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PEDIATRICS (ISSN 0031 4005). Copyright © 1988 by the American Academy of Pediatrics.

270

PEDIATRICS

Vol. 82 No. 2 August 1988

COMMENTARIES

Opinions expressed in these commentaries are those of the authors and not necessarily those of the American Academy of Pediatrics or its Committees.

Adolescent

Medicine:

Growth

of a Discipline

Adolescent medicine encompasses the major health and developmental conditions of young peo-ple in the second decade of life (Fig l).1 Many of these conditions result from the rapid physical and psychologic growth that young people experience. This commentary will reflect on the development of adolescent medicine as a discipline and the chal-lenges that the field now faces 30 years after its inception.6’7

The growth of adolescent medicine as a discipline is reflected in the development of professional or-ganizations for those interested in providing health services to adolescents, the dissemination of new findings pertinent to this age group, and the train-ing of young professionals who will provide care to and conduct research into the health care of ado-lescents.

There are several professional organizations

in-terested

in adolescent medicine. These include The Society for Adolescent Medicine, an interdiscipli-nary organization begun in 1968, which now num-bers nearly 1,000 members; The American Academy of Pediatrics’ Section on Adolescent Health, which was organized in 1978 and is the Academy’s third largest section; and numerous local groups of na-tional organizations, such as the regional chapters of the Society for Adolescent Medicine and the committees on adolescence of the American Acad-emy of Pediatrics’ state chapters.

Articles featuring topics in adolescent medicine are included in many biomedical and social science journals. The Journal of Adolescent Health Care,

developed by the Society for Adolescent Medicine

in 1980, includes research and clinical articles, re-views of contemporary topics, and an extensive bibliography of articles concerning adolescent health. There are also several major textbooks of

adolescent medicine,’#{176} and the major pediatric textbooks contain topics concerning adolescent medicine and health care.11’3

Training programs in adolescent medicine in-dude those for physicians as well as those for other professionals such as nurses, social workers, psy-chologists, nutritionists, and others. There are 56 postresidency fellowship programs in adolescent medicine, including six interdisciplinary fellowship training programs funded by the Division of

Ma-ternal and Child Health Services, Bureau of Health

Care Delivery and Assistance. In addition, most pediatric residencies include an adolescent medi-cine component, although the quality and quantity ofthese experiences vary widely among programs.’4 Several medical school curricula also allow a focus on adolescent medicine during specific clerkships or electives.

The academic challenges that adolescent medi-cine now faces are the pursuit of answers to signif-icant research questions, the training of young professionals to answer these significant research questions, and consideration of the need for board certification.

Significant research questions in adolescent med-icine will be defined and answered through collab-orative investigations among colleagues in adoles-cent medicine, the basic sciences, and the clinical sciences. Major technologic advances in the neural sciences, endocrinology, biochemistry, immunol-ogy, the social sciences, and the reproductive sci-ences will provide remarkable opportunities to Un-derstand the maturation of several systems during adolescence (the CNS, the endocrine system, the immune system, and the reproductive system). Ex-amples of future research foci are given in Fig 2.

An understanding of the developing adolescent’s

CNS may be facilitated by new scientific

method-ology in the basic sciences. It is not entirely clear why puberty begins when it does, why formal op-erational thinking develops during adolescence, why adolescents experience eating disorders, and why the major affective disorders of adulthood be-come evident initially during adolescence.

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. Physical and psychologic development

(princi-pies and application)

. Clinical approaches to adolescent health care (interviewing, legal rights of minors, confiden-tiality, gynecologic evaluation, well-adolescent health care, self-examination)

. Delayed or accelerated growth

. Consequences of risk-taking behavior (coital ac-tivity: pregnancy, sexually transmitted diseases; violence: accidents, suicide, homicide; substance abuse)

. Nutrition (basic requirements for adolescent growth; obesity; anorexia nervosa, bulimia, and variants)

. Sports medicine . Orthopedic conditions . Dermatologic conditions

. Chronic illnesses (eg, congenital, genetic, neuro-logic, endocrine/metabolic, hematologic, oncol-ogic, collagen vascular/rheumatic, infectious die-orders)

