisciplinary Approach

The aim of treatment is to enable the young person to return to age appropriate activities and lifestyle. Ideally this would be pain free but, in many cases, this is initially with the pain. Physiotherapists, occupational therapists and psychologists (67-69) are key players in the team. They will be the primary professionals supporting the young person and the family. The physician is there to provide support if needed, occasional analgesic advice and very rarely, direct intervention. In some...

What Doctors And Health Professionals Should Know About What It Is Like To Be A Young Person Living With A Chronic

You can never really know what it's like. You can describe the pain you go through, but they don't know how bad it is until they have the illness themselves. It makes you sad and angry inside. I became frustrated and very angry. When I'm out with friends and they are running about having fun, I know that I can't join them physically because I'm just too tired. Some days can be worse than others. I can wake up full of energy, but lose it just as easily, and just can't be bothered to even move on...

Assessing Parental Advocacy

The challenge of negotiating the appropriate extent of parental involvement is an integral component of adolescent health care whatever the setting. Parental overprotectiveness has been reported in the context of JIA (27) as in other chronic conditions (28-31). In a national survey of rheumatology health professionals, parental overprotectiveness was reported to put adolescents with JIA at risk of transitional difficulties (27). Geenen reported a significant discrepancy between the perceived...

Different Perspectivesyoung People And Health Professionals

Adolescent friendly services need to accessible, equitable, acceptable, appropriate, comprehensive, effective, and efficient (1). Provider behavior is an important determinant of adolescent satisfaction with their health care. In a survey of 124 adolescents attending a university-based general adolescent medicine clinic, pre-visit attitudes about provider style predicted satisfaction with the consultation, and visit satisfaction was associated with intention to keep follow-up appointments (2)....

Acknowledging Different Perspectives

The different perspectives of the adolescent and their parent(s) caregiver(s) need to be considered by health professionals involved in the triadic consultations of child-centered health services. Within the generic literature, the most comprehensive study of parents as proxies of adolescents has been conducted by Waters et al. who examined the relationship between 2096 Australian adolescents (aged 12-18 years) and their parents using the Childhood Health Questionnaire (12). This study...

Psychogenic

Conversion reactions are predominantly found in late childhood to early adolescent girls, and may begin after a minor illness or trauma (1). Patients may report diffuse spinal tenderness, with marked allodynia, numbness, paralysis, or a bizarre gait. These are often inconsistent with organic pathology (1,57). Despite their reports of pain and limitation, the patient is often smiling or cheerful (la belle indifference). Physical examination does not reveal any neurological or organic pathology....

Skills Training For Young People

Consultations with health professionals can be perceived as opportunities to practice communication, problem-solving, and negotiation skills, all of which are important in the rest of life. The clinic is a safe place to start such skills training, and this can be an effective sales technique to encourage parents to allow their son daughter to be seen alone. This is a safe place for your son daughter to practice talking to professionals on their own, which will prepare them for the world of work...

Socioeconomic Factors

Socioeconomic risk factors refer to demographic factors and family-related determinants. A number of demographic factors have been identified that may increase the risk of poor adherence, including ethnicity (i.e., non-white race), onset of disease at a younger age, and the high burden of cost of medication (24). Male adolescents seem to be more prone to poor adherence (5), because they generally exhibit greater risk-taking behavior, putting them at a higher risk for experimentation with their...

Preparation for Clinic Visits

This aforementioned ventriloquist parental role described above often comes from a real need to ensure that the doctor knows everything that has gone on at home and the strong belief that something will be missed if the young person is allowed to speak for themselves. One strategy to address this is to encourage the parent to prepare for each visit. A simple exercise is detailed in Table 2 to aid such discussions and is based on templates used in the OnTrac program at the Children's Hospital in...

Communication With Health Professionals The Young Persons Perspective

You want to say all these things, but then you stop yourself and you think you're just a teenager. They think that . . . you won't understand what it means or how it'll work, but you do really you just need a little more information sometimes. Some of the medical terms, like these quite big long posh words . . . . I didn't know what they meant. I didn't understand. I didn't want to ask. He talks down to you, well with me anyway. He never seemed to realize that I had grown up. He thought I was...

