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Since the early 1980s, the focus on the importance of puberty to adolescent development has continued with variability in the methodology selected to measure puberty. To capture the relevant and important issues regarding the measurement of puberty in the last decade, this paper will address (1) the neuroendocrine aspects of puberty and its components, as well as the timing of puberty and its tempo; (2) why puberty is measured, including the relevance of puberty and its timing to health and development as well as the relevance of being off‐time, that is, early or late with respect to a reference group; (3) the measurement of puberty and its methodology with respect to pubertal staging by physical examination, self‐report measures, and their agreement with other methods and measures, hormones and their methods of measurement, and comparison of hormone concentrations to pubertal stage; and (4) recommendations for what is needed in the next decade regarding the measurement of puberty.

Background The Breast Cancer and the Environment Research Centers (BCERCs) include collaborators from basic sciences, epidemiology, and the community, conducting studies to investigate whether environmental exposures are associated with the timing of puberty. A pilot study of a subset of the study participants assessed the feasibility of measuring selected biomarkers of exposure in blood and urine in girls 6–8 years of age. In the Greater Cincinnati study population, we found an elevated serum concentration of perfluorooctanoate (PFOA) among > 90% of young girls living in a small community. Objectives The research team deliberated whether and how to report the PFOA findings to our study families. We will address the issues considered in our decision, as well as the formats we used to present the findings. Methods The results were verified as we searched for potential sources of the elevated PFOA levels. As a research team, we grappled with issues regarding the reporting of unexpected results, derived from unknown sources and with unknown clinical significance. Ultimately, we did decide to present these findings to the study families through a well-developed communication plan. Discussion Research team members came from a variety of experiences and backgrounds, which led to different interpretations about the clinical, ethical, and public health issues surrounding these findings. The ethical debates centered around the precautionary principle, the right to know, and do no harm. Conclusions Given advances in environmental biomarker technologies and greater use of the transdisciplinary research model, a communication plan must be developed for those involved as study participants.

OBJECTIVES: The objective of this study was to describe the assessment methods and maturation status for a multisite cohort of girls at baseline recruitment and at ages 7 and 8 years. METHODS: The method for pubertal maturation staging was developed collaboratively across 3 sites. Girls at ages 6 to 8 years were recruited at 3 sites: East Harlem, New York; greater Cincinnati metropolitan area; and San Francisco Bay area, California. Baseline characteristics were obtained through interviews with caregivers and anthropometric measurements by trained examiners; breast stage 2 was defined as onset of pubertal maturation. The κ statistic was used to evaluate agreement between master trainers and examiners. Logistic regression models were used to identify factors that are associated with pubertal maturation and linear regression models to examine factors that are associated with height velocity. RESULTS: The baseline cohort included 1239 girls. The proportion of girls who had attained breast stage 2 varied by age, race/ethnicity, BMI percentile, and site. At 7 years, 10.4% of white, 23.4% of black non-Hispanic, and 14.9% of Hispanic girls had attained breast stage ≥2; at 8 years, 18.3%, 42.9%, and 30.9%, respectively, had attained breast stage ≥2. The prime determinant of height velocity was pubertal status. CONCLUSIONS: In this multisite study, there was substantial agreement regarding pubertal staging between examiners across sites. The proportion of girls who had breast development at ages 7 and 8 years, particularly among white girls, is greater than that reported from studies of girls who were born 10 to 30 years earlier.

The prevalence and severity of obesity have increased in recent years, likely the result of complex interactions between genes, dietary intake, physical activity, and the environment. The expression of genes favoring the storage of excess calories as fat, which have been selected for over many millennia and are relatively static, has become maladaptive in a rapidly changing environment that minimizes opportunities for energy expenditure and maximizes opportunities for energy intake. The consequences of childhood and adolescent obesity include earlier puberty and menarche in girls, type 2 diabetes and increased incidence of the metabolic syndrome in youth and adults, and obesity in adulthood. These changes are associated with cardiovascular disease as well as with several cancers in adults, likely through insulin resistance and production of inflammatory cytokines. Although concerns have arisen regarding environmental exposures, there have been no formal expert recommendations. Currently, the most important factors underlying the obesity epidemic are the current opportunities for energy intake coupled with limited energy expenditure.

Background Levels of brominated flame retardants are increasing in US populations, yet little data are available on body burdens of these and other persistent hormonally active agents (HAAs) in school-aged children. Exposures to such chemicals may affect a number of health outcomes related to development and reproductive function. Objective Determine the distribution of biomarkers of polybrominated diphenyl ethers (PBDEs), polychlorinated biphenyls (PCBs), and organo-chlorinated pesticides (OCPs), such as DDT/DDE, in children, and their variation by key descriptor variables. Methods Ethnically diverse cohorts of girls 6–8 y old at baseline are being followed for growth and pubertal development in a multi-site, longitudinal study. Nearly 600 serum samples from the California and Ohio sites were analyzed for lipids, 35 PCB congeners, 11 PBDE congeners, and 9 OCPs. The biomarker distributions were examined and geometric means compared for selected analytes across categories of age, race, site, body mass index (BMI), parental education, maternal age at delivery, and breast feeding in adjusted models. Results Six PBDE congeners were detected among greater than 70% of samples, with BDE-47 having the highest concentration (median 42.2, range 4.9–855 ng/g lipid). Girls in California had adjusted geometric mean (GM) PBDE levels significantly higher than girls in Ohio. Furthermore, Blacks had significantly higher adjusted GMs of all six PBDE congeners than Whites, and Hispanics had intermediate values. GMs tended to be lower among more obese girls, while other variables were not strongly associated. In contrast, GMs of the six PCB congeners most frequently detected were significantly lower among Blacks and Hispanics than Whites. PCBs and the three pesticides most frequently detected were also consistently lower among girls with high BMI, who were not breast-fed, whose mothers were younger, or whose care-givers (usually parents) were less educated. Girls in California had higher GMs than in Ohio for the pesticides and most PCB congeners, but the opposite for CB-99 and -118. Conclusions Several of these potential HAAs were detected in nearly all of these young girls, some at relatively high levels, with variation by geographic location and other demographic factors that may reflect exposure pathways. The higher PBDE levels in California likely reflect differences in fire regulation and safety codes, with potential policy implications.