. Reproductive health . School problems

. Psychophysiologic disorders . Psychiatric disorders

. Miscellaneous (abuse/neglect; running away; in-carceration; prostitution; juvenile delinquency)

CNS

Onset of puberty

Development of cognitive thinking Biology of eating disorders Onset of psychiatric disorders Biology/Behavior Interface

Hormones/behavior

Psychophysiologic conditions

Biologic sequelae of risk-taking behavior (preg-nancy, violence, substance abuse)

Nutritional habits/adolescent growth Prevention

Of sexuality-related problems (adolescent preg-nancy, sexually transmitted diseases, AIDS) Of substance abuse

Of stress Of violence

Of adult medical and psychologic morbidity

COMMENTARIES 271

Fig 1. Health and developmental conditions of adoles-cence included in most residency and adolescent fellow-ship training programs.

The interface between biology and behavior ideally is studied in the adolescent age group. The effects of sex hormones on adolescent sexual be-havior, the biologic basis of the psychophysiologic conditions, the biologic sequelae of risk-taking be-havior, and nutritional habits and practices and their effects on the growth of adolescents are all areas in which more data are needed.

The research in adolescent medicine that is of the most immediate public health concern is that focusing on prevention. Prevention of sexuality-related problems, namely, adolescent pregnancy, sexually transmitted diseases, and particularly AIDS, warrant careful attention. The development and evaluation of educational programs designed to help adolescents either delay initiation of sexual activity or take appropriate precautions to prevent sexuality-related problems are of utmost impor-tance. Prevention of adolescent pregnancy might be hastened by the development of contraceptive methods that are independent of adolescent com-pliance. Methods such as subdermal hormonal im-plants, which release hormones regularly, could be an ideal method for adolescents. The prevention of sexually transmitted diseases by use of vaccines is unlikely in the near future; until such vaccines are developed, effective use of barrier methods such as condoms would reduce not only the incidence of

adolescent pregnancy but also of sexually trans-mittable diseases.

Prevention of substance abuse, including pre-venting the initiation of tobacco use (smoking and nonsmoking), alcohol, and other illicit drug use during the vulnerable adolescent years, might also significantly improve the health of the nation’s adults and decrease the cost of care for those pre-maturely afflicted with cardiovascular and/or lung disease. Prevention of adolescent stress and stress-related conditions might decrease the incidence of the major adult behavioral and medical conditions, such as hypertension and ulcer disease. In addition, it is extremely important to decrease the major morbidity and mortality resulting from accidents, suicide, and homicide. Prevention and early iden-tification of hypertension, obesity, and genital can-cers through screening programs and self-exami-nation are also critically important areas for re-search. The development of major research programs in adolescence will be fostered by both national and local efforts. Convening groups of creative biomedical, clinical, and social science in-vestigators whose research has focused on different aspects of adolescence will provide forums for de-bating research questions of mutual interest and for suggesting areas of future collaboration. Fund-ing for research that crosses traditional organ sys-tern lines might be encouraged for cross-discipli-nary research. For example, foundations might be interested in funding clusters of scientists within specific institutions to define

and

examine the ma-jor research questions in adolescent medicine.

Local efforts within institutions often include collaboration among clinical investigators and basic scientists. These efforts have already begun in areas such as adolescent pregnancy and childbearing,

sex-Fig

2.

Future research foci.

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272

PEDIATRICS

Vol. 82 No. 2 August 1988

ually transmitted diseases, risk-taking behavior, and chronic illness. Local resources often support the initial research efforts, which are critical in

preparation for larger collaborative research

pro-grams.

What is needed to train academic scientists in adolescent medicine is no different from that needed to train other biomedical subspecialists and will be facilitated by the development of 3- or 4-year fellowship programs. One or more years should be devoted to learning about the basic science of the area in which the fellow is planning to pursue research. For example, a fellow interested in the

biologic basis of anorexia nervosa might study in

the laboratory of a neuroscientist specializing in the investigation of neurotransmitters.

It is timely that board certification in adolescent medicine is being debated at the national level. The

discipline of adolescent medicine is now defined,

there is consensus as to what constitutes reasonable clinical knowledge and technical skills in this area, and the research base is being established.