Improvement Knowledge

The health care system has an aim to improve the health of the patients it serves. This care is made through several processes, such as diagnostic services, assessments, plans of care, and delivery of care at the ward or in the clinic. All these processes include many steps that need to be analyzed and understood in greater detail before we plan to change and redesign processes for improved performance and outcomes. The clinical microsystems are the essential building blocks of the larger...

Social Security Support

If working is not an option to attain financial independence, the health care professional should guide the young person with rheumatic disease to look into social security supports. In the United States, it is called Supplemental Security Income (SSI), and it is a monthly payment for individuals with disabilities. To qualify for SSI, individuals must meet both disability and financial eligibility requirements. SSI eligibility is re-determined using adult criteria when adolescents turn 18 years...

Studies on Resilience

Research on resilience usually focuses on social competence despite bad conditions. The latter are most often described as major negative life events. Apart from methodological limitations in assessing life events (60) it should be kept in mind, that there may also be a profound (cumulative or even exponential) interactive effect if more than one bad condition is present (58,57). Also, life stress not only results from major life events the chronic influence of so-called daily hassles may...

Psoriatic JIA

Psoriatic arthritis is classified as arthritis associated with psoriasis or arthritis and at least two of the following dactylitis i.e., when the whole digit (toe or finger) is swollen as a result of inflammation in the digital joints and associated tendon sheaths , nail pitting or onycholysis, and or psoriasis in a first-degree relative. Arthritis may predate the onset of psoriasis by many years in the juvenile form. Even if psoriasis is present, it may be limited in its extent (e.g., natal...

Sexual and Reproductive Health

Establishing a sexual identity is a key task of adolescent development, and addressing sexual and reproductive health issues during adolescence and adulthood are important aspects of management. Women with JIA have similar levels of sexual activity and relationships when compared to healthy controls. However, this group has a higher rate of gynecological problems than controls these include increased incidence of menorrhagia, pelvic inflammatory disease, difficulty in conceiving, and a...

The Importance of Planning

One of the key attributes of components of transition, and indeed of adolescence itself, is envisioning a future for the young person (34). In the context of a chronic condition, planning is essential for success. Individualized transition plans have been advocated for young people by several authors (25,27,35), but it is worth considering similar plans for parents as their son daughter moves through adolescence. An example of such a plan for parents of adolescents in the 14- to 16-year-old age...

Chronic Illness And Friendship

For a young person with a chronic rheumatic disease like juvenile idiopathic arthritis (JIA), maintaining friendships outside the family may pose additional challenges. This may be a direct consequence of the disease, such as pain, stiffness, and fatigue or secondary consequences such as limited knowledge and or inaccurate beliefs about their condition and the benefits of social and sporting activities. Fear of hurting themselves or making worse their condition may lead to self-imposed...

Health Transition

Ideally, health care transition should be family-centered, continuous, comprehensive, coordinated, compassionate, and culturally competent and developmentally appropriate as it is technologically sophisticated (4). Access to quality health care continues to be a major issue for all young people as well as those with rheumatic disease. In the United States, a national survey of adolescents with chronic illness and severe disability conducted between 1997 and 2002 established that nearly 35 of...

Psychological Morbidity

There are features of JIA that suggest that young people may be at high risk of psychological complications, these include pain, disability and physical deformity. A number of studies have shown that psychological problems, particularly depression, are higher in adults with inflammatory arthritis compared to the general population (45,46). The major psychological difference between adult-onset inflammatory arthritis and JIA is that coping strategies are not fully developed in childhood and that...

Sexual Behavior Statistics

The beginning of sexual (coital) behavior is in adolescence for most people in the world (13). The American 2005 Youth Risk Behavior Survey (YRBS) noted that 46.8 of all high school students (ages 13-18 years) are coitally sexually experienced, with a range of 67.6 for African-American youth, 51 for Hispanic youth, and 43 for Caucasians(14). This survey also comments that over 6.2 are sexually active before age 13 (4 in females and 9 in males) while over 14 have at least four sex partners 11 of...

