Health Problems of School-Age Children and Adolescents

Nursing Care Management

Regardless of the techniques used, the nurse can help both children and parents understand the problem of enuresis, the treatment plan, and the difficulties they may encounter in the process. The nurse can also provide consistent support and encouragement to help sustain both the child and the parents through the inconsistent and unpredictable treatment process. Parents need to understand that punishment is contraindicated because of its negative emotional impact and limited success in reducing the behavior. Positive reinforcement of the desired behavior may be beneficial (Sethi, Bhargava, and Shipra, 2005). Children need to believe that they are helping themselves, and they need to sustain feelings of confidence and hope.

Parents should also be taught to observe for side effects of any medications used. All children with primary enuresis should be encouraged to void before bedtime. Diapering should be avoided. Positive reinforcement in the form of keeping diaries to record dry nights has been effective in motivating children.

Nursing Care Management

The nursing care of the child with encopresis involves education and support of the family and treatment of existing constipation. Education regarding the physiology of normal defecation, toilet training as a developmental process, and the treatment outlined for the particular family is essential to a successful outcome. Family counseling is directed toward reassurance that most problems resolve successfully, although relapses during periods of stress are possible (see Family Focus box).

 Frictional, or rubbing of one structure against another

 Tractional, or repeated pull on a ligament or tendon

 Cyclic, or repetitive loading of impact forces (stress fractures)

Stress Fractures

Given the intensity and duration of sports training, many young athletes suffer stress fractures, especially after a recent increase in training regimens. These fractures occur as a result of repeated muscle contraction and are seen most often in sports involving repetitive weight bearing such as running, gymnastics, and basketball. They occur less often in swimming (in the upper extremities). Tibial fractures are most common.

The most common symptom of stress fracture is a sharp, persistent, progressive pain or a deep, persistent dull ache located over the bone. Sometimes there is pain on impact (heel strike), but the most important clinical sign is pain over the involved bony surface. Diagnosis is based on clinical observation. Plain radiographs are rarely diagnostic of stress fractures during the initial few weeks, since callus formation is not yet evident. Occasionally a bone scan may be needed and will indicate a “hot spot.”

Therapeutic Management

Development of inflammation is common to all overuse syndromes; therefore management involves rest or alteration of activities, physical therapy, and medication. Rest is the primary therapy, usually interpreted as reduced activity and the use of alternative exercise—not bed rest or immobilization with casting. The main purpose is to alleviate the repetitive stress that initiated the symptoms. It is important to keep the child or adolescent mobile, and training can be continued. Alternative exercise is selected that maintains conditioning without aggravating the injury. For example, pool running (treading water in the deep end of a pool) can use the same movements as running but without the weight bearing; bicycling, swimming, and rowing are viable alternatives.

Other modalities include cryotherapy and cold whirlpool baths. Sometimes taping, bracing, splinting, and other orthoses are employed, depending on the injury. NSAIDs are often prescribed to reduce inflammation and pain. Topical medications are of questionable value.

Nursing Care Management

Deviation from the normal course of puberty is a significant concern for affected adolescents. For some adolescents, this concern assumes monumental proportions. Many cases of delayed development are caused by simple constitutional delay of puberty, and the child can be assured that normal development will eventually take place.

One difficulty related to a size that is incongruent with chronologic and mental age is the manner in which others relate to the child. People often respond to children with short stature as though they were younger than their age. Consequently, these children may react with babyish or juvenile behavior, thus establishing a circular pattern of behavior and response. Conversely, children who are tall or physically advanced for their age are frequently treated as though they were more advanced than their years. They are often considered clumsy, cognitively delayed, or immature when they perform according to the normal behavioral expectations for their age.

Listening to distressed adolescents and conveying interest and concern are important interventions. Slowly maturing adolescents need support and reassurance that they are unique individuals who have an important contribution to society that is equally as important as that of their peers. Counseling and therapy are individualized for each youth. Encouraging these children to focus on the positive aspects of their bodies and personalities and to adopt sound health practices and practice good grooming fosters a more positive self-image.

Turner Syndrome

Turner syndrome is caused by absence of one of the X chromosomes. Most girls who have this disorder have one X chromosome missing from all cells (45,XO). This disorder is often recognized at birth if the newborn has a webbed neck, low posterior hairline, widely spaced nipples, and edema of the hands and feet. This condition is often diagnosed in the preschool child because growth is restricted or delayed around 3 to 4 years of age. In some cases it may be diagnosed at puberty because of three features: short stature, delayed sexual development, and amenorrhea; individuals with Turner syndrome are generally infertile. They may also have difficulty with peer relationships and understanding social cues. They frequently exhibit behavioral problems, especially immature, socially isolated behavior. Diagnosis is confirmed on the basis of a negative sex chromatin test.

Therapy is individualized for these girls and consists primarily of female hormone treatment and psychologic counseling for both the child and parents. Linear growth can be increased by the administration of growth hormone if therapy is begun early. Estrogen therapy is initiated during the usual time for puberty to promote the development of secondary sex characteristics. Responses to estrogen therapy vary from girl to girl, but gradual feminization is accomplished to some degree in most individuals.

Klinefelter Syndrome

Klinefelter syndrome, the most common of all sex chromosome disorders, is caused by the presence of one or more additional X chromosomes and only one Y chromosome. Most males with this syndrome have a chromosome complement of 47,XXY. The disorder is infrequently diagnosed before puberty, at which time varying degrees of failure of adolescent virilization occur. Some males are not diagnosed until they appear for evaluation for infertility. All have absence of sperm in the semen (azoospermia), small testes, and defective development of secondary sex characteristics (gynecomastia, hypogonadism). In 80% of these boys there is a chromatin-positive buccal smear, and the extra chromosome is apparent on chromosome analysis.

Cognitive impairment is a frequent clinical finding and appears to be related to the number of X chromosomes. Boys may also have gross motor skill difficulties, a developmental language delay, poor verbal skills, reduced auditory memory, shyness, passivity, behavioral problems, and school difficulties. Therapy is directed toward enhancing the masculine characteristics through administration of testosterone.

Nursing Care Management

The nursing care of children with Turner or Klinefelter syndrome is primarily supportive. Nurses assist in the diagnosis, explain tests and therapies, and provide support and encouragement to the child and family. Because both disorders render the individual unable to reproduce, psychologic counseling is an important aspect of care. In young adults marriage and sexual relationships are possible, but alternative reproductive options, such as artificial insemination and adoption, should be discussed.

Therapeutic Management

First-line treatment for adolescents with dysmenorrhea is the administration of NSAIDs, which block the formation of prostaglandins for 2 to 3 days of the menstrual cycle. The girl should be instructed to begin the medication at the first sign of cramping or bleeding. Girls with regular menstrual cycles benefit from beginning the medication 1 or 2 days before the onset of their menses. The medications should be taken with food.