Purpose (1) To propose a new method using statistical modeling to determine relative timing of pubertal maturation; (2) to validate the new method by evaluating its relationship with pubertal growth and timing parameters, including age at menarche, age onset of areolar maturation, age of peak height velocity, age at attainment of adult height, adult height, peak height velocity, body mass index, and percent body fat; and (3) to contrast the new method with relative timing of menarche on these pubertal parameters. Background The timing of puberty has a well-known impact on anthropometric and psychosocial outcomes. Multiple methods have been used to determine pubertal timing, but all with limitations. A uniformly applicable method is needed for different study designs and study populations. Methods Using the National Heart Lung and Blood Institute Growth and Health Study data, an ordinal logistic modeling was used to assess relative timing of pubertal maturation. Results The proposed method demonstrated good reliability and strong associations with all pubertal timing parameters, also body mass index and percent body fat. Timing was not significantly associated with adult height and peak height velocity. Conclusions The proposed method is highly feasible, easy to implement, and valid. The study demonstrated important differences between the relationships of relative timing of secondary sexual characteristics and the timing of menarche on pubertal parameters. The study also demonstrates that individuals with early or late timing at one point of time are likely to maintain the same relative timing throughout puberty.

A previous editorial in this journal (Puberty - Whither goest?) discussed whether pubertal maturation was occurring earlier in U.S. girls, and the potential causes of those changes.1 Several original manuscripts, review papers, and convened consensus groups have discussed these topics, and most of the published works have accepted that 1) there is a decrease in the age of onset of puberty, as defined by breast development, and 2) there is a more modest decrease in the age of menarche (reviewed by Kaplowitz).2 Black women experience menarche approximately six months earlier than white women, whereas their breast development appears to be up to one year earlier than white women. When examining the potential causes of the continued decrease in age of onset of puberty in girls, many have noted that there has been a coincident epidemic in rates and degrees of obesity. They concluded that increased body mass index (BMI) accounts for much of the change in age of onset of puberty in girls; the changes in pubertal onset, and association with increased BMI, are not as clear in boys.

Racial/ethnic differences in prevalence and patterns of oral and anal sex were analyzed among girls participating in a microbicide acceptability study.Cross-sectional analysisRecruitment to participate in a 6-month study examining microbicide acceptability was conducted at a school-based health clinic and local colleges in Galveston, Texas and through snowball sampling.Sexually experienced girls (n = 202) ages 14 to 21 years of age.Girls reported on their demographic and sexual history at the intake interview.Their mean age was 18.2 years; 26% were white, 43% African-American, and 31% Hispanic. African-American girls were significantly less likely than whites and Hispanics to have had oral sex; no differences were found for anal sex. African-American girls were significantly older than whites and Hispanics when they initiated oral sex. African-American girls had a greater difference between ages of vaginal and oral sex initiation than whites and Hispanics. Oral sex history was associated with a 6-factor increase and anal sex history was associated with a 3-factor increase in the likelihood of a history of sexually transmitted infection. Future studies should explore these differences in greater depth in order to develop culturally specific STI prevention efforts.

Biomonitoring is a critical tool to assess the effects of chemicals on health, as scientists seek to better characterize life-course exposures from diverse environments. This trend, coupled with increased institutional support for community-engaged environmental health research, challenge established ethical norms related to biomonitoring results communication and data sharing between scientists, study participants, and their wider communities.Through a literature review, participant observation at workshops, and interviews, we examine ethical tensions related to reporting individual data from chemical biomonitoring studies by drawing relevant lessons from the genetics and neuroimaging fields.In all three fields ethical debates about whether/how to report-back results to study participants are precipitated by two trends. First, changes in analytical methods have made more data accessible to stakeholders. For biomonitoring, improved techniques enable detection of more chemicals at lower levels, and diverse groups of scientists and health advocates now conduct exposure studies. Similarly, innovations in genetics have catalyzed large-scale projects and broadened the scope of who has access to genetic information. Second, increasing public interest in personal medical information has compelled imaging researchers to address demands by participants to know their personal data, despite uncertainties about their clinical significance. Four ethical arenas relevant to biomonitoring results communication emerged from our review: tensions between participants' right-to-know their personal results versus their ability or right-to-act to protect their health; whether and how to report incidental findings; informed consent in biobanking; and open-access data sharing.Ethically engaging participants in biomonitoring studies requires consideration of several issues, including scientific uncertainty about health implications and exposure sources, the ability of participants to follow up on potentially problematic results, tensions between individual and community research protections, governance and consent regarding secondary use of tissue samples, and privacy challenges in open access data sharing.

Purpose Health research that includes youth and family stakeholders increases the contextual relevance of findings, which can benefit both the researchers and stakeholders involved. The goal of this study was to identify youth and family adolescent health priorities and to explore strategies to address these concerns. Methods Stakeholders identified important adolescent health concerns, perceptions of which were then explored using concept mapping. Concept mapping is a mixed-method participatory research approach that invites input from various stakeholders. In response to prompts, stakeholders suggested ways to address the identified health conditions. Adolescent participants then sorted the statements into groups based on content similarity and rated the statements for importance and feasibility. Multidimensional scaling and cluster analysis were then applied to create the concept maps. Results Stakeholders identified sexually transmitted infections (STIs) and obesity as the health conditions they considered most important. The concept map for STIs identified 7 clusters: General sex education, support and empowerment, testing and treatment, community involvement and awareness, prevention and protection, parental involvement in sex education, and media. The obesity concept map portrayed 8 clusters: Healthy food choices, obesity education, support systems, clinical and community involvement, community support for exercise, physical activity, nutrition support, and nutrition education. Ratings were generally higher for importance than for feasibility. Conclusions The concept maps demonstrate stakeholder-driven ideas about approaches to target STIs and obesity in this context. Strategies at multiple social ecological levels were emphasized. The concept maps can be used to generate discussion regarding these topics and to identify interventions.

