looking back

looking back

Journal of Adolescent Health 38 (2006) 169 –172 Presidential address Looking forward/looking back At the end of our annual business meeting I will a...

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Journal of Adolescent Health 38 (2006) 169 –172

Presidential address

Looking forward/looking back At the end of our annual business meeting I will assume office as the 35th President of the Society for Adolescent Medicine (SAM). In the words of my patients in Boston, this is an “awesome” responsibility that is also decidedly “wicked cool.” I’ve chosen Janus, the Roman god of gates and doors, to symbolize my theme of “Looking Forward, Looking Back” (Figure 1). Janus was the god of beginnings and endings, represented with a double-faced head, each face looking in opposite directions. He was worshipped by the Romans at the beginning of important events in a person’s life. Janus was also viewed as a symbol of the maturation of youth. As I look back, I wish to share two experiences from one of my first SAM meetings, now more than 25 years ago. As a newly minted faculty member, just out of fellowship training, I was charged with developing a comprehensive adolescent medicine program at my institution. Presentations by two of SAM’s founding members drew my attention as I was eager to develop my own teaching materials in a discipline that was new to our Department of Pediatrics at Tufts-New England Medical Center. Adele Hofmann, a recent SAM President, had presented a fascinating history of the evolution of the legal rights of adolescents over the ages, and Dick MacKenzie, Executive Secretary-Treasurer at the time, had conducted a workshop on adolescent sexuality from a developmental perspective. During the course of the meeting I hesitantly approached each of these senior SAM members with a request for references in order to develop similar presentations of my own. Adele Hofmann graciously referred me to a wonderful resource—the threevolume reference work entitled Children and Youth in America—that sits on the top shelf of my office bookcase to this day. Dick MacKenzie gave me permission to use his materials, but did not provide a specific reference because the development stages were his own creation. I’ve come to view Dick MacKenzie as the Dick Clark of our Society, just This address was given at the Society for Adolescent Medicine’s annual meeting in Los Angeles on April 2, 2005. *Address correspondence to: Dr. John Kulig, Director, Adolescent Medicine, Floating Hospital for Children at Tufts-New England Medical Center, 750 Washington Street, NEMC #479, Boston, MA 02111. E-mail address: [email protected]

as youthful, enthusiastic, caring and committed to adolescent health as he was three decades ago—a role model for each of SAM’s past presidents. Earlier in our meeting we paid tribute to Felix Heald, SAM’s second president, who died in August 2004. In listening to the scientific abstracts being presented at SAM over the past few years, I’ve come to miss the signature announcement of often the very first questioner to reach the microphone—“Heald – Baltimore.” As I look back, I also value the unique opportunity I had to spend a three-month elective in adolescent medicine as a fourth-year medical student in Cincinnati, under the mentorship of Jerry Rauh, SAM’s fifth president. I then returned to Cincinnati for fellowship training after completing my pediatric residency in Boston. Rich Brookman, SAM’s 24th president, was a fellow in adolescent medicine when I was a medical student and a new faculty member during my fellowship in Cincinnati. My own experience highlights the need to address manpower concerns about the future of our discipline, not solely by addressing fellowship training in adolescent health, or even by addressing postgraduate or residency training programs, but rather by reaching further back to develop interest in adolescence at the student level, across all disciplines. Our new Mission Statement states that: “The Society for Adolescent Medicine is a multidisciplinary organization committed to improving the physical and psychosocial health and well-being of all adolescents through advocacy, clinical care, health promotion, health service delivery, professional development, and research.” SAM’s activities as an organization of professionals fall into four broadly defined categories: Research, Advocacy, Clinical Care and Education. At a time of change in leadership it is useful for an organization to pause and take stock, to look forward and look back—where we have been and where we are headed—in each of these categories. The theme for next year’s annual meeting in Boston will be “Adolescents and Public Health.” Given the current causes of morbidity, mortality and adverse health outcomes among adolescents, a broadening of our perspective is indicated. We need to move beyond the clinical setting to a broader model of prevention and intervention involving all

1054-139X/06/$ – see front matter © 2006 Society for Adolescent Medicine. All rights reserved. doi:10.1016/j.jadohealth.2005.12.012

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J. Kulig / Journal of Adolescent Health 38 (2006) 169 –172 Table 3 Actual causes of death: U.S. population, total, 2000[2,3] Rank