Cyclic estrogen therapy and oral contraceptives are also effective. Simple exercises such as pelvic rocking, assuming the knee-chest position, and breathing exercises may be beneficial. Adequate personal hygiene, participation in regular activities, and methods to decrease stress should be discussed with the adolescent. Dietary changes, supplements, and herbal medications are often used to treat dysmenorrhea. Randomized controlled clinical trials have demonstrated that vitamins B₁ and E are effective in the treatment of dysmenorrhea (Dennehy, 2006).

Nursing Care Management

All adolescent girls need reassurance that menstruation is a normal function. When nurses are asked for advice regarding menstrual problems, they have a valuable opportunity to engage in health teaching concerning menstrual physiology; hygiene; and the importance of a well-balanced diet, exercise, and general health maintenance. Health teaching can dispel myths about menstruation and femininity. When assessment indicates a potential problem and the need for evaluation, referral to an appropriate practitioner, health service, or clinic may be necessary.

One of the most difficult experiences facing the adolescent girl is the gynecologic examination. Whether it is her first experience or not, she is often filled with apprehension. Almost all adolescents are extremely self-conscious about their bodies and the changes taking place. They need continuing support in the form of anticipatory guidance regarding what to expect and suggestions of what to do to relax during the procedure. Most girls favor a semisitting position, which has the additional advantage of allowing eye contact during the procedure. Sometimes a pillow helps the patient feel more comfortable and less vulnerable. The provision of a mirror for the girl to see what is taking place if she so desires helps the examiner explain various aspects of anatomy. When possible, it is important to respect the adolescent’s request for a female provider.

 Infections, such as urethritis (see Urinary Tract Infection, Chapter 27)

 Hematuria

 Penile problems, such as nonretractable foreskin in uncircumcised males, carcinoma, and trauma

 Scrotal conditions, such as varicocele (elongation, dilation, and tortuosity of the veins superior to the testicle)

 Testicular torsion (a condition in which the testicle hangs free from its vascular structures, which can result in partial or complete venous occlusion with rotation)

Nursing Care Management

The adolescent boy is also self-conscious about his changing body and needs preparation for a genital examination. The most successful approach is to assume a matter-of-fact attitude toward the examination, explain precisely what will take place, and maintain a continuous commentary about what is being done and the findings at each phase of the examination.

The routine health assessment of every adolescent boy should include teaching about testicular cancer and how to perform a testicular self-examination (TSE) every month. This rare malignancy is curable if detected early. Nurses are in an ideal position to teach TSE in a manner that is respectful of the adolescent boy’s anxieties and that promotes early treatment (see Critical Thinking Exercise).

The normal testicle is a firm organ with a smooth, egg-shaped contour; the epididymis is palpated as a raised swelling on the superior aspect of the testicle and should not be taken for an abnormality.

Nursing Care Management

Treatment usually consists of assurance to the adolescent and his parents that this is a benign and temporary situation. A physical examination with palpation is necessary to differentiate gynecomastia from increased adiposity caused by being overweight. Adolescents who are distressed about physical integrity and masculinity may benefit from the knowledge that this condition occurs in more than 50% of all adolescent boys.

Nursing Care Management

A pregnant teenager needs careful assessment by the nurse to determine the level of social support available to her and her partner. The adolescent needs to make many important decisions and may not have the life experience to know how to cope with this stress. Whenever possible, guidance from the adults in her life will be invaluable. Information about options to continue the pregnancy and parent the child, continue the pregnancy with adoption, or terminate the pregnancy with abortion should be given in a nonjudgmental manner. If the adolescent chooses to continue the pregnancy, prenatal care should be initiated as soon as possible. No matter what the teenager decides, nutrition information will be necessary.

Nursing Care Management

Nurses are often involved in providing education about contraception. Such education is ideally combined with ongoing sex education. Although sexual abstinence is a highly desirable form of contraception for teenagers, nurses working with adolescents must recognize that teens feel multiple pressures to engage in sexual intercourse. Postponing sexual involvement requires effective communication and decision-making skills. Adolescents benefit from role-playing refusal skills and opportunities to practice making decisions in a safe environment. Information about safe sex must be provided, and role-playing how to discuss condom use with a partner is helpful to teenagers.

Education concerning contraception should be provided in both oral and written form. All available methods, including their benefits, disadvantages, and side effects, should be discussed. Concrete, concise language must be used, demonstrations of how to use the contraceptive should be provided, and adolescents should repeat all instructions in their own words. If teenagers are using oral contraceptive pills, they should be encouraged to use a daily activity as a reminder or cue to take the pill. A knowledgeable phone triage person should be available for questions and concerns. Parents or other important adults may be included in all discussions, with the adolescent’s permission.

Therapeutic Management

Effective treatment of both males and females with an STD involves administration of the appropriate therapeutic agent. Treatment of sexual partners is also an essential part of therapy. Adolescents need help to develop strategies to inform their partner and to abstain from sex until both have completed treatment.

A totally effective prophylaxis against infection is not yet available; therefore preventive efforts must be directed toward finding and treating affected persons, locating and examining contacts of affected persons, educating young people regarding the facts of the disease and its spread, and encouraging the use of condoms in sexually active young people.

Nursing Care Management

Nursing responsibilities encompass all aspects of STD education, confidentiality, prevention, and treatment. Part of the sex education of young people should include providing information about these diseases, including their symptoms and treatment, and dispelling the myths associated with their mode of transmission. Many vulnerable adolescents are uninformed or misinformed about STDs.

Primary prevention efforts for STDs include encouraging abstinence and postponing sexual involvement; encouraging condom use; and ensuring vaccination for hepatitis A and B and HPV. Nurses play a role in secondary prevention by helping to identify early cases and referring adolescents for treatment. Nurses can also be involved in tertiary prevention by decreasing the medical and psychologic effects of STDs; conducting support groups for adolescents with HIV, herpes simplex virus, and HPV infections; and assisting pregnant adolescents in obtaining adequate prenatal screening and treatment of STDs.

Diagnostic Evaluation

The rape victim may exhibit a variety of reactions (Box 17-2), and the circumstances of the initial medical evaluation may be frightening and stressful. The initial contact with the rape victim must be supportive because the interrogation and associated activities have the potential to add to the trauma of the sexual assault. First of all, the victim needs to know that she (or he) is (1) all right and (2) not being blamed for the situation.

It is important to obtain a clear account of the circumstances of an alleged rape without forcing the victim to relive a painful experience. Information includes date, time, location, and an accurate description of any type of sexual contact. The physical examination is carried out as soon as possible, since physical evidence deteriorates rapidly. The victim should not bathe or shower before the examination.

The young person is always told in advance in understandable terms exactly what to expect in the way of tests and procedures, and the explanation is accompanied by strong emotional support. The victim is examined thoroughly, including nongenital areas, for evidence of injury that might substantiate the use of force.