Interventions to Increase Psychosocial Support

Emotional difficulties or psychopathology displayed by the patients (e.g., depression) or dysfunction in the family (e.g., substance abuse, coercive patterns of interaction) should be identified and specialized care (e.g., psychotherapy or psycho-pharmacological treatment) should be suggested and arranged (69). Evidence also showed that increased parental supervision is quite effective in the improvement of general adherence (1). Yet, the aim is that adolescents learn to care for themselves...

Disclosure

Friendships may facilitate an adolescent's adjustment to a chronic disease or their ability to cope with a difficult medical treatment (2,15,16). However, this is very difficult if peers are unaware of their friend's condition. For some young people with chronic illness the fear of disclosing their illness and the impact they perceive this will have on how others respond to them means that they will sometimes try to keep their diagnosis secret. However disclosure can be a great relief and can...

Assessment of Parental Needs

In a study using focus group methodology, parents of adolescents with JIA acknowledged that they found it difficult to let go of their son daughter but realized that it was important for them to become their own advocates (24). They suggested that health care providers could help them to facilitate increasing autonomy for their son daughter by encouraging self-advocacy skills training for the adolescent. The parents suggested that the health professionals should actively involve the young...

For Physicians

American Medical Association, Osteoporosis CME (enet.ama-assn. org public cme regLhtm) This link goes directly to the American Medical Association's three-part CME course on managing osteoporosis. 2. American Society for Bone and Mineral Research (www.asbmr.org) This Web site offers information on ASBMR's abstracts, grants, meeting information, job placement, publications, and events. 3. International Bone and Mineral Society (www.ibmsonline.org) The International Bone and Mineral Society is a...

AdolescenceA Stage or a Passage

There are numerous theories of adolescence, which mostly refer to one of two paradigms at one end of the continuum, adolescence is perceived as a passage, characterized by certain transitions, leading to pre-fixed developmental endpoints. This is concisely exemplified in the concept of developmental tasks (7). At the other end, the characteristics of adolescence are rather described as a stage or developmental moratorium, a period characterized by experimentation and defining one's own identity...

Clinical Assessment Stature

Assessment of stature starts with regular height measurement (Box 1). This requires consistent and correct technique for reliable data. It is helpful, if Accurate height measurement Calculation of height velocity Comparison with appropriate growth charts and standards Calculation of mid-parental height range Correct interpretation of data possible, for young people to be measured by the same person at each visit, especially when the young person has significant joint deformities or treatment...

Infections Presenting as Musculoskeletal Disorders

Musculoskeletal infections in adolescents, although uncommon, represent a unique therapeutic challenge (Table 6). The pathogenesis and prognosis of musculoskeletal infections differs in children and adults due to behavioral differences, bone growth and changing vascularity. For example, in children less than 8 months of age, the metaphysis is traversed by capillaries, allowing spread of infection. In contrast, the growth plate in older children and adolescents is avascular and, together with...

Interviewing And Assessment Skills

The fundamental skill necessary for effective assessment of adolescents is empathy and a nonjudgmental approach. Praise of the young person is another, frequently forgotten aspect of communication with this age group, and is key to success. As in pediatrics, acknowledging the reciprocal influences of growth and development during adolescence on health and illness is imperative (44) (see Chapters 2,3). Using this development as a lens through which effective communication takes place is useful...

Transition Modelsprocess And Planning Models of Transition

Models for improving transition care have been described for condition-specific diagnoses (50) within professional disciplines (3,51), for primary care settings (52) and non-disease-specific, non-medical programs (53). Only a few studies have been conducted to examine the effectiveness of various health care transition models on health status and health-related outcomes (54). Recently McDonagh demonstrated improved health-related quality-of-life, disease knowledge, satisfaction, and vocational...