Children exposed to endocrine disruptors are hypothesized to be susceptible for cancer development later in life. Identifying functional biomarkers of specific exposures may indicate predisposition for this disease. The objectives of this study were to identify protein biomarkers of 1) effect and 2) susceptibility for cancer from the blood of girls exposed to select environmental chemicals. In prepubertal girls, urine concentrations of bisphenol A (BPA), genistein, mono-ethyl hexylphthalate (MEHP) and mono-benzyl phthalate (MBzP) were used to identify girls in the top quintile of exposure for each of these environmental chemicals, and age-matched prepubertal girls with urine analyte concentrations below the median. Blood samples of these girls were depleted of the seven most abundant proteins using human-specific affinity spin columns. Using isobaric Tandem Mass Tags and quantitative mass spectrometry (TMT-MS), 51, 34, 57 and 47 differentially expressed proteins were identified from the blood of prepubertal girls with high urine concentrations of BPA, genistein, MEHP and MBzP, respectively, compared to controls. The data demonstrates the potential of proteomic technology to not only provide biomarkers of effect from aminimally invasive source of biological material, blood, but to identify protein molecules that are intimately involved in the pathobiology of cancer. The differentially regulated cancer associated proteins in girls with high concentrations of BPA and genistein are consistent with reported roles of BPA in carcinogenesis and of genistein in mammary cancer prevention, respectively.

Environmental exposures to many phenols are documented worldwide and exposures can be quite high (>1 μM of urine metabolites). Phenols have a range of hormonal activity, but knowledge of effects on child reproductive development is limited, coming mostly from cross-sectional studies. We undertook a prospective study of pubertal development among 1239 girls recruited at three U.S. sites when they were 6–8 years old and were followed annually for 7 years to determine age at first breast or pubic hair development. Ten phenols were measured in urine collected at enrollment (benzophenone-3, enterolactone, bisphenol A, three parabens (methyl-, ethyl-, propyl-), 2,5-dichlorophenol, triclosan, genistein, daidzein). We used multivariable adjusted Cox proportional hazards ratios (HR (95% confidence intervals)) and Kaplan–Meier survival analyses to estimate relative risk of earlier or later age at puberty associated with phenol exposures. For enterolactone and benzophenone-3, girls experienced breast development 5–6 months later, adjusted HR 0.79 (0.64–0.98) and HR 0.80 (0.65–0.98) respectively for the 5th vs 1st quintiles of urinary biomarkers (μg/g-creatinine). Earlier breast development was seen for triclosan and 2,5-dichlorophenol: 4–9 months sooner for 5th vs 1st quintiles of urinary concentrations (HR 1.17 (0.96–1.43) and HR 1.37 (1.09–1.72), respectively). Association of breast development with enterolactone, but not the other three phenols, was mediated by body size. These phenols may be antiadipogens (benzophenone-3 and enterolactone) or thyroid agonists (triclosan and 2,5-dichlorophenol), and their ubiquity and relatively high levels in children would benefit from further investigation to confirm these findings and to establish whether there are certain windows of susceptibility during which exposure can affect pubertal development. Keywords: Phenols, Breast development, Puberty, Environment

Background Hormonally active environmental agents have been measured among U.S. children using exposure biomarkers in urine. However, little is known about their variation by race, age, sex, and geography, and no data exist for newly developed biomarkers. Objective Our goal was to characterize relevant, prevalent exposures for a study of female pubertal development. Methods In a pilot study among 90 girls from New York City, New York, Cincinnati, Ohio, and northern California, we measured 25 urinary analytes representing 22 separate agents from three chemical families: phytoestrogens, phthalates, and phenols. Exposures occur chiefly from the diet and from household or personal care products. Results Participants represented four racial/ethnic groups (Asian, black, Hispanic, white), with mean age of 7.77 years. Most analytes were detectable in > 94% of samples. The highest median concentrations for individual analytes in each family were for enterolactone (298 μg/L), monoethylphthalate (MEP; 83.2 μg/L), and benzophenone-3 (BP3; 14.7 μg/L). Few or no data have been reported previously for four metabolites: mono(2-ethyl-5-carboxypentyl) phthalate, triclosan, bisphenol A (BPA), and BP3; these were detected in 67–100% of samples with medians of 1.8–53.2 μg/L. After multivariate adjustment, two analytes, enterolactone and BPA, were higher among girls with body mass index < 85th reference percentile than those at or above the 85th percentile. Three phthalate metabolites differed by race/ethnicity [MEP, mono(2-ethylhexyl) phthalate, and mono-3-carboxypropylphthalate]. Conclusions A wide spectrum of hormonally active exposure biomarkers were detectable and variable among young girls, with high maximal concentrations (> 1,000 μg/L) found for several analytes. They varied by characteristics that may be relevant to development.

Self-esteem is a major "predictor" of satisfaction with life. This longitudinal study examined mean and individual changes in self-esteem, and how self-esteem is affected by race and body mass.Girls were recruited at ages 9 and 10 years, and followed to age 22 years. The Harter Self-Perception Profile was administered every other year, analyzing scores from the Global Self-Worth Scale, by age or developmental phase: ages 9-12 (I), 13-16 (II), and 17-22 (III). Regression modeling included main effects and interactions between age/phase, race, and body mass index (BMI).Self-worth was greater in black than white women, and greater with lower BMI in both races. In the model with age ("traditional model") (with race and BMI), significant variables included BMI (inverse relationship) and the interactions between age and race, race and BMI, and the triple interaction between age, race, and BMI. In the model with phase ("transitional model") (with race and BMI), BMI, and the interactions between BMI and race, and race and phase, were significant. For example, self-worth was generally lower in Phase II (middle adolescence) for white women. Self-esteem tracked significantly (correlation 0.22, p.001). An individual's self-worth during any given phase of adolescence was correlated significantly with the other two phases.In this longitudinal analysis of self-esteem in adolescent girls, race and BMI are important predictors of self-esteem. Self-esteem is consistent across the phases of adolescence, and comparable with other personality traits. As noted by others, lower levels of self-esteem may increase the vulnerability of adolescents to risky behaviors.

Objectives Since pubertal maturation is an important covariate in studies that evaluate physical and social changes that occur during the teen years, we examined pubertal parameters in a group of US girls. Study design Black and white girls recruited at age 9 were followed annually for 10 years. Preece-Baines model 1 was used to estimate tempo and growth parameters. The temporal trend between age of menarche and onset of puberty was calculated. Results The study included 615 (77.2% prepubertal) white and 541 (49.4% prepubertal) black participants. Mean onset of puberty was 10.2 and 9.6 years in white and black girls, respectively, menarche was 12.6 and 12.0, achievement of Tanner growth stage 5 was 14.3 and 13.6, and achievement of adult height was 17.1 and 16.5 years. The Pearson’s correlation coefficient between menarche and onset of puberty was .37. Conclusions Menarche is often used as a marker for onset of puberty and for timing of puberty. Data gathered over the past 20 years suggest only moderate correlation between menarche and onset of puberty (.37-.38), which has decreased significantly during the last 50 years. This suggests the existence of both similar and unique factors that impact the age at onset of puberty and age at menarche.