The forensic examination of a sexual assault victim must follow strict legal requirements. The medical record may provide key evidence for the legal case. Practitioners specially trained for rape examination should be used when possible. Nurses are often members of this group and are known as sexual assault nurse examiners (SANEs). Evaluation for STDs is an important part of the evaluation. All potential infection sites are tested to detect gonorrhea, chlamydia, and trichomoniasis. Blood samples for syphilis, hepatitis B virus, and HIV are obtained as a baseline (American Academy of Pediatrics, 2001a). The adolescent is reexamined at appropriate intervals (4 to 6 weeks for syphilis; 2 to 3 days for gonorrhea) to determine if a disease was acquired from the assailant.

Prophylactic treatment for chlamydia and gonorrhea is recommended. Female victims should be provided with emergency contraception. The recommendation for HIV prophylaxis varies depending on the geographic area, the circumstances of the assault, and the known HIV status of the perpetrator. The Centers for Disease Control and Prevention (2006a) maintains updates and recommendations for treatment of STDs incurred as a result of sexual assault.^*

Therapeutic Management

Adolescents who have been raped arrive at the emergency department or practitioner’s office under a variety of circumstances. They are usually brought by parents, friends, or police officers, but some may seek medical help on their own. It is advisable to obtain parental consent for examination, but the examination may be performed without parental consent if the adolescent is mature and the parents are unavailable. A female observer should be present during the history and examination of female victims who are examined by a male practitioner. Whether a parent should be present during the examination is determined on an individual basis. The parent’s presence is usually encouraged if the parent is supportive and the young person agrees.

Rape Trauma Syndrome

The term rape trauma syndrome refers to the victim’s reaction to a sexual assault. The syndrome involves two phases: (1) the acute phase of disorganization of lifestyle and (2) a long-term process of reorganization. These phases encompass behavioral, somatic, and psychologic reactions to the stressful event. Counseling should begin immediately upon the adolescent’s entrance into the emergency department with follow-up within the first 24 hours. Early intervention has been shown to be effective in decreasing the extent of rape trauma syndrome (Patel and Minshall, 2001).

Nursing Care Management

Many of the approaches that have been described for the sexually abused child (see Chapter 14) apply to the adolescent. Sexual assault is a devastating experience with long-lasting effects. The primary goal of nursing care is to avoid inflicting further stress on the adolescent, who is often angry, confused, frightened, embarrassed, and filled with self-blame. The nurse must do everything possible to reduce the stress of the interrogation and examination. Although most health professionals and law enforcement officers are sensitive to the needs of the adolescent and attempt to make the process as nonstressful as possible, the nurse should be alert to cues that indicate the victim is being overstressed.

Follow-up care of the rape victim is essential and extends over a long period. Aside from the universal need for emotional support, the needs of rape victims vary widely and depend on the nature of the incident, the victim’s age when the rape occurred, the physical and emotional injuries sustained by the victim, the legal actions being considered as a result, the resources available for informal support, and the anticipated reactions of persons in the informal support network (see Family Focus box).^*

Etiology and Pathophysiology

Obesity results from a caloric intake that consistently exceeds caloric requirements and expenditure and may involve a variety of interrelated influences, including metabolic, hypothalamic, hereditary, social, cultural, and psychologic factors (Fig. 17-2). Because the etiology of obesity is multifactorial, the treatment requires multilevel interventions.

Birth weight is not a contributing factor in detection and prediction of childhood obesity; obese children do not have higher birth weights than nonobese children. There is, however, a high correlation between childhood adiposity and parental adiposity.

A balance between energy intake and energy expenditure is a critical factor in regulating body weight. Factors that raise energy intake or decrease energy expenditure by even small amounts can have a long-term impact on the development of overweight and obesity. For example, a positive balance of one serving of a sweetened juice or soft drink (about 120 kcal) per day would produce a 50 kg (110 pound) increase in body mass over a 10-year period (Hill, Wyatt, Reed, and others, 2003).

Familial influence is an epidemiologic consideration in regard to a child’s weight. Twin studies suggest that approximately 50% to 70% of the tendency toward obesity is inherited (Kiess, Galler, Reich, and others, 2001). Twin studies have also suggested that this tendency is a combination of genetic and environmental factors. If both parents are lean, the likelihood of the child becoming overweight is just 9%. When both parents are obese, there is a 60% to 80% increase in the likelihood of the child becoming obese (Koeppen-Schomerus, Wardle, and Plomin, 2001). The specific influences of genes and environment within the developing child is not well defined. The increasing rates of obesity within genetically stable populations suggest that environmental and some perinatal factors (e.g., bottle feeding) are contributors to the current increases in childhood obesity (National Institute for Health Care Management Foundation, 2003).

Fewer than 5% of the cases of childhood obesity can be attributed to an underlying disease. Such diseases include hypothyroidism; adrenal hypercorticoidism; hyperinsulinism; and dysfunction or damage to the central nervous system as a result of tumor, injury, infection, or vascular accident. Obesity is a frequent complication of muscular dystrophy, paraplegia, Down syndrome, spina bifida, and other chronic illnesses that limit mobility.

A major focus of obesity research has been on appetite regulation. The expression of appetite is chemically coded in the hypothalamus by distinctive circuitry. Orexigenic substances produce signals that promote eating behaviors, and anorexigenic substances promote the cessation of eating behaviors. Feedback loops between signals have been identified where one signal peptide is able to alter the secretion of another signal peptide. No one signal has been identified as the gatekeeper of appetite. It is apparent that an entire network of signals, including their frequency and amplitude, is responsible for triggering eating behaviors.

There is little evidence to support a relationship between obesity and “low metabolism.” Small differences may exist in regulation of dietary intake or metabolic rate between obese and nonobese children that could lead to an energy imbalance and inappropriate weight gain, but these small differences are difficult to accurately quantify. No differences in basal metabolic rate, sleeping metabolic rate, respiratory quotient, heart rate, or total energy expenditure have been found in normal weight children with or without a familial predisposition to overweight (Baker, Barlow, Cochran, and others, 2005). In childhood, overeating is the dominant feature in obesity, whereas in adult life, reduced physical activity with normal intake is more likely.

The tendency toward obesity is manifested whenever environmental conditions are favorable to excessive caloric intake, such as an abundance of food, limited access to low-fat foods, reduced or minimum physical activity, and snacking combined with excessive television viewing. Family and cultural eating patterns, as well as psychologic factors, play an important role; many families and cultures consider fat to be an indication of good health. It is not uncommon for obese children to have families that emphasize large meals or admonish children for leaving food on their plates. Parents may have an exaggerated concept of the amount of food children require and expect them to eat more than they need. The prevalence of obesity shows a marked difference between upper- and lower-class children, with differences often becoming apparent before 6 years of age. Lower socioeconomic groups have a greater prevalence of obesity, especially in girls. Physical activity may also be influenced by sociocultural factors.