Concurrent Visits for Parents

The ideal albeit costly solution to address parental needs would be for parents to be seen by another person while the young person is having their appointment (24). Imperative to such visits is both informing the adolescent that their parent wishes to talk over their concerns to another member of the team whilst they are being seen. Furthermore, both the young person and the parent should be made aware of their rights to confidentiality. Nurse specialists often take on this role. Another...

Bisphosphonates

Bisphosphonates have been extensively used in adult osteoporosis with positive effects on bone fracture risk. Their use in younger patients has been limited by fear of adverse effects on a growing skeleton and their long-term permanence in bone tissue. However, after more than 10 years of use in severe conditions such as osteogenesis imperfecta, bisphosphonates have been shown to be quite safe. No adverse effects on growth, pubertal spurt and healing of fractures have been reported, even after...

Rebecca A Demorest

Department of Orthopedics and Sports Medicine, Children's National Medical Center, and The George Washington University School of Medicine and Health Sciences, Washington, D.C., U.S.A. It is estimated that more than 30 million children in the United States participate in organized sports each year, with more than 7.5 million high school students playing competitive sports during the 2005 2006 school year. With the advent of year round recreational and competitive teams along with travel teams...

Medical Therapies

The number of analgesics and interventions used is a sign that there are no well controlled therapeutic trials in the arena of childhood chronic pain. It is becoming widely accepted, however, that any analgesic intervention should be alongside multidisciplinary therapy (58-61). It is unusual for analgesia to work alone. Oral treatments that have been used, with variable success, include tricyclic antidepressants, nonsteroidals, opioids, anticonvulsants and glucocorticoids (62,63). Sympathetic...

Mobile Phones

Mobile phones have become an integral part of adolescent culture for expressing identity and style. They are vital in most young people's social lives for arranging meetings with friends, chatting up a potential girlfriend boyfriend, and also for getting information via the internet. Mobile phones also provide a sense of security for young people and their parents (30). In 2005, a U.K. study found that 97 of females and 92 of males aged 11-21 have access to a mobile phone (31) Texting was by...

Terminology

Unfortunately, earlier terms like stress-resistance or invulnerability were misleading inasmuch as they insinuate that some children and young people were so constitutionally tough that they would not succumb to the pressure of stress and adversity (57). Nowadays, resilience is considered as an ability to recover from negative events (58). This does not presuppose absence of any kind of impact following exposure to adversity. Rather, it means absence of lasting disturbance. Similarly, Fonagy et...

Vascular

Patients with sickle cell anemia may develop vaso-occlusive crises in their spine, especially in the lumbosacral region (60). Onset of pain is usually acute, severe, and may be accompanied by localized spine tenderness, fever, and tachycardia. Most patients will have worsening hemolytic anemia, elevated leukocyte counts, and have evidence of sickling on their smear such patients should be treated with hydration and analgesics (60,61). Radiographs can show osteopenia, sclerosis, fractures, and...

Medical Treatment

A correct approach to low bone mass in adolescents with rheumatic diseases should always start with the simplest measures, that is, correct calcium intake and a physical activity program. Whenever serum vitamin D levels are inappropriately low, active metabolites of vitamin D should be initially used. Among more specific drugs, only bisphosphonates have been consistently used, especially in the presence of a high fracture risk, even if only a few studies have been carried out in young patients....

Tasks And Transitions Of Adolescence

The key tasks of adolescence are listed in Table 2. Alongside these tasks are several important life transitions, including moving from primary to secondary education and eventually from secondary education to either work or further education. There is also the transition from living in the family home to living independently, although the average age at which this happens is increasing in Western Europe (10). Finally there is the transition from pediatric to adult health care providers, a...

Higher and Further Education

Similar findings are seen in the percentage of young persons with SHCN that attain higher education (19). While nearly 85 of all young people in the United States will pursue some form of higher education, those with orthopedic and other health impairments go on to any post-secondary school at the rate of 46.3 and 56 , respectively (19). Key to making the post-secondary education experience successful is referring the young person to a disability support service (or the equivalent) in college....

