Troubled Teens

Educational Objectives

The goal of this program is to improve management of adolescent performance-enhancing substance use and to review con­cepts in healthy adolescent development. After hearing and assimilating this program, the clinician will be better able to:

1.   Describe effects of commonly used performance-enhancing substances such as creatine and caffeine.

2.   Discuss adverse effects associated with use of anabolic steroids and testosterone precursors.

3.   Counsel adolescents and young athletes about lack of efficacy and safety of performance-enhancing substances.

4.   Explain cultural factors that weaken the mechanism of transferring values from parents to children.

5.   List the Seven Significant skills and perceptions that constitute the basic operating system for effective adulthood.

Faculty Disclosure

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the plan­ning committee to disclose relevant financial relationships within the past 12 months that might create any personal con­flicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the faculty and planning committee reported nothing to disclose.

Acknowledgemens

Dr. Howe spoke in Boston, MA, at the American Academy of Family Physicians’ Scientific Assembly 2009, presented Octo­ber 14-17, 2009. Dr. Deiro was recorded in Seattle, WA, at the 11th Annual Fundamentals of Addiction Medicine Confer­ence, presented March 5-6, 2009, by the Providence Regional Medical Center, Everett, WA. The Audio-Digest Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.

Performance Enhancing Substances: What Adolescents are Taking and Not Telling You

Allyson S. Howe, MD, Faculty, Family Medicine Residency and Sports Medicine Fellowship, Maine Medical Center, Portland, ME

Definitions and terms: performance-enhancing substances  —substances taken to increase physical performance and body’s ability to do work; cycling  —  associated with anabolic steroids; temporarily discontinuing drugs (eg, at time of drug testing), then restarting them; stacking  —  using multiple agents simultaneously (agents may be contained in same syringe, pill, or bottle); pyramiding  —  increasing and decreasing doses repeatedly to increase strength or performance

History: 1950s and 1960s  —  medical community felt androgenic anabolic steroids ineffective, but athletes perceived them as effective (caused divide between athletes and physicians); Anti-Drug Abuse Act of 1988  —  anabolic steroids became illegal (classified as schedule III drug); Dietary Supplement and Nonprescription Drug Consumer Protection Act of 2006  —consumers and physicians obligated to inform Food and Drug Administration about negative effects of supplement; anony­mous reporting tool available online

Illegal and banned substances: anabolic steroids and androstenedione (steroid precursor); diuretics and caffeine banned in professional athletics; to be banned, substances must meet 2 of following criteria: enhance sport performance, carry in­herent risk to athlete, or violate spirit of sport

Anabolic steroids: enhance protein synthesis; help muscles grow; anticatabolic (ie, block natural glucocorticoid response after exercise; prevent breakdown of muscles); common street names include “roids,” “juice,” “hype,” or “pump”; presumed ef­fects include increased muscle mass and strength, enhanced athletic performance, and improved self-esteem; obtained by ad­olescents on internet; used by male and female athletes; estimated use in United States, 3 million; 1 in 4 adult users began use as teenager; 1 in 10 users adolescents; medical indications  —  HIV wasting; hypogonadism; palliative treatment of breast cancer; anemia; hereditary angioedema; in 1993, survey found »2% of adolescents admitted to using anabolic steroids (in 2003, 6%); most commonly used in football, but also seen in basketball, gymnastics, weight training, and baseball; adverse effects  —  hepatotoxicity; peliosis hepatitis (blood cysts in liver can rupture and cause death); hepatocellular carcinoma; glu­cose intolerance; diabetes; cardiomyopathy; decreased high-density lipoprotein (HDL); increased low-density lipoprotein (LDL); aggressive behavior (desired side effect by some users); depression; sleep disturbance; infertility; testicular atrophy; impotence; menstrual irregularity; gynecomastia; baldness; severe acne (tends to appear on back); withdrawal can be life-threatening; drugs that raise suspicion of steroid use  —  clomiphene (eg, Clomid) taken by boys and men to combat estrogen effects; human chorionic gonadotropin (HCG) taken to increase endogenous testosterone in men