Cause

No. deaths

% Total

1 2 3 6 7 8 9

Tobacco Diet/inactivity Alcohol consumption Motor vehicles Firearms Sexual behavior Illicit drug use

435,000 365,000 85,000 43,000 29,000 20,000 17,000

18.1 15.2 3.5 1.8 1.2 .8 .7

Figure 1. Janus, god of beginnings and endings.

of SAM’s multiple disciplines, while including public health professionals and agencies in the mix. Our new Vision Statement states that: “The Society for Adolescent Medicine will be the leader in promoting optimal health and well-being for adolescents and young adults.” As the leaders in adolescent health, SAM members have long recognized that both healthy lifestyle choices and behavioral changes require comprehensive, multidisciplinary and early interventions. Mortality data for high-school-age adolescents in the U.S. indicate that 77% of all deaths among 15–19-year-olds are attributed to unintentional injury, homicide and suicide [1] (Table 1). These three causes of death combined account for 4.6 million years of potential lives lost (YPLL) before age 75 in the U.S. [1] (Table 2). When one examines overall U.S. mortality, calculation of population-attributable risk reveals the actual causes listed in Table 3 [2,3], although disease-specific mortality is commonly categorized as heart disease, cancer, stroke, emphysema, etc. Research Scientific session abstracts for SAM’s 2005 annual meeting included 31 platform presentations and 85 posters, for a total of 116 presentations. Analysis by topic revealed a

Table 1 U.S. mortality: ages 15–19 years, 2002[1]

Accidents (unintentional injuries) Assault (homicide) Intentional self-harm (suicide) Total

Deaths

%

7137 1892 1513 10,542

52% 14% 11% 77%

Table 2 Years of potential life lost (YPLL) before age 75, United States, 2002[1]

Accidents (unintentional injuries) Assault (homicide) Intentional self-harm (suicide) Total

YPLL

%

2,931,565 940,781 749,521 4,621,867

15% 5% 4% 24%

marked disparity between public health priorities and topics addressed in our current research studies [4] (Table 4). No studies addressed unintentional injury from motor vehicle crashes, drowning, falls, or sports injuries. No studies looked beyond drinking and driving to examine the influence of graduated licensure, speeding, and seat belt use on motor vehicle crashes involving adolescents. No studies addressed interpersonal violence, assault, weapons or homicide. Only two studies (2%) addressed suicide. A recent event brought home the reality of the statistics related to health risks for adolescents and young adults. On February 10, 2005, my 21-year-old daughter Jessica, a student at Smith College, was driving two friends from Northampton, Massachusetts to a Josh Groban concert in Manchester, New Hampshire. Along with five other drivers, she slid off the road on black ice as the temperature dropped in a matter of 15 minutes. Her car struck a tree, deploying the airbags and sustaining nearly $10,000 in damage. In a curious twist of fate, Alain Joffe’s daughter Kaitlin was Jessica’s front-seat passenger—the daughters of two adolescent medicine physicians in the same car crash. After a harrowing drive to New Hampshire in a developing snowstorm, my wife and I picked up the three students in the Emergency Room and drove them back to Smith. Fortunately, all three escaped with minor injuries. Tobacco use, diet and inactivity cause 800,000 deaths in the U.S. population annually, accounting for one-third of all deaths [2,3], yet only two SAM abstracts (2%) addressed tobacco or smoking and only seven abstracts (6%) ad-

Table 4 SAM annual meeting abstracts, 2005[4]

Accidents (unintentional injury) Assault (homicide) Intentional self-harm (suicide) Alcohol/substance use Tobacco/smoking Weight/physical activity Sexual behavior: Sexuality STI Contraception