Some community factors that influence activity patterns include unsafe neighborhoods that keep children from playing outside. Many communities lack affordable and accessible areas for low-income youth to be active, thus limiting opportunities for young people to participate in physical activities. Social policies also contribute to obesity. The increased availability of high-fat foods, pricing strategies that promote unhealthy food choices, and overzealous food advertising that targets children and adolescents with high-fat and high-sugar foods are some examples.

Institutional factors also influence patterns of obesity and decreased physical activity. Many school policies allow students to leave school for lunch. Vending machines in school often are filled with high-fat and high-calorie foods and soft drinks. Although well-balanced, nutritious school lunches may be available to students, they will often opt for less nutritious choices such as high-fat snacks.

Physical inactivity has also been identified as an important contributing factor in the development and maintenance of childhood overweight. There is little doubt that physical activity has decreased in elementary and secondary schools in the United States. Consequently, most of a child’s physical activity must occur within the family or outside of school. Decreased physical activity within the family is a powerful influence on children, since children imitate their parents and other adults. Parental obesity and low levels of physical activity are correlated with decreased physical activity in children.

The growing attraction and availability of many sedentary activities, including television, video games, computers, and the Internet, have greatly influenced the amount of time that children spend participating in sedentary behaviors. A study conducted by the Kaiser Family Foundation demonstrated that children watch an average of 2½ hours of television per day, and that one in five kids watches TV for 5 hours or more every day (Rideout, Foehr, Roberts, and others, 1999). When combining television viewing with video games, it is estimated that children may spend as much as 6½ hours per day on various media, which takes time away from meaningful activities such as exercise and reading (American Academy of Pediatrics, 2001b).

Psychologic factors also affect eating patterns. In infancy, children experience relief from discomfort through feeding and learn to associate eating with a sense of well-being, security, and the comforting presence of a nurturing person. Eating is soon associated with the feeling of being loved. In addition, the pleasurable oral sensation of sucking provides a connection between emotions and early eating behavior. Many parents use food as a positive reinforcer for desired behaviors. This practice may become a habit, and the child may continue to use food as a reward, a comfort, and a means of dealing with depression or hostility. Many individuals eat when they are not hungry or in response to boredom, loneliness, sadness, depression, or tiredness. Difficulty in determining feelings of satiety can lead to weight problems and may compound the factor of eating in response to emotional rather than physical hunger cues.

Eating behaviors are closely related to memory. Memory and appetite are chemically encoded, with each individual having his or her own circuitry relating to eating behaviors. Like memory, the circuitry can be modified over time (Feldman, Friedman, and Sleisenger, 2002).

Diagnostic Evaluation

A careful history is obtained regarding the development of obesity, and a physical examination is performed to differentiate simple obesity from increased fat that results from organic causes. A family history of obesity, diabetes, coronary heart disease, and dyslipidemia should be obtained for all children who are overweight or at risk for overweight. Specific information from the patient and family about the effects of obesity on daily functioning—for example, problems with nighttime breathing and sleep, daytime sleepiness, pain in the joints, ability to keep up with family activities and peers at school—will be helpful. The physical examination should focus on identifying comorbid conditions and identifiable causes of obesity. For some, psychologic assessment, by interviews and standardized personality tests, may provide insight into the personality and emotional problems that contribute to obesity and that might interfere with therapy.

It is useful to estimate the degree of obesity to determine the component of body weight that can be modified. All the following methods have been used to assess obesity: BMI, body weight, weight-height ratios, weight-age ratios, hydrostatic (underwater) weight, skinfold measurements, bioelectrical analysis, computed tomography (CT), magnetic resonance imaging (MRI), and neutron activation. Each of these methods has advantages and disadvantages. Hydrostatic, or underwater, weighing provides the most accurate measurement of lean body weight.

BMI is currently considered the best method to assess weight in children and adolescents. The calculation is based on the individual’s height and weight. In adults, BMI definitions are fixed measures without regard for sex and age. The BMI in children and adolescents varies to accommodate age- and gender-specific changes in growth. The formula for BMI calculation is:

BMI measures in children and adolescents are plotted on growth charts that enable heath care professionals to determine BMI-for-age for the patient (see Appendix B).

The initial assessment of obese children and adolescents should include screening to evaluate for comorbidities. The history is an important guide to determine the workup. A complete physical examination is important. Some areas to focus on include (1) skin for stretch markings and discolorations (e.g., acanthosis nigricans), (2) joints for swelling and evidence of pain, and (3) airway for evidence of obstruction and enlarged tonsils. Basic laboratory studies include a fasting lipid panel; fasting insulin level; fasting glucose hepatic enzymes, including γ-glutamyltransferase (GGT); and, in some institutions, hemoglobin A_1c. Other studies, such as a sleep study, metabolic studies, and radiographic evaluations, may be added based on the history and physical examination. These assessments may determine whether the patient needs a referral to specialty services for more focused evaluation and treatment, such as endocrinology (insulin resistance, diabetes), hepatology (elevated liver enzymes, NAFLD), orthopedics (Blount disease), or pulmonary medicine (sleep-disordered breathing, continuous positive airway pressure).

Therapeutic Management

The best approach to the management of obesity is a preventive one. Early recognition and control measures are essential before the child or adolescent reaches an obese state. Health care providers must educate families about the medical complications of obesity, and families are encouraged to be involved in the treatment plan.

The treatment of obesity is difficult. Many approaches do not achieve long-term success. The average individual only loses about 5% to 10% of his or her weight with available therapies. Losing weight can have a significant positive effect on many comorbidities, but unfortunately the lost weight is frequently regained in a year or two (Yanovski and Yanovski, 2002).

Diet modification is an essential part of weight-reduction programs. Dietary counseling is directed toward improving the nutritional quality of the diet rather than on dietary restriction. Children should avoid fad diets. Most dietitians and nutrition experts recommend a diet with low-saturated fat, moderate total fat (≤30%), and five servings of fruits and vegetables, consistent with the MyPyramid^* food guide for children. Also, promoting high-fiber foods and avoiding highly refined starches and sugars will decrease caloric intake. The Dietary Guidelines for Americans^† may be used as a guide for caloric intake for adolescents concerned about weight control; these guidelines also emphasize daily exercise in weight management for children and adolescents. Many programs recommend using a food diary as a helpful tool to increase awareness of food choices and eating behaviors. The goal is to encourage the individual to make healthier choices in food selection and discourage eating food by habit or to appease boredom.

In patients with severe obesity, strict diets have been used, such as the protein-sparing modified fast, a hypocaloric, ketogenic diet that is designed to provide enough protein to minimize loss of lean body mass during weight loss. Such diets need to be closely monitored and should be used only with multidisciplinary teams that include a physician, nutritionist, and behavioral therapist. Generally, the diet consists of 1.5 to 2.5 g of protein per kilogram. The intake of carbohydrates is low enough to induce ketosis. The benefits of the diet are relatively rapid weight loss and anorexia induced by ketosis. Potential complications include protein losses, hypokalemia, hypoglycemia, inadequate calcium intake, and orthostatic hypotension. Potassium and calcium supplements and adequate calorie-free beverages can minimize these complications (Baker, Barlow, Cochran, and others, 2005). It is difficult to sustain such diets over the long term, and the long-term outcomes of using these diets have not been established.