Creatine: commonly used; naturally occurring substance formed by liver, pancreas, and kidneys; found in meat and fish; in­volved in creation of energy in muscle; shown to build muscle mass and to increase strength; enhances recovery after work­out; large study of high school football players found creatine used by »10% of freshmen, 23% of sophomores, 41% of juniors, and >50% of seniors; use by girls fairly limited, but associated with track sports, gymnastics, tennis, and volleyball; used by boys in football, swimming, hockey, and baseball; dosing  —  typically dosed by loading (eg, 5 g qid, or 20 g/day for 1 wk, then 2-5 g/day); loading shown to damage kidneys; often mixed with insulin-releasing carbohydrates (eg, Gatorade) to facilitate absorption; side effects  —  gastrointestinal (GI) distress (eg, abdominal cramping) most common; muscle cramping; weight gain; may be associated with acute renal failure; gateway substance; 30% of users do not respond; not illegal; impor­tant to remind athletes to drink large amounts of water, avoid taking loading dose, and to avoid use during periods of intense exercise, high heat, and humidity; >70% of users notice side effects (>80% would continue use despite GI distress)

Human growth hormone (HGH): according to 1992 data, used by 5% of tenth grade boys who had low awareness of po­tential side effects; use highly associated with anabolic steroids; polypeptide produced in pituitary gland; increases natu­rally with sleep or strength training; causes skeletal muscle hypertrophy with myopathy (“muscles not necessarily stronger”) and lipolysis; medical indications  —  HGH deficiency; short stature; Prader-Willi syndrome; Turner syndrome; adverse effects  —  Creutzfeldt-Jakob disease; fluid retention; mild increases in blood pressure (BP); acromegaly gigan­tism; cardiac hypertrophy; diastolic dysfunction; increased free fatty acids, leading to arrhythmias; associated with hyper­tension, diabetes, hyperlipidemia, respiratory disease, osteoarthritis, breast cancer, and colorectal cancer; costs  —  $3000 per syringe; recombinant-type HGH, <$1000; athletes' perceptions  —  enhances performance; decreases fat; stacking in­creases potency; undetectable (no reliable testing available)

Ephedra: used for weight loss, respiratory ailments, and to increase energy; meta-analysis saw modest weight loss (»2 lb) and short-term athletic improvement when taken with caffeine; most research showed no significant effect on strength, O2 up­take, or time to exhaustion; moderate increase in weight loss; adverse side effects  —  2- to 3-fold increase in psychiatric, auto­nomic, cardiovascular, or GI symptoms; hypertension; tachycardia; impaired thermoregulation; one-third of deaths associated with ephedra use “suspicious”; illegal to manufacture or to sell since 2004; testing performed randomly by Na­tional Collegiate Athletic Association (NCAA)

Caffeine: ergogenic effects well-established; most widely used ergogenic aid; increases free fatty acids to be used as energy source instead of muscle glycogen; causes lipolysis and increased catecholamine release, leading to decreased sense of fatigue; helps prolong exercise and increases endurance; energy drinks (eg, Red Bull) contain less caffeine than coffee; lower doses (eg, 3-6 mg/kg) more effective; adverse effects  —GI disturbances; palpitations; dizziness; headache; fatigue; tremor; restricted by International Olympic Committee (IOC; positive urine test result, »15 mg/L in urine); caffeine vari­ably excreted

Erythropoietin: increases red blood cells (RBCs) to 3 to 10 times normal; higher hemoglobin results in higher likelihood for better O2-carrying capacity; medical indications  —  malignancies; AIDS; renal failure; improves endurance and aero­bic performance; recombinant erythropoietin  —  banned by IOC in 1990; tests available for detection; single molecular weight (peaks once when measured; molecular weight of endogenous erythropoietin more variable); half-life short; ad­verse effects  —RBC aplasia; thrombotic events; hypertension

Arginine and nitric oxide (NO): arginine presumed to increase levels of NO and to stimulate release of HGH and glucose uptake by cells; NO increases muscle perfusion and muscle repair; common dosage, 6 to 15 mg/day; study  —  12 mg/day given to 35 men who performed resistance training; after 8 wk, significant difference in strength and power noticed; blood glucose increased; adverse effects  —  hyperglycemia or diabetes; flushing; nausea; diarrhea; widely available online and in stores