This article addresses pragmatic issues regarding the assessment of puberty in research on adolescent health and development. Because pubertal processes have a major effect on physical, psychological, and social development, we posit that the assessment of pubertal status is at least as important as the specification of age for characterizing adolescent participants in research studies. Yet, a sampling of recent literature shows that the majority of publications addressing health and developmental issues in adolescence lack any measure of puberty. A more comprehensive review of 447 articles reporting to have assessed puberty reveals considerable inconsistencies in methods, definitions, and conceptualizations of puberty and its stages, which highlights the need for better standardization. This article provides an in-depth review of existing methods to assess pubertal status and timing and enumerates the relative merits and shortcomings of several approaches. Conceptual and practical guidelines are provided...

The number of meals and snacks including beverages consumed by children and adolescents has increased over the past few decades(1,2) from approximately three per day in 1977 to five per day in 2006(1). During this time, children’s (ages 2–18 years) daily energy intake has increased by ~770 kJ (184 kcal), which may be partially attributed to greater consumption of sugar-sweetened beverages (SSB) and energy-dense foods(3). The local food environment, areas surrounding children’s homes and schools, may play an important role in shaping children’s dietary behaviours by providing easy access to energy-dense food items and beverages. In a recent study of children’s (grades 4–6) purchasing behaviours at urban corner stores, it was reported that, on average, children spent $US 1·07 on approximately two items that contained 1494 kJ (357 kcal). The most frequently purchased items were those with low nutritional value, such as chips, candy and SSB(4). Previous research has examined the influence of the local food environment on children’s dietary intakes and behaviours, especially within schools(5); a smaller number of studies have focused on the influence of local food environments. Close proximity of homes and/or schools to convenience stores and other food outlets, as assessed by objective geographic measurements, is associated with SSB intake(6–8), low scores on a modified Healthy Eating Index(9) and greater likelihood of eating/snacking outside the home(8). However, null associations of these measures and intakes of fruits and vegetables, high-sugar foods and fast foods are also reported(6,10). Results from studies using subjective measures are also mixed. Reported use of fast-food restaurants(11) and shorter perceived walking time from home to food retail outlets(7) are positively associated with SSB purchases, but there is no association for walking time and purchases of convenience store foods or fast foods(7). There is a continued need to understand the role of the local food environment in shaping dietary intakes, especially in young children. We used data collected from a multi-site (New York, Cincinnati and the San Francisco Bay area) observational cohort study of girls of elementary-school age to describe the availability and frequency of use of local snack-food outlets (convenience stores, fast-food outlets and food stands) en route from home to school. We also determined whether reported use of these outlets was associated with daily intakes of energy, SSB and snack foods/sweets. The study provides unique information regarding the potential influence of the local food environment on the dietary intakes of young children living across the USA.

When adolescent girls choose to have sexual intercourse, it is important for them to have the knowledge, resources, and communication skills necessary to avoid unintended pregnancies. There are many barriers to contraceptive use that are specific to adolescents, and it is possible that parents and partners could help to support consistent and correct use of contraception. This paper reviews the existing literature on the role of parents and partners, and discusses the implications of this knowledge base for clinical practice. The specific recommendations in this manuscript are designed to aid health care providers in supporting the involvement of parents and partners in the lives of adolescent girls in order to promote the positive emotional and physical growth of adolescent girls.

Teenagers undergo biological, cognitive, and social changes. Each of these changes interacts with the other developmental parameters and may affect outcomes in late adolescence and adulthood. Sequence, tempo, and timing of puberty all affect when changes in hormones, feelings, and behavior will emerge in children. The pediatrician should recognize stages of pubertal development and be able to provide counseling and information to patients and parents. Some suggested resources are listed in the Sidebar.

Herpes simplex virus (HSV) infections occur commonly among adolescents. Most HSV-2 infections are genital, but genital herpes can be caused by either HSV-1 or HSV-2. Weighted means were calculated based on published seroprevalence data on adolescents from the United States and found HSV-1 rates of 53.1 percent for adolescent males and 49.4 percent for adolescent females. The weighted means for HSV-2 was 15 percent for adolescent females and 12 percent for adolescent males. Most individuals who are infected with HSV-2 are unaware of their infection. Healthcare providers of adolescents should consider genital herpes even when an adolescent presents with nonspecific genital symptoms. In this article, we review current recommendations for diagnosis and management and review the psychological sequelae that can be associated with having genital herpes. Finally, we discuss biomedical interventions that are being developed to help reduce the epidemic of HSV and the challenges that these interventions face with regard to implementation.

Background Cross-sectional seroprevalence studies indicate that infections with herpes simplex virus (HSV) types 1 (HSV-1) and 2 (HSV-2) and cytomegalovirus (CMV) are common. However, data on the rates of acquisition of these infections are limited. Methods A 3-year longitudinal study of HSV-1, HSV-2, and CMV seroprevalence was conducted in a cohort of 174 adolescent girls (age at enrollment, 12-15 years). Results At study entry, 41% of the girls reported a history of sexual activity, and by the end of the study, 73% reported a history of sexual activity. At enrollment, 71% of all participants were seropositive for CMV, 44% were seropositive for HSV-1, and 7% were seropositive for HSV-2. By the end of the study, 81% of the girls were seropositive for CMV, 49% were seropositive for HSV-1, and 14% were seropositive for HSV-2. Among girls with a history of sexual activity, 15.5% were HSV-2 seropositive at the beginning of the study, and 18.9% were HSV-2 seropositive at the end of the study. The attack rates, based on the number of cases per 100 person-years, were 13.8 for CMV infection and 3.2 for HSV-1 infection (among all girls) and 4.4 for HSV-2 infection (among girls with a history of sexual activity). Participants with preexisting HSV-1 antibodies were associated with a significantly lower attack rate for HSV-2 infection. A generalized estimating equation model indicated that participants with a longer history of sexual activity and those who had more sexually transmitted diseases during the 6-month periods before the study visits were more likely to be HSV-2 seropositive. Conclusions This longitudinal study of adolescent girls found high baseline CMV and HSV-1 seroprevalence rates and substantial attack rates for all 3 pathogens.