Developmental Influences on Disease Perception and Management

Harrington et al. (21) outlined three important developmental differences between adolescents and children (1) the conception of their illness becomes more complex and realistic (even though misperceptions and gaps may eventually remain undetected), (2) growing independence and responsibility for therapy (with nonadherence occurring frequently), (3) more pronounced, adult-like pain perception (possibly due to the broader knowledge of the disease and symptoms, which are increasingly being...

Practical Aspects Of Training Provision

While comprehensive theoretical knowledge of a field is important for appropriate practice, experiential learning is crucial for consolidating theoretical knowledge and for the development of interviewing, counselling and examination skills. It also allows development of experience in answering questions from patients and or their carers and facilitates reflective learning. A consultation needs to be of adequate length so that it is effective and worthwhile for the patient and also allows the...

Quantitative Computed Tomography

The main advantage of quantitative computed tomography (QCT) is that of actually measuring the volume (and, consequently, mineral density) of the studied bone. Normally, QCT instruments endowed with a specific software and calibration phantom can measure BMD only at the level of lumbar spine. More recently, specific peripheral QCT (pQCT) instruments have been developed to measure BMD at appendicular sites (forearm and femur). Both QCT and pQCT can measure cortical and trabecular bone density...

Importance of Time and Listening

Young people are new users of health services they may not have been given many opportunities to make decisions for themselves when they were younger or, indeed, even asked for their opinion. It is therefore important to give them both time to find the words they want to answer with and time to make their own decisions. In adolescent health, listening skills are more important than talking skills Young people have reported that their own communication skills impact on their ability to...

Markers of Bone Metabolism During Adolescence

Table 3 lists the most common available markers of bone formation and bone resorption. Changes in bone biochemical markers during growth, and especially during adolescence, are more complex to interpret than in adults. In the growing skeleton, and particularly during puberty, all the mechanisms contributing to bone turnover (longitudinal growth, modeling, and remodeling) are accelerated (41). In girls, the peak of bone markers is earlier but lower than in boys, reflecting gender differences in...

Epidemiology

Epidemiological studies provide data crucial to the understanding of the etiology, natural history, impact, aggregation, and transmission of a disease or condition. Pain is a health care problem that carries severe personal and economic consequences. The Nuprin Pain Report (3), conducted in the United States, estimated that half a billion dollars were lost directly because of pain among those employed full time. Pain in adolescents does not create the same economic hardship as adult pain, thus,...

Patellar Dislocations

Case 7 A 17-year-old ice hockey goalie injured her right knee during a game. She was trying to block a shot and felt her patella move out of place. She had immediate pain and swelling and was unable to continue playing. She has a large effusion and pain around the patella. She has discomfort along the medial retinaculum and a positive apprehension test. Ligament testing in stable although she can only flex to 60 . She has had one previous patellar dislocation and has a hypermobile patella on...

Meniscus

Case 5 A 15-year-old wrestler injured his knee in practice. He was taking someone down, and as his knee pad got stuck on the mat, he twisted his right knee. He can not fully extend the knee and has pain along the posterolateral joint line along with a small knee effusion. The meniscus are the shock absorbers that cushion the knee and protect the femur and tibia from being bone on bone. They are C shaped structures that absorb shock with weight bearing activity. Meniscal injuries are not very...

School To Postsecondary Education And Work School

Graduation from school is associated with the greatest social disruption. The end of formal education, the end of the structured schedule provided by school attendance, and the rising expectation for work and independent living place increasing stress on the young person at this time. Increasing levels of education predict better a chance of labor force participation and higher level of income (18). Thus, making post-secondary education a key goal for the young person with rheumatic disease is...

J

Figure 17 Normal AP of the wrist (A) widening and sclerosis of the distal radial and ulnar physes on oblique view (B) consistent with Salter Harris I fractures. sleeping. Upon return to sports activity which can be 6 weeks to 6 months, tiger paws (specialized gymnast wrist splints that prevent excessive dorsi-flexion) can be used while performing their sport. Not all athletes with radiographic changes have pain. Not all athletes with pain have radiographic changes. Chronic changes in the wrist...