Some drugs have been used to promote weight loss in children with certain conditions such as metformin in obese adolescents with insulin resistance and hyperinsulinism, octreotide for hypothalamic obesity caused by intracranial tumors, growth hormone in children with Prader-Willi syndrome, and leptin for congenital leptin deficiency. The drug sibutramine, in addition to behavioral therapy, significantly reduced BMI and body weight more than placebo; however, the drug was associated with side effects (tachycardia and hypertension) (Berkowitz, Fujioka, Daniels, and others, 2006).

Bariatric surgery may be the only practical alternative for increasing numbers of severely overweight adolescents who have failed organized attempts to lose or maintain weight loss through conventional nonoperative approaches and who have serious life-threatening conditions. Some preliminary studies suggest that adolescents with severe obesity have successful weight loss up to 14 years after bariatric surgery; most adolescents were reported to have a significant change in lifestyle as a result of the weight loss after surgery (Sugerman, Sugerman, DeMaria, and others, 2003). Others suggest that bariatric surgery in adolescents is safe and they have fewer postoperative complications than adults, but the procedure is relatively uncommon in comparison to the number of adults having surgery for obesity (Tsai, Inge, and Burd, 2007). In general, bariatric surgery should be reserved for severely obese adolescents with comorbidities after careful consideration. Candidates for surgery should be referred to centers that offer a multidisciplinary team experienced in the management of childhood and adolescent obesity, and the surgery should be performed by surgeons who have participated in subspecialty training in bariatric medical and surgical care as detailed by the American College of Surgeons and the American Society for Metabolic and Bariatric Surgery.

Nursing Care Management

Nurses play a key role in the adherence and maintenance phases of many weight-reduction programs. Nurses assess, manage, and evaluate the progress of many overweight adolescents. They also play an important role in recognizing potential weight problems and assisting parents and adolescents in preventing obesity. The nursing process in the care of the adolescent with obesity or overweight is outlined in the Nursing Process box.

The presence of obesity may not be obvious from appearance alone. Regular assessment of height and weight and computation of the BMI facilitate early recognition. Children with a BMI greater than or equal to the 95th percentile for age and sex should receive in-depth medical assessment. Children with a BMI in the 85th to 95th percentile range should be evaluated for secondary complications, such as hypertension and hyperlipidemia, and family history (Greaser and Whyte, 2004). Evaluation includes a height and weight history of the adolescent and family members, eating habits, appetite and hunger patterns, and physical activities. A psychosocial history is also helpful in understanding the impact of obesity on the child’s life.

Before initiating a treatment plan, it is important to be certain that the family is ready for change. Lack of readiness may result in failure, frustration, and reluctance to address the problem in the future. The nurse should explore with adolescents the reasons behind the desire to lose weight, since motivation to lose weight is the key to success. Adolescents need to take a personal responsibility for dietary habits and physical activity. Teens who are forced by their parents to seek help are seldom motivated, become rebellious, and are unwilling to control their dietary intake.

Etiology and Pathophysiology

The etiology of these disorders remains unclear. There is a distinct psychologic component, and the diagnosis is based primarily on psychologic and behavioral criteria. Dieting appears to be common to the initiation of both AN and BN. The disorders appear to be caused by a combination of genetic, neurochemical, psychodevelopmental, and sociocultural factors. The dominant aspects of AN are a relentless pursuit of thinness and a fear of fatness, usually preceded by a period of mood disturbances and behavior changes.

Weight loss may be triggered by a typical adolescent crisis such as the onset of menstruation or a traumatic interpersonal incident that precipitates serious, out-of-control dieting. Situations of severe family stress (such as parental separation or divorce) or circumstances in which the adolescent perceives a lack of personal control (such as teasing at school, changing schools, or going to college) may precipitate a desire for control and the decision not to eat. Frequently, there is an exaggerated misinterpretation of the normal fat deposition characteristic of early adolescence or anxiety because of comments that the adolescent is putting on weight.

Many experts have associated the development of an eating disorder with family characteristics such as an adolescent perception of high parental expectations for achievement and appearance, difficulty managing conflict and poor communication styles, enmeshment and occasionally estrangement between family members, devaluation of the mother or the maternal role, and marital tension. Families struggling with an eating disorder have been characterized as often having difficulties responding positively to the changing physical and emotional needs of the adolescent. Family stress of any kind may become a significant factor in the development of an eating disorder (Forman, 2007).

Society’s emphasis and the media’s focus on tall, thin individuals may also play a role. Studies evaluating the possible association of eating disorders and sexual abuse have been conflicting. Childhood sexual abuse may be a factor in some cases of AN.

Patients with eating disorders commonly have psychiatric problems, including affective disorder, anxiety disorder, obsessive-compulsive disorder, and personality disorder. Adult women with eating disorders were found to have higher rates of obsessive-compulsive behavior traits in their childhood. Patients with eating disorders have also been found to have higher reported rates of substance abuse, with alcohol problems being more common in those with BN than AN (Forman, 2007). It is important to note that many of the clinical findings are directly related to the state of starvation and improve with weight gain.

Many sports and artistic endeavors that emphasize leanness (e.g., ballet and running) and sports in which the scoring is partly subjective (e.g., skating and gymnastics) have been associated with a higher incidence of eating disorders such as AN. The term female athlete triad, characterized by disordered eating behavior, amenorrhea, and osteoporosis, has been applied to young women with restrictive eating disorders and amenorrhea (Rome, Ammerman, Rosen, and others, 2003).

A genetic role has been postulated for eating disorders; a significant number of young females with a first-degree relative having an eating disorder were at a significantly higher rate of having an eating disorder (Forman, 2007).

Diagnostic Evaluation

Diagnosis of AN is made on the basis of clinical manifestations (Box 17-4) and conformity to the criteria established by the American Psychiatric Association (2000) (Box 17-5). Diagnosis of BN is confirmed, according to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (2000) (Box 17-6), by at least two binge-eating episodes per week for the preceding 3 months.

A complete history and physical examination are important to rule out other causes for weight loss. The medical assessment of an eating disorder focuses on the complications of altered nutritional status and purging. A careful history assesses weight changes, dietary patterns, and the frequency and severity of purging and excessive exercise. The patient’s weight and height should be measured and evaluated for appropriateness according to standard weight for height, age, and sex determined according to the percentile of his or her expected body weight or BMI.