There are several issues that arise regarding the evaluation of teens with urethritis and cervicitis. What are the appropriate treatments for adolescents? What are the issues regarding rescreening and do we need to consider tests of cure? Chlamydia is the most common bacterial sexually transmitted disease in adolescents in the United States. The prevalence appears to be leveling off or decreasing which may reflect several reasons. More frequent screening utilizing more sensitive diagnostic techniques such as nucleic acid amplification techniques and screening populations that are traditionally more difficult to reach may have led to the lower rates. However there still are many young men and women with high-risk behaviors who are not receiving appropriate screening. (excerpt)

Higher socioeconomic position (SEP) has been associated with increased risk of breast cancer. Its relationship with the age of menarche, which is inversely associated with risk of breast cancer, and to the age of pubertal onset, is less clear. We studied the relationship of SEP to pubertal onset in a multiethnic cohort of girls aged 6–8 years at baseline and followed for 5–8 years in the Breast Cancer and the Environment Research Program in three study sites across the United States that included annual clinical examinations performed from 2004 to 2012. Analyses were conducted with accelerated failure time models using a Weibull distribution, with left, right and interval censoring. Among 1059 girls, an index of SEP comprised of household family income, mother's education and whether the home was owned or rented was assessed for associations with pubertal onset, measured by breast budding (Tanner Stage B2) and pubic hair development (Tanner Stage PH2). Girl's BMI% at entry to the study and black or Hispanic race/ethnicity were the strongest predictors of age at pubertal onset by both measurements, but the SEP index was an independent predictor in adjusted models. Girls from the lowest quintile of SEP entered puberty on average 6% earlier (6.0–7.5 months) than girls from the highest quintile (time ratio = 0.94, 95% confidence interval 0.91–0.97) adjusted for BMI%, race/ethnicity and their interaction. The meaning of SEP in this relationship bears further study, but our results suggest that early life social circumstances beyond race/ethnicity and body size may influence the timing of pubertal development. The following are the 17 highest-scoring abstracts of those submitted for presentation at the 40th Annual ASPO meeting held March 13–15, 2016, in Columbus, OH.

Objective Patterns of pubertal maturation may have an impact on several risk factors associated with adult morbidity and mortality, such as obesity. We examined the relationship of the initial manifestation of puberty in girls with anthropometric measures, as well as age at menarche. Methods White females (n = 1166, ages 9 and 10 at intake) were followed with annual visits for 10 years. Physical examinations included height, weight, skinfold thicknesses, and pubertal maturation assessment. Results During the course of the study, 443 of 859 eligible females (51.6%) were observed to have asynchronous maturation in the development of puberty, that is, initial areolar/breast (thelarche pathway) or pubic hair (adrenarche pathway) development, without development of the other characteristic. Using a longitudinal regression model, significant interactions were noted between initial pubertal manifestation and years since onset of puberty on the following outcomes: sum of skinfolds thickness, percent body fat, waist-to-hip ratio, and body mass index (BMI). However, age of onset of pubertal maturation was the same in the 2 groups (10.7 years). Females in the thelarche pathway had earlier menarche (12.6 vs 13.1 years) as well as greater skinfolds, body fat, and BMI at the time of menarche. Females in the thelarche pathway also had greater body fat and BMI 1 year before puberty and throughout puberty compared with those in the adrenarche pathway. Conclusions Females who enter puberty through the thelarche pathway, as compared with the adrenarche pathway, had greater sum of skinfold thicknesses, BMI, and percent body fat 1 year before the onset, as well as throughout, puberty. Because larger body composition and earlier age of menarche of females in the thelarche pathway parallel the epidemiologic profiles of women who are obese or at risk for obesity, these females may be at greater risk for adult obesity.

Objective To determine the role of increasing free testosterone and estradiol in pubertal changes in male lipids. Methods We conducted a 3-year, longitudinal, observation study with biannual visits of 251 black and 285 white boys who were 10 to 15 years of age at enrollment. Sex hormones, lipid parameters, and body composition measures were obtained according to a standard protocol. The body mass index (kg/m 2 ) was used to characterize obesity. Results White boys had higher triglycerides, lower high-density lipoprotein cholesterol (HDL-C), lower apolipoprotein (apo)AI, and higher apoB than black boys. In boys of both races, increased body mass index was associated with increases in triglycerides, low-density lipoprotein cholesterol, apoB and decreases in HDL-C and apoAII. Within this framework, increased free testosterone was associated with increased apoB and decreased HDL-C and apoAI, whereas increased estradiol was associated with increased HDL-C and decreased triglycerides, low-density lipoprotein cholesterol, and apoB. Conclusion Changes in sex steroid hormones have significant effects on changes in lipid parameters—increasing free testosterone levels has atherogenic effects and increasing estradiol has antiatherogenic effects.

Background/Objectives: Depo-Provera–induced menstrual irregularity is believed to be secondary to relative estrogen deficiency. Weight gain associated with this contraceptive method is believed to be due to Depo-Provera's steroid-like appetite stimulation effect and to an altered tryptophan metabolism. We examined whether vitamin C, an important factor in uterine estrogen binding, and vitamin B 6 , a glucocorticoid antagonist and an important coenzyme in the tryptophan-serotonin pathway, might alleviate menstrual irregularities and weight gain associated with Depo-Provera. Methods: Fifty-five adolescent girls (age 16 ± 1 yr, gyn age 4 ± 1 yr, body mass index 25.2 ± 0.9) who decided to initiate Depo-Provera (150 mg intramuscularly every 3 months) were randomly assigned to one of four groups (group 1: vitamin B 6 50 mg plus placebo pill/day; group 2: vitamin C 500 mg plus placebo pill/day; group 3: vitamin B 6 50 mg plus vitamin C 500 mg/day; group 4 (control): 2 placebo pills/day) for 6 months. Participants were assessed by their care providers every 3 months. Setting: Two urban hospital-based adolescent clinics. Results: Number of days of bleeding during the first interval (first 3 months) as well as during the second interval (months 4–6) among groups 1, 2, and 3 did not differ statistically from days of bleeding in control group. There were no significant body mass index (BMI) changes among groups 1–3 (−0.15 ± 0.18, 0.34 ± 0.56, 0.01 ± 0.31) compared with control (−0.38 ± 0.38) during the first interval as well as during the second interval (0.68 ± 0.37, −0.39 ± 0.21, 0.45 ± 0.32, compared with 0.28 ± 0.43). When data from all 55 participants were collapsed, there was no significant change in BMI during the first 6 months of Depo-Provera use. About 48% at 3 months and 44% at 6 months were very or somewhat concerned about menstrual irregularity; 41% at 3 months and 18% at 6 months were very or somewhat concerned about weight changes. More than half (57%) at 3 months and 74% at 6 months reported less tampon/pad use, and 77% at 3 months and 78% at 6 months reported decreased menstrual cramps. Overall, 59% at 3 months and 70% at 6 months were very satisfied with Depo-Provera; 97% at 3 months and 96% at 6 months said that they would recommend Depo-Provera to a friend or a relative. Conclusions: This study does not support a role for vitamin C in the prevention of Depo-Provera–induced menstrual irregularities or for vitamin B 6 in the prevention of weight changes associated with Depo-Provera. The unchanged BMI during the first 6 months of Depo-Provera use in the present study suggests that raising awareness and close follow-up may prevent weight gain among adolescent girls using this contraceptive method.