Family

JIA often has significant implications for family structure and dynamics (see Chapter 14). The effect on the family can be at many levels, such as financial, emotional, and with intra-family relationships. There may also be a negative effect on the siblings of a child with JIA. Financially, the family may incur additional expenses in travel and health care costs. A parent or partner may be restricted in the ability to work, because of their role as carer. Adults with JIA are more likely to be...

General Principles Of Transition

Transition is defined as the purposeful, planned movement of adolescents and young adults with chronic illness disability from child-centered to adult-oriented systems (3). Successful transition planning is the result of partnerships among the individual, his or her family, school personnel, the health care system, local community and adult service organization representatives, and interested others. The goal is to maximize lifelong functioning, social participation, and human potential....

What Is High Quality Care

The 2001 IOM report proposed that high-quality care should be Patient centered providing respectful, responsive, individualized care Safe avoiding injury from care that is intended to help Timely reducing waits and harmful delays in care Equal providing equal care regardless of personal characteristics, gender, ethnicity, geography, or socio-economic status Effective avoiding under use, overuse, or misuse of services Efficient avoiding waste of all kinds These suggested six aims have gained...

Growing Up as Seen by Other People

I just feel like people are always looking at us if I'm in a wheelchair and if I'm wearing my neck brace. I mean I should use the wheelchair more than I do really, but I'll not use it because I'm afraid that I look different. People look at us differently and I think that's hard, especially for teenagers. Older people see it as an old person's disease. They don't believe that young people can suffer with it, and that we can have problems or pain like they can. People don't like to sit next to...

Physical Activity

In the United States, according to the 2005 YRBS (Youth Risk Behavior Survey), 35.8 of high school students had been physically active for one hour per day on more than five out of 7 days preceding the survey. Nationwide, 9.6 of high school students had not participated in any kind of moderate or vigorous physical activities during the seven days preceding the survey. Twenty-one percent of students engaged for three or more hours per day on an average school day in playing video or computer...

Residential Camps

Summer camps are another way of addressing peer support, and they have been shown to be a valuable way of addressing psychosocial issues including locus of control (23), self-esteem (24), physical fitness (24,25), independence from parents, health care self-management and an opportunity to meet similar others (23). Many rheumatology centers throughout the world, including Melbourne, Vancouver, San Diego, and Newcastle (U.K.) run their own summer camps. Each differs in content however, all are...

Growing Up and Going

I'd just like to be a normal teenager again . . . just getting out with the girls. You can't go to parties. You can't get anywhere on your own when you're a teenager. It's very difficult having a social life and to stay with all your mates, to do what they want to do and do what you want to do at the same time. There's, like, clubs I can't go to, or go and talk to boys or do anything stupid. I can't even dance with my mates because I'm in agony. It's really depressing to deal with, as well as...

Transition Planning

In line with the agreement on first steps, the transition process in health care should begin early and be developed in earnest with a transition plan by the age of 14. A study of young people with SHCN showed that after age 13-14 the gap between youth with disabilities and those without disabilities widened, and a transition program intervention was most successful if started by ages 11 to 14 years (51,53,55). The transition process should be a collaborative one between health care...

Health Insurance

The final point on the U.S. joint pediatric and adult consensus statement was to ensure health insurance for all young people with SHCN. The health care provider should encourage the young person with rheumatic disease and his her family to review, understand, and plan for the young person's future health insurance options. This is a particular problem for the United States and in a recent study the majority of young adults with disabilities reported gaps in insurance coverage, and many were...

Self Determination Through Childhood and Adolescence

Self-determination is a combination of attitudes and abilities that lead people to set goals for themselves, and to take the initiative to reach these goals (11). The capabilities needed to become self-determined are learned through real-world experience (including mistakes) and an open, supportive acknowledgement of their chronic illness disability (12). Too often families, teachers, and other well-intentioned people protect young people with SHCN from making mistakes and avoid discussing the...