Additional diagnostic measures may include a complete blood count to evaluate for anemia and other hematologic abnormalities; erythrocyte sedimentation rate or C-reactive protein to detect evidence of inflammation; electrolytes as well as calcium, magnesium, phosphorus, blood urea nitrogen, and creatinine; urinalysis, including specific gravity; and bone density studies for osteopenia, which is commonly observed in patients with AN. In patients with prolonged amenorrhea, human chorionic gonadotropin (hCG) is assessed to determine the presence of pregnancy. Other tests for patients with amenorrhea include thyroid function tests and measurement of serum prolactin and follicle-stimulating hormone to help rule out prolactinoma (hormone-secreting pituitary tumor), hyperthyroidism, hypothyroidism, or ovarian failure. In addition, a comprehensive cardiac evaluation is often recommended in those with AN. Further diagnostic tests may be required based on the history and findings from above diagnostic tests.

Therapeutic Management

The treatment of AN involves four major goals:

Most adolescents are treated on an outpatient basis, but those with problems requiring immediate medical attention, such as severe malnutrition or electrolyte or psychiatric disturbances (severe depression or suicidal ideation), require hospitalization. A multidisciplinary team of dietitians, physicians, nurses, and counselors provide the interventions.

Persons with BN may benefit from cognitive behavioral therapy, other psychotherapy, antidepressant medications, or a combination of antidepressant medication and psychotherapy (Forman, 2007).

Nursing Care Management

Nurses need to adopt and maintain a kind and supportive yet firm manner in managing the care of the adolescent with eating disorders without creating a passive-dependent attitude. The individual requires sustained support and reassurance to cope with ambivalent feelings related to body concept and the desire to be seen as cooperative, reliable, and worthy of receiving kindness. Encouraging the adolescent with education and activities that strengthen self-esteem facilitates the resocialization process and promotes social acceptance among peers.

It is important for nurses to be aware of the physical side effects of AN. Patients frequently limit their fluid intake. Urinary tract problems are common, and ketones and protein may be detected in the urine as a result of breakdown of fat and protein. Vital sign instability can be severe and can include orthostatic hypotension; the pulse becomes irregular, and the rate decreases markedly. Bradycardia and hypothermia can result in cardiac arrest (see Critical Thinking Exercise).

The team responsible for the management of young people with AN arranges a carefully structured environment. First, there must be consistency. The team decides on an approach and adheres to it. The plan is structured with reality testing regarding caloric intake and body-image perception as an essential component. The team members provide a unified front to avoid any possibility of manipulation or inconsistency. Second, all team members are involved; responsibility for the program cannot be left to one person. The role and boundaries of each member are clearly spelled out. Third, continuity of team members is important; it is helpful to have the same team members all the time.

Fourth, communication among team members is essential. Communication with the patient regarding what is expected is also important. Sometimes the limit setting may seem unreasonable; if the adolescent does not understand the rationale for the limits, he or she may sabotage the entire program. It is also important to communicate with the family. Fifth, the plan must provide for support of the adolescent, the family, and team members. The adolescent’s efforts should be supported, and positive feedback should be provided for accomplishments made in normalizing eating habits. Meetings are held to discuss the feelings and concerns of the patient, immediate caregivers, and team members.

A behavioral contract, an agreement that the adolescent makes with others to change a maladaptive behavior, has proved to be effective in some cases. The written contract is constructed by the therapeutic team and approved and signed by the adolescent. Unless the adolescent agrees to its terms, the contract can become the source of a power struggle. However, it can be an effective tool that places the responsibility for weight gain or other behavioral change on the adolescent.

Nursing care of the adolescent with BN is similar to care of the patient with AN. Acute care involves careful monitoring of fluid and electrolyte alterations and observation for signs of cardiac complications. Nutritional consultation and follow-up care are essential. The nurse should encourage the adolescent and family members to structure the environment to reduce the binging behavior. Getting rid of binge foods; restricting eating to one room of the house; not engaging in other activities while eating; and substituting exercise, crafts, visualization, and relaxation techniques for binging are helpful interventions.

Health professionals, patients, and families can find assistance and information from several organizations. The National Association of Anorexia Nervosa and Associated Disorders, Inc.,^* and the National Eating Disorders Association^† provide counseling, referrals, and self-help programs.

Diagnostic Evaluation

The behaviors exhibited by the child with ADHD are not unusual. The difference lies in the quality of motor activity and developmentally inappropriate inattention, impulsivity, and hyperactivity that the child displays. The manifestations may be numerous or few, mild or severe, and vary with the child’s developmental level. Any given child will not have every symptom of the condition. The basic characteristics of ADHD are outlined in Box 17-7.

A comprehensive battery of tests is needed to confirm an LD. These include intelligence tests (many children have normal or above-average intelligence quotients [IQs]); hand-eye coordination tests; and measurements of auditory and visual perception, spatial organization, comprehension, and memory. Often there is a wide gap between verbal and performance scores on IQ tests.

Behavioral checklists and adaptive scales are also helpful in measuring school adaptive functioning in children with ADHD. Psychiatric disorders, medical problems, and traumatic experiences are ruled out, including lead poisoning, seizures, partial hearing loss, psychosis, and witnessing of sexual activity or violence.

Therapeutic Management

Management of the child with ADHD usually involves multiple approaches that include family education and counseling, medication, proper classroom placement, environmental manipulation, and behavioral therapy or psychotherapy for the child. Interventions for children with LD are primarily educational.

Nursing Care Management

Nurses are active participants in all aspects of management of the child with ADHD or LD. Nurses in the community work with families and school personnel on a long-term basis to help plan and implement therapeutic regimens and to evaluate the effectiveness of therapy. They coordinate services and serve as a liaison between health and education professionals directly involved in the child’s therapy program. School nurses understand the child’s special needs and work with teachers (see Family Focus box). Nurses in any setting (community, school, hospital, practitioner’s office) provide support and guidance to children and families during the difficult period of the child’s growing up with a disabling condition.

Management begins with an explanation to the parents and the child about the diagnosis, including the nature of the problem and the practitioner’s concept of the underlying central nervous system basis for the disorder. Most parents are confused and feel some measure of guilt. To some parents, a diagnosis of ADHD is confirmation of the fear that their child has some irreversible, serious disease; to others it is a relief. All need the opportunity to vent their feelings and suspicions.

Parents need information about the prognosis and an understanding of the treatment plan. The greater their understanding of the disorder and its effects, the more likely they will be to carry out the recommended program of therapy. It is important that they understand that the therapy is not necessarily a panacea and that it will extend over a long period. This has particular significance for changes they need to make in environmental management. Reading material to help the child and family can be obtained from a variety of sources.

Nursing Care Management

Children need to deal with any traumatic event. Their reactions depend heavily on their social environment and the way in which their caretaking adults react to the event. In the second phase of PTSD, the appropriateness of the defense mechanism must be assessed, and children must be assisted in application of their defense. If children do not engage in some catharsis or if their defense phase is prolonged, they need referral for special psychologic help.