Background. Smoking is highly prevalent in young women and little is known about early multilevel independent risk or protective factors that are predictive of daily smoking in young women. Methods. Multiple logistic regression was conducted on data from NGHS, a 10-year cohort study of Black (1,213) and White (1,166) girls recruited from three clinical centers in the United States, ages 9-10 years on entry to ages 18-19. Results. Compared with never smokers, White girls were at higher risk than Black girls of being daily smokers at ages 18-19. Early predictors of daily smoking at ages 18-19 years included lower parental education, one parent in the household, drinking alcohol at ages 11-12, higher drive for thinness at ages 11-12, lower behavioral conduct at ages 11-12, and lower stress at ages 10-11 and higher stress at ages 12-13. For both Black and White girls weight-related variables were significant. Stress, behavioral conduct, and one-parent household were also important predictors for White girls. Conclusions. There is evidence that childhood and adolescent factors are related to young adult smoking behavior. Body weight concerns as well as family, social environment, and behavioral factors are important issues in determining which girls will become daily smokers. (C) 2002 American Health Foundation and Elsevier Science (USA).

High-density lipoprotein cholesterol (HDL-C) concentrations decrease during adolescence in males in association with increasing pubertal maturation and free testosterone (F-T). To determine whether F-T effects lower HDL-C levels by decreasing the amount of cholesterol associated with the major protein moeities associated with HDL-C (apolipoprotein [apo]AI and AII) or by decreasing the concentrations of these proteins, we studied 251 black and 285 white boys, ages 10 to 15 years. In cross-sectional analysis, advancing puberty associated with decreasing HDL-C, apoAI, and apoAII in boys of each ethnic group. The decreases were greater in white (1.49 to 1.24 mmol/L) than black boys (1.68 to 1.53 mmol/L). Backward stepwise regression analyses indicated that F-T was a significant negative predictor of all 3 lipid parameters[mdash ]HDL-C, apoAI, and apoAII. Ethnic group was associated with HDL-C (blacks higher) and apoAII (whites higher), but not apoAI. The ratio of HDL-C to apo (AI+AII) varied significantly (and negatively) with body mass index (BMI; kg/m2), but not with pubertal stage or F-T. Thus, increased F-T appears to explain decreased HDL-C via decreased apoAI and apoAII, not decreases in the amount of cholesterol associated with these proteins.

Exposures of children to phthalates, parabens, and bisphenol-A (BPA) are of concern because of their hormonal potential. These agents are found in a wide range of foods and packaging. We investigated whether intake of certain foods predict exposures to these chemicals in young girls.Among 1101 girls (6-8 years at enrollment) from the Breast Cancer and Environment Research Program (BCERP) study, we measured urinary exposure biomarkers for phthalates, parabens, and BPA and assessed dietary intake using 24-h recall 2-4 times. We examined the average daily servings of major and minor food groups categorized as 0 to0.5, 0.5 to1 and ≥ 1 servings per day. Items included dairy, eggs, fats, fish, fruit, single grains, meat, non-poultry meats, pasta, poultry and vegetables. Covariate-adjusted least squares geometric means and 95% confidence intervals of creatinine-corrected phthalate and phenol metabolite concentrations in urine were calculated in relation to food intake.Grains, flour and dry mixes and total fish consumption were positively associated with BPA and the sum of four di-2-ethylhexylphthalate (DEHP) urinary metabolite concentrations. Non-fresh vegetables and poultry were both positively associated with BPA and paraben urinary concentrations. Fats, oils and poultry consumption were positively associated with BPA. Whole-fat dairy consumption was associated with ΣDEHP.Some foods may contribute to child exposures to certain chemicals, and this may constitute modifiable means to reduce these environmental exposures.

Study Objective To evaluate the effectiveness of a sexually transmitted infection (STI) intervention by a health educator that included partner notification, condom use, and retesting within 3 months. Design, Setting, and Participants Retrospective chart review was conducted, and data were collected from 274 sexually active adolescent girls, aged 15 to 19 years, who were diagnosed with gonorrhea (GC), Chlamydia (CT), and Trichomonas (TV) infection, during a 9-month span in an urban hospital–based adolescent medicine clinic. Methods Data regarding recurrent STIs (GC, CT, and TV) were collected for 12 months following the incident infection. There were 161 in the intervention group (health educator counseling), and 113 controls who received usual care. Differences between groups were analyzed using χ2 and survival analyses. Results There were no significant differences in age, gender, or race between the intervention and control groups at baseline. The majority in both groups were diagnosed initially with CT infection (57% CT, 16% GC, and 5% TV in the intervention group; 46% CT, 21% GC, and 12% TV in the control group). There was a significantly lower rate of STI in the intervention group for those retested within 12 months of the initial diagnosis (P = .002). The median (SD) time to recurrence in the intervention group was greater: 134 (14.7) days versus 116 (12.1) days (P = .034). Health education counseling, initial diagnosis with TV, and duration of time from initial diagnosis to retest (interval to retest) were significant protective factors for recurrent STI. Conclusions Health education counseling in an urban adolescent clinic is effective in reducing recurrent infection at 12-month follow-up and can serve as an important component in reducing STI recidivism.