The field of adolescent medicine has grown rap-idly. Its future depends on the quality of its research and training programs. Our major goal should be to improve the well-being of the optimal number of adolescents afflicted by adolescent morbidity and mortality. Those of us in the field

can

no longer focus on its defmition; it is time for us to move

forward, ask fundamental questions, and take full

advantage of the scientific advances in related dis-ciplines.

ACKNOWLEDGMENTS

This work was supported, in part, by grant MCJ-360534 from the Bureau of Health Care Delivery and Assistance Division of Maternal and Child Health Serv-ices, and grant 11483 from the RObert Wood Johnson Foundation.

REFERENCES

ELIZABETH R. MCANARNEY, MD

Division of General Pediatrics and Adolescent Medicine

University

of Rochester

Medical

Center

Rochester, NY

1. McAnarney ER, Kreipe RE: Adolescent medicine. JAMA 1986;256:2060-2061

2. Sahler OJZ: The teenager with failing grades. Pediatr Rev

1983;4:293-300

3. Violent death among young persons 15-24 years of age. MMWR 1983;32:453-457

4. Johnston LD, O’Malley PM, Bachman JG: Use of Licit and

Illicit Drugs by America’s High-School Students, 1974-1984.

Rockville, MD, The National Institute on Drug Abuse,

Alcohol, Drug Abuse, and Mental Health Administration, 1985

5. Shenker IR, Aten M, Bennet D, et a!: A curriculum guide for adolescent medicine. Clin Pediatr 1977;16:516-520

6. Editorial. Appraisal of the adolescent. N Engi J Med

1953;248:437-438

7. Cohen MI: Adolescent health: Concerns for the eighties.

Pediatr Rev 1982;4:4-7

8. Gallagher JR, Heald FP, Garell DC: Medical Care of the Adolescent, ed 3. New York, Appleton-Century-Crofts, 1976 9. Daniel WA: Adolescents in Health and Disease. St Louis, CV

Mosby, 1977

10. Hofmann A, Greydanus DE (eds): AdolescentMedicine. Nor-walk, CT, Appleton & Lange, in press, 1988

11. Adolescent behavioral problems, in Hoekelman BA, Blat-man 5, Friedman SB, et al (eds): Primary Pediatric Care.

St Louis, CV Mosby, 1987, pp.785-831

12. Litt IF: Special healthproblems duringadolescence, in Behr-man RE, Vaughan VC, Nelson WE (eds): Nelson Textbook ofPediatrics. Philadelphia, WE Saunders, 1987, pp 436-454 13. The adolescent interview, in Rudolph AM, Hoffman J (eds):

Pediatrics. Norwalk, Appleton & Lange, 1987, pp 22-27 14. Comerci GD, Witzke DB, Scire AJ: Adolescent medicine

education in pediatric residency programs following the 1978 Task Force on Pediatric Education Report. JAdolesc Health

Care 1987;8:356-365

Twenty-Fifth

Anniversary

of

the National

Sudden

Infant

Death

Syndrome

Foundation

When 6-month-old Mark Addison Roe of Green-wich, CT, died suddenly and unexpectedly in Oc-tober 1958, his parents were told that the cause was “acute bronchial pneumonia.” In those days, “it” was called by many names, such as suffocation, overlaying, aspiration, or various forms of pneu-monia. The common thread was that all of the

terms connoted that parents were either directly,

or indirectly, by virtue of failing to secure medical care, responsible for the infant’s death.

Mark’s death might have been the end of it were it not for the existence of a life insurance policy that his grandparents had bought at the time of his birth. Jedd and Louise Roe wanted to contribute the proceeds ofthat policy to research ofthe disease that claimed their infant’s life, a 3-year quest that was unsuccessful. There was no research founda-tion or project that could use the money. The Roe’s

reluctantly were forced to organize their own

foun-PEDIATRICS (ISSN 0031 4005). Copyright © 1988 by the American Academy of Pediatrics.

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1988;82;270

Pediatrics

ELIZABETH R. MCANARNEY

Adolescent Medicine: Growth of a Discipline

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1988;82;270

Pediatrics

ELIZABETH R. MCANARNEY

Adolescent Medicine: Growth of a Discipline

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American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 1988 by the

been published continuously since 1948. Pediatrics is owned, published, and trademarked by the

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