Coping is a learned response, and children in the third phase can be helped to deal with their fear. Children usually are willing to accept reasoning. Those who are assisted in their catharsis and allowed expression will survive without serious lasting effects. They should be encouraged to play out the stress and to discuss their feelings about the event. If they are unable to do this, they may become obsessed with the traumatic event and require professional help. Conversion reactions are common obsessive behaviors in children suffering from PTSD.

Children need professional help if any of the phases of PTSD are prolonged. Boys tend to have a prolonged defense phase more often than girls. Occasionally the event will be unrecognized, and the affected child will engage in what is considered to be unusual behavior. Children exhibiting any sudden change in behavior need to be assessed for a traumatic event. When the change in behavior is traced to a traumatic event, treatment can be implemented.

Nursing Care Management

Treatment for school phobia depends on the cause. The primary goal is to return the child to school. The longer a child is permitted to stay out of school, the more difficult it is for the child to reenter. Parents must be convinced gently but firmly that immediate return is essential and that it is their responsibility to insist on school attendance.

A school reentry protocol may be necessary for the child with severe symptoms. In reentry programs, the child role-plays routines involved in getting ready for school and that occur at school. Relaxation techniques are also used. The child usually goes to school initially for a half-day and then progresses to a full day. Often the school nurse is asked to provide support to the parents and the teacher during the reentry process. If the problem persists, professional help is recommended.

Nursing Care Management

Once the diagnosis has been established, the parents and the child need an explanation of the pain, which can be compared to a skeletal muscle cramp, “charley horse,” or headache for easier comprehension. Reassurance that the symptoms are not unique to their child and that the pain is rarely associated with a severe disease can be helpful in relieving parental fears and anxieties.

The simple measure of having the child rest in a peaceful, quiet environment and providing comfort will often relieve the symptoms in a short time. A heating pad may also help ease the discomfort (see Nonpharmacologic Management, Chapter 7). When pain is not relieved by these simple measures, the parents are taught how to administer antispasmodics, if prescribed. For example, if pain is precipitated by meals, having the child take the medication 20 to 30 minutes before mealtime may prevent an episode.

The most valuable assistance that the nurse can provide is support and reassurance to the family. When open communication is established and families appreciate the relationship between stress-provoking situations and the child’s symptoms, the chance for remedial action is enhanced. Follow-up care and continued support are essential because the symptoms tend to remit and exacerbate. The availability of a supportive health professional is a source of comfort to the child and family.

Nursing Care Management

Nursing care is similar to that for the child with RAP. If significant personality problems are evident, psychiatric consultation is indicated.

Nursing Care Management

Depressed children are managed by a health team especially prepared in the care of children with mental disorders. Treatment is highly individualized and undertaken in the least restrictive environment. Suicidal children are admitted to the hospital for protection if the family is unable to provide constant monitoring. Pharmacotherapy may involve tricyclic antidepressants or SSRIs such as fluoxetine (Prozac), trazodone (Desyrel), sertraline (Zoloft), paroxetine (Paxil), bupropion (Wellbutrin), and venlafaxine (Effexor).

Nurses should be aware that depression is a problem that can be easily overlooked in the child and one that can interrupt normal growth and development. Recognizing depression and suicidal tendencies in depressed adolescents and making appropriate referrals are important nursing functions. Identification of the depressed child requires a careful history (health, growth and development, social and family health); interviews with the child; and observations by the nurse, parents, and teachers (see also Suicide, p. 568). Some antidepressant medications may cause increased suicidal thinking and behaviors in pediatric patients. This has prompted the U.S. Food and Drug Administration (FDA) to recommend black box drug warnings detailing potential suicide-related risks for pediatric patients (Jick, Kaye, and Jick, 2004; US Food and Drug Administration, 2004). In 2007 the FDA expanded the black box warning, noting that the risk of suicide was highest among adolescents and young adults ages 18 to 24 years, yet added that there is risk in not administering antidepressants. Some data suggest that the suicide rate among adolescents on therapeutic doses of SSRIs was lower than among those who were not being treated with antidepressant medication (Gibbons, Hur, Bhaumik, and others, 2006). However, the issue remains controversial, and further studies are needed.

Nursing Care Management

Nursing of psychotic children is a highly specialized area. However, nurses should be alert to the possibility that schizophrenia can occur in children and refer children who consistently demonstrate abnormal behavior to a psychiatrist for evaluation. In addition, nurses will need to teach family members of children taking antipsychotic drugs to observe for possible side effects. Common side effects of these drugs include dizziness; drowsiness; tachycardia; hypotension; and extrapyramidal effects, such as abnormal movements and seizures.

Motivation

Most drug use begins with experimentation. The drug may be used only once, may be used occasionally, or may become part of a drug-centered lifestyle. Children and adolescents initiate drug use out of curiosity. Adolescents who use drugs may fall into one of two broad categories—experimenters and compulsive users—or they may fall into a third category somewhere on the continuum between these extremes, referred to as recreational users, principally of drugs such as marijuana, cocaine, alcohol, and prescription drugs. For many the goal is peer acceptance; these users fit more closely with the experimenting, intermittent users. For others the goal is intoxication or the sustained intense effects from using a particular drug; these users resemble the compulsive users. These users may engage in periodic heavy use, or binges. The groups of greatest concern to health care workers are those whose patterns of use involve high doses or mixed drugs with the danger of overdose, and those compulsive users with the threat of dependence, withdrawal syndromes, and altered lifestyle.

Types of Drugs Abused

Any drug can be abused, and most are potentially harmful to adolescents still going through formative life experiences. Although rarely considered drugs by society, the chemically active substances frequently abused are the xanthines and theobromines contained in chocolate, tea, coffee, and colas. Ethyl alcohol and nicotine are other drugs that are legal and socially sanctioned. Any of these substances can produce mild to moderate euphoric or stimulant effects and can lead to physical and psychologic dependence.

Drugs with mind-altering abilities that are available on the “street” and are of medical and legal concern are the hallucinogenic, narcotic, hypnotic, and stimulant drugs. In addition, health professionals are concerned about the use of alcohol and volatile substances that are inhaled to achieve altered sensation (such as gasoline, antifreeze, plastic model airplane cement, typewriter correction fluid, and organic solvents). Recently, abuse of prescription and synthetic drugs such as oxycodone, alprazolam (Xanax), and amphetamine-dextroamphetamine (Adderall) has become a concern for professionals who work with children and adolescents. Many of the prescription drugs are available at a decreased cost in comparison to the more exotic drugs of abuse and are often found in the medicine cabinet at home. Internet websites also promote the “safe use” of some psychoactive drugs and supply information on new “designer” drugs that are not detectable on a standard urine drug screening test.

Nursing Care Management Related to Therapeutic Management

Nurses who have contact with children and adolescents are in an excellent position to provide information about substance abuse and to serve as patient advocates. The nurse most often encounters young drug abusers when they are (1) experiencing overdose or withdrawal symptoms, (2) manifesting bizarre behavior or confusion secondary to drug ingestion, (3) worried that they are or will become addicted, or (4) worried about a friend or family member who is addicted.