Study question Does phthalate exposure during early childhood alter the timing of pubertal development in girls? Summary answer Urinary concentrations of high-molecular weight phthalate (high-MWP) metabolites are associated with later pubarche. What is known already Phthalates are anti-androgenic environmental agents known to alter early development, with possible effects on pubertal onset. Study design, size, and duration This multi-ethnic study included 1239 girls from New York City, greater Cincinnati, and the San Francisco Bay Area who were 6-8 years old at enrollment (2004-2007) and who were followed until 2011. PARTICIPANTS/MATERIALS, SETTING, METHODS Phthalate metabolites were measured in urine collected at enrollment from 1170 girls; concentrations ranged from 10,000 µg/l. Breast and pubic hair stages and body size were assessed one to two times annually to determine the age at transition from stage 1 to 2 for breast and pubic hair development. Associations between exposures and pubertal ages were estimated using Cox proportional hazard ratios (HR) with 95% confidence intervals (CI) and survival analyses. Associations were examined with respect to age-specific body mass-index percentile, one of the strongest predictors of pubertal onset. Main results and the role of chance Urinary concentrations of high-MWP including di(2-ethylhexyl) phthalate (ΣDEHP) metabolites were associated with later pubic hair development during 7 years of observation. The relationship was linear and was stronger among normal-weight girls. Among normal-weight girls, age at pubic hair stage 2 (PH2) was 9.5 months older for girls in the fifth compared with the first quintile of urinary ΣDEHP (medians: 510 and 59 µg/g creatinine, respectively; adjusted HR 0.70, CI 0.53-0.93, P-trend 0.005. Age at first breast development was older for fifth quintile of mono-benzyl phthalate versus first (HR 0.83, CI 0.68-1.02; P-trend 0.018). No associations were observed between low-molecular weight phthalate urinary metabolite concentrations and age at pubertal transition in adjusted analyses. Limitations, reasons for caution While there is evidence that phthalate exposures are fairly consistent over time, the exposure measure in this study may not reflect an earlier, more susceptible window of exposure. We investigated alternative explanations that might arise from exposure misclassification or confounding. Wider implications of the findings Phthalates are widespread, hormonally active pollutants that may alter pubertal timing. Whether exposures delay or accelerate pubertal development may depend on age at exposure as well as other factors such as obesity and exposures earlier in life. Whether exposures act independently or as part of real life mixtures may also change their effects on maturation from birth through childhood. Study funding/competing interest(s) This project was supported by the US National Institutes of Health, Environmental Protection Agency, New York State Empire Clinical Research Investigator Program and the Avon Foundation. L.H.K. is employed by Kaiser Permanente. The remaining authors declare they have no actual or potential competing financial interests.

Study Objective: The purpose of this study was to describe adolescent girls' perceptions of their parents' contact with and knowledge of the girls' boyfriends. A second objective was to determine if knowledge was related to demographic characteristics of the girls or aspects of the relationship with their boyfriend. Design: Cross-sectional analysis of data from an interview with adolescent girls enrolled in a longitudinal study. Setting: Urban adolescent medicine clinic. Participants: Adolescent girls (n = 109) with a mean age of 17.6 (range 14.9–19.3 yr). Eighty percent were African-American and 20% were Caucasian. Results: Most girls reported that their parents had some contact (either in person or on the phone) with their boyfriends. Thirteen girls reported that their parents did not know their boyfriends well, 40 reported that their parents knew their boyfriends somewhat, and 56 reported that their parents knew their boyfriends well. Age, race, and sexual experience were not related to how well the parents knew the boyfriend. Girls who had been involved with their boyfriends longer, believed that their relationship would last longer, were more satisfied, were more likely to tell their boyfriends private information and were more likely to describe their parents as knowing their boyfriends well. Conclusions: These results provide an initial description of girls' perceptions of their parents' relationships with their boyfriends. It would be important to understand how to utilize the information regarding these parental-boyfriend relationships to further adolescent girls' development of healthy (both psychologically and physically) relationships.

Study Objective: Approximately three million teenagers are infected with an STD each year. The ways in which an adolescent girl copes with an STD may have implications for future risk and for psychological adjustment. The purpose of the current study was to compare whether coping with an STD was similar to coping with other stressors. Setting: Urban, hospital-based adolescent medicine clinic. Design and Participants: Sixty-seven girls with a mean age of 15.9 (sexual debut was 13.8) yr completed the KIDCOPE in response to both an STD acquisition and an interpersonal stressor within the previous 6 months. Results: Problem solving was used less often, and self-blame was used more often, in response to an STD acquisition. Frequency of use of self-blame was not correlated with perceived helpfulness. Conclusions: These findings suggest that clinicians need to help adolescent girls manage STD acquisition from the perspective of problem solving rather than self-blame.

Objective: This study examined the relationship between timing of sexual maturation and eating disorders symptoms in adolescent girls. Method: Data were collected over 10 years for a cohort of 1,213 Black girls and 1,166 White girls who were either 9 or 10 years old at study entry. Annually, girls' height and weight were measured and, biannually, girls completed self-report measures of eating disorders symptoms. Results: Early-onset menarche is a risk factor for the development of body image and dieting concerns, but the effect of timing is due to the impact of early and late maturation on body weight. Discussion: Findings underscore the importance of adiposity as a risk factor for poor mental health. (C) 2001 by John Wiley & Sons, Inc.

Studies comparing physical activity levels in children with and without asthma have had mixed results. Our objective was to investigate the association between asthma diagnosis and physical activity and to examine differences in these associations by race/ethnicity, weight status and caregiver education.We investigated the association between asthma (defined as report of physician-diagnosed asthma with at least one asthma related symptom) and measures of physical and sedentary activity in a study of 6- to 8-year-old girls in the Breast Cancer and the Environment Research Project. We compared reported activity and pedometer measurements among girls with and without asthma, and examined modification of these associations by race/ethnicity, weight status and caregiver education.Girls (n = 1182) were included with 33.5% White, 4.8% Asian, 30.6% non Hispanic Black and 30.7% Hispanic. Asthma was present in 16.2% of girls. Overall, 38% of girls reported no participation in organized recreational activities and 58% had2 h/day of television, video game and computer time combined. Girls with asthma whose parents were less educated reported fewer pedometer steps and less non-scheduled activity than girls without asthma with similar caregiver education level. Among girls with asthma, those on a controller medication had higher levels of sedentary activity and more structured physical activity but were less likely to report high intensity physical activity.Among girls whose parents are less educated, girls with asthma may have lower physical activity levels than girls without asthma. Use of a controller medication may be related to physical and sedentary activity.