No. abstracts

% Total

0 0 2 1 2 7 59 27 21 11

0% 0% 2% 1% 2% 6% 51% 23% 18% 10%

J. Kulig / Journal of Adolescent Health 38 (2006) 169 –172

dressed weight management or physical activity. Studies suggest that 3000 adolescents begin smoking cigarettes each day and that 2000 of them will become daily smokers. The prevalence of obesity among adults in the U.S. increased by 50% per decade in the 1980s–1990s, 28% of adult men and 34% of adult women are currently obese, extreme obesity (body mass index ⬎ 40) is rapidly increasing, and lifetime risk of diabetes has risen to 30%– 40%, leading to predictions of an eventual decline in life expectancy [5]. Emerging data suggest that some European countries, such as Greece, may have an even higher prevalence of obesity than the U.S. Alcohol, the third leading cause of death in the U.S., was included in one abstract (1%) addressing substance use. Yet 38% of eighth grade students and 71% of 12th grade students surveyed in the 2004 Monitoring the Future Study report consumption of flavored alcoholic beverages (“malternatives”) [6]. In contrast, 59 SAM abstracts (51%) addressed sexual behavior, including sexuality, sexually transmitted infection, and contraception. As researchers, we need to broaden the scope of our studies of the behaviors established in youth that influence lifelong health and wellness. Advocacy SAM’s second generation of leaders—those of us who were adolescents in the 1960s and 1970s— experienced rapid and unprecedented growth in the legal rights of youth. In the 1969 Supreme Court decision, Tinker v. the Des Moines School District, the Court held that students “do not shed their constitutional rights at the schoolhouse gate,” and that the First Amendment protects public school students’ rights to express political and social views. John Tinker, a 15-year-old student, had been suspended from school for wearing a black armband in protest of the U.S. government’s policies in Vietnam. This decision was followed in the subsequent decade by affirmation of adolescent rights in reproductive health matters. In contrast, the past two decades have been characterized by an erosion of these rights. Individual states have enacted restrictive parental consent and notification laws limiting an adolescent’s access to reproductive health care. Pharmacists are being supported by state laws in their refusal to fill lawfully prescribed medications based upon their personal beliefs. The U.S. Food and Drug Administration has refused to approve broadening the availability of emergency contraception despite overwhelming evidence of safety and efficacy. The same U.S. Congress that took the extraordinary step of meeting in special session to support prolonging the life of a woman in a persistent vegetative state for 15 years is posed to enact legislation that would criminalize the transportation of minors across state lines to access legal pregnancy termination services. One recent victory was the narrow Supreme Court decision to ban the death penalty for juvenile offenders, a position supported by strong advocacy

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efforts from SAM and collaborating organizations. The year ahead will require vigilance to defend against further challenges to the rights of adolescents. Clinical Care Patients aged 13 to 21 years comprise the age group with the lowest utilization rate of physician office visits per person in the U.S. [7]. Changing demographics and cultural diversity will further alter our patient population as the proportion of Hispanic youth in the U.S. grows to far exceed the proportion of African American youth [1], while new immigrants continue to arrive from all corners of the globe. Evidence-based health care and clinical practice guidelines have been developed for a variety of disorders that affect children and adults, but few have been developed for adolescent health issues, perhaps because of the complexity of behaviorally determined risk. Clinicians who care for adolescents are continually challenged to maneuver through the increasingly complex barriers posed by multiple health insurers that limit access to mental health and substance abuse services, restrict choice of prescription medications, and threaten the maintenance of confidentiality. A growing body of research supports the value of school-based health care and health promotion, yet funding has been reduced, and many innovative programs have closed in the past decade. SAM’s Clinical Services Committee will address several of these challenges in the years ahead. Education Fewer than 25 physicians have enrolled as first-year fellows in adolescent medicine this year, and the disciplines of nursing, psychology, social work and nutrition have even fewer trainees in adolescent health. The Ad-Hoc Committee on Young Professionals in Adolescent Health in 2003 recommended that SAM: (1) Encourage activities at the local and regional level that nurture interest in the field of adolescent health among students early in their career; (2) Facilitate student membership in SAM, receipt of the Journal of Adolescent Health, and attendance at regional and national meetings; (3) Support ongoing adolescent health educational activities that target students who choose career paths that will potentially produce “adolescent-friendly professionals” rather than experts; (4) Study why M.D.s/Ph.D.s with long-standing interests in an adolescent health career choose otherwise; and (5) Collaborate with other professional organizations that share an agenda of training professionals to improve the health and well-being of adolescents. These important recommendations will be addressed by SAM’s Multidisciplinary Membership Committee and represent a critical component of SAM’s long-range planning process. As adolescents increasingly look to cyberspace as a source for answers to their health-related questions, SAM’s