Home To Independence Legalities of Adulthood

In most countries there is an age when young people become legal adults. In the United States the natural guardianship of parents ends when children reach age 18. When the young person reaches 18 years of age, parents no longer have the legal right to make decisions and sign consent forms for their child or to see their child's medical record, unless the young person is in agreement. The health care professional must address this directly with the young person. In cases where the intellectual...

Physical Ability

Long-term outcome studies of JIA show huge variation, with between 2 and 48 of JIA patients developing severe functional limitation (Stein-brocker classes III and IV or HAQ score > 1.5) (33). The length of follow-up strongly influences long-term outcome. In adult RA, Scott (34) prospectively followed up aggressively DMARD treated patients at 5, 10, and 20 years. Although function initially improved, it deteriorated considerably between 10 and 20 years. These findings are mirrored in JIA in...

Osteoporosis

Osteoporosis occurs more commonly in JIA and is associated with an increased risk of bony fracture. It is covered more thoroughly in Chapter 12. Table 5 Hospital-Based Studies of Long-Term Disease Activity in JIA Ansell (1976) (26) Hanson (1977) (28) Calabro (1989) (29) Wallace and Levinson (1991) (30) David (1994) (2) Zak (2000) (6) Packham (2002) (3) Minden (2002) (31) Foster (2003) (32)

Motor Vehicle Accidents

Motor vehicle accidents (MVAs) are the leading cause of death in adolescents in developed countries drugs, especially alcohol, are involved in 50 or more (41,91). MVAs are also major or leading causes of adolescent deaths in other countries as well. These deaths are related to many factors, including the magical thinking of youth, fast driving, mixing driving with drug use, failure to use seat belts, vehicles not in good repair, combination effects of several adolescent passengers in a car...

Assessing the Impact of Pain

Pain has direct and indirect impact on a young person's life. It also impacts on the lives of those close to them. It is not easy to get a full picture of this pain- associated disability in a time-limited consultation. The pain spider is a useful way to engage adolescents and gain insight into their lifestyle (Fig. 2). This is constructed with them during the assessment and they should be asked to highlight areas that are particularly It is essential that there is also an understanding of the...

Tumors of the Musculoskeletal System

Malignancies may present with musculoskeletal symptoms in the context of primary tumors of bone, fibrous or soft tissue, metastases to bone or leukemia. In the younger child leukemia must always be considered and excluded, however, this is generally not pertinent to the adolescent group. Fortunately metastatic bone disease is very rare. It occurs most commonly in younger children with neuroblastoma (121). Red flags that should alert the clinician to consider this group of disorders include pain...

Summary

With recent and ongoing advances in new therapies for chronic rheumatic diseases, there is hope that in the future children and young people with these conditions will more readily establish disease control with minimal need for systemic steroids. Unfortunately, this is not yet the case and we still have children and young people with difficult-to-suppress inflammation and or dependent on systemic steroids. Addressing the growth and puberty delaying consequences is an important ongoing part of...

Vitamin D

Vitamin D (400IU day) and 25-hydroxy-vitamin D (0.5mcg kg day) have been studied in pediatric patients with various rheumatic diseases, with or without steroid treatment (53-55). These studies treated small numbers of patients with different characteristics (age, type, duration, and severity of the disease), so comparing their results is impossible. Data on the efficacy of vitamin D treatment in reducing or preventing bone loss are not conclusive, even if an increase in bone mass has been...

Classification

Vasculitis may be primary or secondary to a separate pathology, the most common and important of which is infection. The differing terminology used in the classification of the primary systemic vasculitides remains confusing. In 1952, Zeek proposed the classification of the vasculitides according to vessel size (11). Subsequent classification schemes reflected the size of the predominantly affected blood vessels as well as the discovery of the antineutrophil cytoplasmic antibodies. The most...

Growing Up into the World of Work

I mean I went to see the careers officer, and the careers officer sat there and said What do you want to do I said I want to be a singer , Oh be realistic and grow up. All you can do is work in an office. You can be an office clerk and that's it, and so that's what I trained for, but last year I actually had my first professional booking and I got paid 60.00 for three minutes work you know. I wanted to be a teacher. I was told I couldn't be a teacher because I...