PFC serum concentrations were measured in 6–8 year-old girls in Greater Cincinnati (GC) (N = 353) and the San Francisco Bay Area (SFBA) (N = 351). PFOA median concentration was lower in the SFBA than GC (5.8 vs. 7.3 ng/mL). In GC, 48/51 girls living in one area had PFOA concentrations above the NHANES 95th percentile for children 12–19 years (8.4 ng/mL), median 22.0 ng/mL. The duration of being breast fed was associated with higher serum PFOA at both sites and with higher PFOS, PFHxS and Me-PFOSA-AcOH concentrations in GC. Correlations of the PFC analytes with each other suggest that a source upriver from GC may have contributed to exposures through drinking water, and water treatment with granular activated carbon filtration resulted in less exposure for SWO girls compared to those in NKY. PFOA has been characterized as a drinking water contaminant, and water treatment systems effective in removing PFCs will reduce body burdens.

Previous studies of lipids in adolescent males have shown greater increases in triglycerides and decreases in high-density lipoprotein cholesterol (HDL-C) in white boys compared with black boys, significant correlations between sex hormones and lipids, and complex body mass index (BMI) hormone-lipid associations. Within this frame of reference, we assessed race, BMI, and sex hormones as predictors of lipid parameters in 536 black and white boys recruited from area schools. Black boys were more advanced in puberty than white boys. After adjusting for pubertal stage, estradiol (E2) levels were higher in black boys but free testosterone (T) levels did not differ. Age, pubertal stage, race, BMI, free T, and E2 were entered as explanatory variables for lipids in backward stepwise regression analyses. The BMI and race were retained in every model. Black boys had lower triglycerides and apolipoprotein B (apo B) and higher HDL-C. E2 was inversely associated with total cholesterol (TC), triglycerides, low-density lipoprotein cholesterol (LDL-C), apo B, and the LDL-C/HDL-C ratio. Free T was inversely associated with HDL-C and positively associated with apo B. Given the increases in free T and E2 during adolescence and the association of these hormones with both atherogenic and protective lipid parameters, racial differences in E2 could contribute to the more atherogenic lipid profile found in white boys after puberty.

The battle against the epidemic of sexually transmitted infections continues but the clinician has new diagnostic and therapeutic weapons. This manuscript reviews new technologies, as well as novel applications of newer methodologies, such as utilization of amplified DNA techniques for urine specimens or patient-collected specimens. Newest treatment recommendations are also reviewed.

Purpose: To evaluate the relationships of overweight and fat patterning with cardiovascular disease (CVD) risk factors in black and white boys. Design: Cross-sectional analysis of CVD risk factors by weight and central adiposity groups in black and white boys, aged 10 to 15 years. Mean adiposity, lipid, and blood pressure variables were compared between weight and central adiposity groups within race by using linear regression models. Observed clustering of risk factors within weight and adiposity groups was compared with the expected clustering under an assumption of no association. Results: Within each racial group, overweight boys had greater skinfolds, lower high-density lipoprotein cholesterol levels, higher low-density lipoprotein cholesterol and triglyceride levels, and higher systolic and diastolic blood pressure than non-overweight boys. Among overweight boys, greater central adiposity was associated with higher risk factor levels and increased clustering of risk factors. Conclusion: Overweight and central adiposity together profoundly affect CVD risk factor levels and risk factor clustering in black and white boys.(J Pediatr 1999;135:451-7)

To examine adolescent girls' perception of control over general health and sexually transmitted disease (STD) acquisition.Adolescents participating in a longitudinal study were asked questions regarding their perception of their locus of control. These questions, adopted from a previous measure, focused on six loci: internal control, control by parents, partners, peers, and health care providers, and chance.There were 128 girls (mean age, 17 years; range, 14.5 to 18.8); 82% were black and 18% white. Statistically significant associations were found between control of general health and STD acquisition for each locus of control subscale, with the exception of partner control. However, the girls reported significantly less control over STD acquisition than over general health for health care providers, parents, and by chance, and significantly more partner and internal control over STD acquisition than general health. The correlations between parental control over general health and over STD acquisition were inversely correlated with age. Partner control was positively related to current condom use, but internal control was not.The degree of the locus of control was specific for STD acquisition. Girls who believe they should be able to control STD acquisition may not be using condoms. The view of partners as having control over STD acquisition may represent joint communication or coercion. However, in general these findings support the development of female-controlled methods for STD prevention, such as topical microbicides.

Pediatricians with busy practices have limited time to spend with each patient. But because much of adolescent morbidity and mortality is related to behavioral issues, time and energy are crucial to providing effective counseling and care to adolescents. Many barriers to provision of services to adolescents exist, including time, space, décor, office hours, office fees, and support personnel. Despite these barriers to care of adolescents and, in particular, sexually active adolescents, the need for pediatricians to provide these services is clear. Services include anticipatory guidance and counseling about developing sexuality and sexual behaviors, as well as management of health consequences of sexual behavior. Primary care providers have an opportunity to assist adolescents to develop mature and healthy sexual relationships. This necessitates a full understanding of each patient's unique situation, listening to adolescents' concerns, and honest and straightforward discussion of sensitive information. Beginning the process of discussion of sexuality and relationships early in the pediatric years may help adolescents and their parents to develop healthy sexual attitudes and behaviors.

To address the health needs of adolescents, health care providers need to understand adolescent perceptions of the sexual history taking process. Adolescents (n = 113) were recruited from two sources of health care to complete a questionnaire regarding sexual history taking issues. The results revealed that there were differences in demographics, practice characteristics, and communication strategies between the private office and the hospital clinic. Attitudes and beliefs related to the discussion of sensitive issues were similar. Most adolescents would like health care providers to discuss sensitive topics directly. It is important for health care providers to feel comfortable initiating discussion of sensitive issues directly.This study described adolescents' perception of their sexual history taken by health care providers. There were two stages of data collection. The first included focus group discussion, while the second was the administration of a sexual history-taking questionnaire. Adolescents were recruited from three locations (private pediatric practice, adolescent clinic setting, or a Job Corps Center) and were of a mean age of 16 years. Findings revealed differences in demographics and practice characteristics, as well as in strategies used when communicating with the care provider. However, there were similarities in attitudes and beliefs related to the discussion of sensitive issues. The majority of the adolescents believed that issues related to sexuality were important for their health care provider to discuss. Moreover, they preferred that their care provider address sexuality issues within a generally caring context; however, they also favored a direct approach.