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J. Kulig / Journal of Adolescent Health 38 (2006) 169 –172

recently redesigned website will include new resources and links to provide accurate, authoritative information for youth and their families. Outreach to parents has always been a challenge in providing adolescent health care. We must make a greater effort to engage parents as allies and partners in optimizing the health of their children, our patients. Public Health As we look forward, I believe that public health should play an increasing role in all four categories of SAM’s activities as an organization: Research, Advocacy, Clinical Care and Education. SAM is a multidisciplinary organization, including a significant number of professionals with public health training. In addition to its national activities, SAM has a network of active regional chapters with local public health contacts. Morbidity and mortality in adolescence is predominantly behavioral in origin, and effective behavioral change begins in childhood and adolescence. Because public health has evolved from disease prevention to health promotion, this model has particular relevance for adolescent health [8]. “The public health approach moves from problem to solution in four key steps: (1) determine the magnitude, scope and characteristics of the problem; (2) study the factors that increase the risk of disease, injury or disability and determine which factors are potentially modifiable; (3) assess what can be done to prevent the problem by using information about causes and risk factors to design, pilot test and evaluate interventions; and (4) implement the most promising interventions on a broad scale” [9]. As first steps in this initiative, I propose creation of a Special Interest Group in Public Health, plan to explore a SAM liaison with the American Public Health Association, urge SAM regional chapters to develop relationships with their state public health officials, and encourage all SAM members to consider public health approaches when planning research, advocacy and education in adolescent health. Long-range Planning SAM’s Board of Directors has initiated a formal process to study critical issues that will impact our organization for the next 5–10 years. Among the questions to be addressed: (1) Should SAM increase its membership?; (2) Should SAM continue to meet independently each year?; (3) Should SAM maintain its current administrative infrastructure?; and (4) Where, among competing priorities, should SAM focus its limited resources? On a personal note, my wife Cindy remains a strong supporter of my various professional commitments, both

voluntary and otherwise. My daughter Jessica will graduate from Smith College in May and begin work at a residential program for autistic children, and my daughter Jillian will complete her second year as a nursing student at New York University. Both our daughters have taught me much more about adolescence than any textbook or journal, and have confirmed my view that this life transition should be celebrated and not feared. This July I will complete 26 years as Director of Adolescent Medicine at Tufts-New England Medical Center, the only full-time job I’ve ever held. SAM will play a preeminent role in my life over the next 12 months, but I will continue to serve as a medical consultant to the Department of Labor’s Job Corps residential job training program and as volunteer medical director of the Chernobyl Children Project USA. Both these programs provide unique support to a select population of underserved youth. One year from now, as we meet in Boston and look back at the year now before us, I am confident that SAM will have grown and prospered. I invite and encourage each of you to make a personal commitment to join me in advancing our Society’s mission and vision in the year ahead. John Kulig, M.D., M.P.H., F.S.A.M.* Division of General Pediatrics and Adolescent Medicine, Floating Hospital for Children at Tufts-New England Medical Center, Boston, Massachusetts References [1] National Center for Health Statistics. Health, United States, 2005 with Chartbook on Trends in the Health of Americans. Hyattsville, MD: National Center for Health Statistics, 2005. [2] Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual causes of death in the United States, 2000. JAMA 2004;291(10):1238 – 45. [3] Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Correction: actual causes of death in the United States, 2000. JAMA 2005;293(3):293– 4. [4] Abstracts of the Annual Meeting of the Society for Adolescent Medicine. March 30-April 2, 2005, Los Angeles, California, USA. J Adolesc Health 2005;36(2):95–154. [5] Olshansky SJ, Passaro DJ, Hershow RC, et al. A potential decline in life expectancy in the United States in the 21st century. N Engl J Med 2005;352(11):1138 – 45. [6] Johnston LD, O’Malley PM, Bachman JG, Schulenberg JE. Monitoring the Future National Results on Adolescent Drug Use: Overview of Key Findings, 2004 (NIH Publication No. 05-5726). Bethesda, MD: National Institute on Drug Abuse, 2005. [7] Hing E, Cherry DK, Woodwell DA. National Ambulatory Medical Care Survey: 2003 Summary. Advance Data from Vital and Health Statistics; no. 365. Hyattsville, MD: US Department of Health and Human Services, CDC, National Center for Health Statistics, 2005. [8] Awofeso N. What’s new about the “new public health”? Am J Public Health 2004;94(5):705–9. [9] Krug EG, Ikeda RM, Qualls ML, Anderson MA, Rosenberg ML, Jackson RJ. Preventing land mine-related injury and disability: a public health perspective. JAMA 1998;280(5):465– 6.