In particular, nurses who care for hospitalized adolescents need to know if these youths use drugs compulsively. Drug withdrawal can seriously complicate other illnesses. Nurses should be alert for any physical or behavioral clues that indicate the onset of withdrawal or the effects of drugs. School nurses and nurses who work in the community play an essential role in identifying children, adolescents, and families with substance abuse problems. The school nurse may be the first to identify a child or adolescent who has ingested a particular drug by the child’s erratic behavior in class or on the school grounds. Early identification of those at risk for substance abuse problems is an essential aspect of prevention. Pediatric health care professionals also prevent substance abuse by creating trusting relationships so that children and adolescents feel comfortable asking questions about drugs and health professionals can alert them to websites and other aspects of society that encourage experimentation with drugs.

Etiology

Individual, family, and social or environmental factors have all been implicated in suicide. The single most important individual factor is the presence of an active psychiatric disorder (depression, bipolar disorder, psychosis, substance abuse, or conduct disorder). Comorbidity of an affective disorder and substance abuse also increases the risk for suicide. Alcohol use has been associated with more than 50% of suicides (American Academy of Pediatrics, 2000). Gay and lesbian adolescents are at particularly high risk for suicide completion, especially if raised in an environment in which they are denied support systems (see Community Focus box). Family factors influencing suicide include parental loss; family disruption; a family history of suicide, depression, substance abuse, or emotional disturbance; child abuse or neglect; unavailable parents; poor communication and isolation within the family; family conflict; and unrealistically high parental expectations or parental indifference with low expectations. Social or environmental factors include incarceration, isolation, acute loss of a boyfriend or girlfriend, lack of future options, and availability of firearms in the home.

Methods

Firearms are by far the most commonly used instruments in completed suicides among males and females (American Academy of Pediatrics, 2000). For adolescent males, the second and third most common means of suicide are hanging and overdose, respectively; for females the second and third most common means are overdose and strangulation, respectively.

The most common method of suicide attempt is overdose or ingestion of a potentially toxic substance, such as drugs. The second most common method of suicide attempt is self-inflicted laceration.

Motivation

Suicidal ideation is not uncommon in adolescents. It represents numerous fantasies, such as relief from suffering, a means of gaining comfort and sympathy, or a means of revenge against those who have hurt them. Adolescents have the erroneous perception that the act of suicide will evoke remorse and pity and that they will be able to return and witness the grief. Angry children who are unable to directly punish those who have injured or insulted them may take revenge on those who love them through self-destruction (“They’ll be sorry when they find me dead”; “They’ll be sorry they were mean to me”).

For adolescents who are severely depressed, suicide seems to be the only release from their despair. These adolescents rarely provide evidence of their intent and frequently conceal their suicidal thoughts. Many adolescents, however, tell their peers of their suicidal thoughts or plans but avoid telling adults. Social isolation is a significant factor in distinguishing adolescents who will kill themselves from those who will not. It is also more characteristic of those who complete suicide than of those who make attempts or threats.

The frequency of contagion, or copycat suicides (i.e., an increase in youth suicide that occurs after the suicide of one teenager is publicized) is disturbing and may indicate that teenagers perceive suicide as glamorous. In addition, young people may not realize the finality of suicide because they have become desensitized from constantly viewing violence and death on television.

Diagnostic Evaluation

Depression is common among adolescents who attempt suicide. Depression is characterized by both subjective symptoms and objective signs that reflect the adolescent’s sadness and despair. Adolescents describe feelings of sadness, despair, helplessness, hopelessness, boredom, loss of interest, and isolation. They may also feel self-reproach, self-deprecation, and guilt. Subjective symptoms of depression or specific changes in behavior place an adolescent at risk for suicide.

Therapeutic Management

Threats of suicide should always be taken seriously. There has been a tendency to dismiss a suicide attempt as an impulsive act resulting from a temporary crisis or depression. If a suicide attempt fails to draw attention to their problems or makes them worse, the child or adolescent may conclude that suicide is the only answer. Children and adolescents need to know that someone cares and must be provided with swift and efficient crisis intervention. Although ordinary practitioners can manage an acute depressive reaction without difficulty, the adolescent who has made a serious attempt or has a specific plan for suicide should receive immediate attention and competent psychiatric care.

Nursing Care Management

Nurses play a pivotal role in reducing adolescent suicide. Nurses have the opportunity to provide anticipatory guidance to parents and adolescents. They can teach parents to be supportive and to develop positive communication patterns that help teens feel connected with and loved by their families. To foster healthy development, parents can be encouraged to provide teens with creative outlets and to assist young people in accepting strong emotions—pain, anger, and frustration—as a normal part of the human experience.

Care of the suicidal adolescent includes early recognition, management, and prevention. The most important aspect of management is the recognition of warning signs that indicate an adolescent is troubled and might attempt suicide. Health professionals must be alert to the signs of depression, and anyone who exhibits such behavior should be referred for thorough psychologic assessment. Depression is manifested differently in children and adolescents than in adults. In teens it may be masked by impulsive aggressive behaviors. Defiance, disobedience, behavior problems, and psychosomatic disturbances can indicate underlying depression, suicidal ideation, and impending suicide attempts.

Peers or other confidants are valuable observers and excellent sources of information about potential suicide attempts. They may not be able to diagnose depression, but they are able to sense when a friend has undergone a marked personality change. It is important to emphasize that the peer who detects any changes in a friend is a potential rescuer and should not remain silent about the observations. Friendship does not imply collusion. A peer who believes that a friend may be suicidal should alert someone who can help (e.g., a parent, teacher, guidance counselor, school nurse).

Routine health assessments of adolescents should include questions that assess the presence of suicidal ideation or intent. The following questions can be asked (Greydanus and Pratt, 1995):

If children or adolescents express suicidal intent, nurses make a contract, asking them to sign an agreement that they will not attempt suicide during an agreed-on period and that they will call the 24-hour crisis line immediately if they feel that they cannot keep to their contract. The amount of time an adolescent feels comfortable contracting is usually an indication of his or her risk and stability.

Because a suicide attempt is frequently an outgrowth of family distress, it is essential to intervene with the family. It is important to assess family interactions and to recognize disturbed relationships. The most effective approach is recognition of susceptible adolescents during the early stages of family distress so that family counseling can be started. Prevention must be directed toward improving childrearing practices through support and education of parents and changing societal conditions that generate defeat, despair, and maladaptive behavior.

Although confidentiality is an essential part of adolescent counseling, in the case of self-destructive behaviors confidentiality cannot be honored. Suicidal behavior is reported to the family and other professionals, and adolescents are informed that this will be done. Such action conveys an important message to the youth: that the professionals understand and care.

Many schools have instituted suicide prevention programs. These programs include services such as drop-in counseling and a peer-counseling telephone line. Information can also be obtained from the American Association of Suicidology.^*