Diuretics: used in sports where athletes need great weight control (eg, wrestling, swimming); acetazolamide may increase athletic performance; may be used to mask urine; banned by IOC and NCAA due to risk for dehydration, heat injury, and electrolyte abnormalities

Testosterone precursors: prohormones; available over-the-counter since 1996; marketed as natural substances; in 2004, andro­stenedione became schedule III drug; involved in testosterone production; dehydroepiandrosterone (DHEA)  —  produced in ad­renal gland and gonads; converts to androstenedione or androstenediol, but mostly converted to testosterone in testes; often converts to estradiol or other estrogen-type sources in athletes; Andro Project  —  looked at effects of androstenedione on healthy men 35 to 65 yr of age; men participated in 12-wk high-intensity training program; total testosterone increased »16% (returned to baseline within 3 mo); estradiol levels increased 97% (did not return to baseline as quickly); no improvement in lean body mass; no increased muscle strength; HDL decreased; adolescent use  —  2002 study of nearly 500 high school students found 4% admitted to use within past year (many not athletes); according to NCAA survey, used by 5% of athletes (33% use nutritional substances); adverse effects  —  similar to androgenic anabolic steroids; potentially irreversible sex hormone effects (eg, viriliza­tion of girls and women, feminization of boys and men); precocious puberty; stunted growth

Identifying users: male athletes involved in sport that demands high levels of power, speed, or strength; athletes who con­sider themselves highly specialized, on way to Olympics, or candidates for college scholarship at risk; youths trying to avoid feelings of weakness; casual athletes or adolescents with poor self-esteem; youths with friends who use; questions to ask  —do you or your teammates take any medicines or vitamins to make you stronger or faster, or to look better? how important is it for you to excel at your sport? what are your athletic goals? what obstacles do you see in obtaining your goals; “just say no” approach ineffective (use nonjudgmental approach); indirect questioning may be helpful; consider asking parents to leave room during discussion; physical examination  —  rapid change in weight or body composition, or elevated BP (consider use of stimulants, steroids, or HGH); acne; hirsutism; hair loss; gynecomastia; mental illness (eg, sudden depression, anger, rage, change in personality); important to acknowledge that substances often effective, but 20% to 30% of users do not respond; cosmetic effect may be most important result for users; discuss contamination and false advertising; offer alternatives; educate parents

Society’s Missing Infrastructure for Supporting Healthy Adolescent Development

Judy Deiro, PhD, Director, Everett Site Human Services Program, and Faculty, Western Washington University, Woodring College of Education, Everett

H. Stephen Glenn: developed Developing Capable Young People program; died in 2005; Adlerian psychologist, preven­tion specialist, and author; raised 4 biologic children and 14 foster children; in 1961, United States top leader in educa­tion, with low divorce rates; in 1962, Glenn left United States to work with Peace Corps in South Pacific to help native families moving from outbacks to cities; when he returned to United States between 1963 and 1964, Glenn noticed changes that appeared similar to situation in South Pacific; in 1972, Glenn asked by United States Office of Education to direct southwest regional training center for substance abuse

Paradigm of childrearing: children raised with values about working hard, and taught to adjust and cope with things, “turn out all right”; paradigm undermined by subtle cultural shift; cultural adjustment  —  when families move from familiar cul­ture to another culture (as Glenn saw in South Pacific), conflict can result if values of new culture not accepted by all fam­ily members; children become introduced to new things, while parents have difficulty keeping and passing on traditional values (about, eg, dating, role of men and women, food); mechanisms of transferring values (ie, bonds between genera­tions) weaken; conflict interferes with sense of personal adequacy; parents become stricter, more controlling, more limit­ing, and more critical; children rebel; subtle shift in culture weakened mechanism of transferring values from parents to children

Research about family and education: from 1900 to 1964, discipline, motivation, achievement, and comprehension in­creased every year, but began decreasing in 1964 (and continue to decrease); rate of teenage crime, teenage pregnancy, drug use, and teenage suicide began increasing in 1964

Examining cultural shift: because children are “product of 18 yr of development,” examining cultural shift between 1946 to 1963 helpful; increased number of students per classroom  —in 1946, average classroom had 56 students; schools not prepared for large number of students (eg, teachers not properly trained, inadequate building space); average class size in­creased from 20 students to »50 students between 1940 to 1952; children often told to be quiet in school, and did not in­teract with adults or materials; shift to urban culture  —  in 1940, 73% of United States rural, or small community; in 1952 to 1953, men who returned from war moved away from farms to suburbs and cities; 97% of United States became urban or suburban; support of extended families lost because older adults (eg, grandparents) often remained on farm, so children lost having other meaningful adults in their lives; television  —during 1950s, families watched television and did not talk to each other; children lost “apprenticeship for adulthood”

Current problems: Americans watch 7 hr of television per day; youth often employed with other youth rather than in­teracting with adults; increased divorce rates; average family moves every 2 yr

The Significant Seven: 3 perceptions and 4 skills that constitute basic operating system for effective adulthood; perceptions  —1) “I am capable”; 2) “I contribute in meaningful and significant ways”; adolescent should believe people prefer his or her presence, and should feel needed and accepted; important for schools to take attendance; adolescents with poor perception often turn to gangs; 3) “I have power or influence over my own life”; adolescents should be held ac­countable (eg, “the teacher kicked me out of class” shows lack of accountability); must own personal power to feel influ­ence; “I can influence what happens to me”; skills  —  1) intrapersonal; understanding own feelings; before young person can develop self-discipline, they must be aware of their own feelings and learn to make choices in response to feelings; 2) interpersonal; life skills for communicating, negotiating, and resolving conflict; adolescents often have little time to inter­act or communicate with adults; 3) systemic; skills for functioning and adapting in systems; counter to “do your own thing” way of thinking of 1960s to 1970s; adolescents must learn to be flexible, cooperate, and adapt; 4) judgment; ado­lescents must learn to make decisions and to solve problems based on wisdom

Teaching children critical thinking: process developed by Adler; basis to developing judgment; identify with experiences  —acknowledge what happened; what am I feeling? analyze  —  why did that happen? what caused that to happen? why was that significant? learn from experience  —  why did this happen to me? how could I do it differently next time? Adler suggests asking children questions rather than providing answers (eg, ask child, “what do you think caused that to happen?”)

Questions and answers: rules  —  Developing Capable Young People program does not support strictness or permissive­ness; be firm and teach young people with dignity and respect; strictness and permissiveness lead to development of ex­ternal locus of control, because what is right and not right often unclear to children; provide guidance on “middle ground” using dignity and respect; one-child families  —  help children develop Significant Seven perceptions and skills (same with one child or multiple children)

Suggested Reading

Alves C et al: Dietary supplement use by adolescents. J Pediatr 85:287, 2009; Bojsen-Møller J et al: Use of performance- and image-enhancing substances among recreational athletes: a quantitative analysis of inquiries submitted to the Danish anti-doping authorities. Scand J Med Sci Sports 2009 Oct 16 [Epub ahead of print]; Bowers LD: Science and the rules governing anti-doping violations. Handb Exp Pharmacol 195:513, 2010; Buckman JF et al: Risk profile of male college athletes who use performance-enhancing substances. J Stud Alcohol Drugs 70:919, 2009; Fahs CA et al: Hemodynamic and vascular re­sponse to resistance exercise with L-arginine. Med Sci Sports Exerc 41:773, 2009; Glenn H. Stephen et al. Raising Self-Reli­ant Children in a Self-Indulgent World. Rocklin, CA: Prima Publishing; 1989; Lewig K et al: Challenges to parenting in a new culture: Implications for child and family welfare. Eval Program Plann 2009 May 27 [Epub ahead of print]; Little JP et al: Creatine, arginine alpha-ketoglutarate, amino acids, and medium-chain triglycerides and endurance and performance. Int J Sport Nutr Exerc Metab 18:493, 2008; Lumia AR et al: Impact of anabolic androgenic steroids on adolescent males. Physiol Behav 2010 Jan 22 [Epub ahead of print]; Weitzel LR et al: Performance-enhancing sports supplements: role in critical care. Crit Care Med 37:S400, 2009; Williams N: Establishing the boundaries and building bridges. A literature review on ecological theory: implications for research into the refugee parenting experience. J Child Health Care 2009 Nov 20 [Epub ahead of print].