- Adolescent Medicine
- Underserved youth
- Tobacco/alcohol/other drug use
- Eating Disorders
Clinical Professor, Pediatrics - Adolescent Medicine
Honors & Awards
Fellow, Society for Adolescent Medicine (2004-present)
electee, Alpha Omega Alpha (2000-present)
Board Certification: Addiction Medicine, American Board of Internal Medicine (2018)
Board Certification: Pediatrics, American Board of Pediatrics (1986)
Internship:Univ Michigan (1981)
Medical Education:George Washington University (1980) DC
Board Certification, American Board of Pediatrics, Adolescent Medicine (2008)
Board Certification: Adolescent Medicine, American Board of Pediatrics (1994)
Fellowship:UCSF Medical Center (1989) CA
Residency:University of Michigan Medical Center (1983) MI
Community and International Work
Adolescent Outreach Project
Mobile Clinic Program
Homeless and uninsured youth
Opportunities for Student Involvement
Current Research and Scholarly Interests
At-risk and high-risk youth; smoking cessation and prevention; eating disorders
- Independent Studies (5)
A randomized clinical trial of the efficacy of extended smoking cessation treatment for adolescent smokers.
Nicotine & tobacco research
2013; 15 (10): 1655-1662
INTRODUCTION: Relatively few well-designed smoking cessation studies have been conducted with teen smokers. This study examined the efficacy of extended cognitive-behavioral treatment in promoting longer term smoking cessation among adolescents. METHODS: Open-label smoking cessation treatment consisted of 10 weeks of school-based, cognitive-behavioral group counseling along with 9 weeks of nicotine replacement (nicotine patch). A total of 141 adolescent smokers in continuation high schools in the San Francisco Bay Area were randomized to either 9 additional group sessions over a 14-week period (extended group) or 4 monthly smoking status calls (nonextended group). Intention-to-treat logistic regression analysis was used to assess the primary outcome of biologically confirmed (carbon monoxide < 9 ppm) point prevalence abstinence at Week 26 (6-month follow-up from baseline). RESULTS: At Week 26 follow-up, the extended treatment group had a significantly higher abstinence rate (21%) than the nonextended treatment (7%; OR = 4.24, 95% CI: 1.20-15.02). Females also were more likely to be abstinent at the follow-up than males (OR = 4.15, 95% CI: 1.17-14.71). CONCLUSIONS: The significantly higher abstinence rate at follow-up for the extended treatment group provides strong support for continued development of longer term interventions for adolescent smoking cessation.
View details for DOI 10.1093/ntr/ntt017
View details for PubMedID 23460656
Efficacy and Tolerability of Pharmacotherapies to Aid Smoking Cessation in Adolescents
2012; 14 (2): 91-108
Adolescent smoking remains a public health problem. Despite concerns regarding adolescent nicotine dependence, few well-designed smoking cessation studies have been conducted with teen smokers. This is particularly true regarding pharmacologic treatments for nicotine dependence. Currently, pharmacologic aids are not recommended for treating adolescent nicotine dependence, as efficacy has not been shown in this population. This review includes studies that have examined the efficacy of pharmacotherapy for smoking abstinence and/or reduction in cigarette consumption among adolescent smokers who want to quit smoking, laboratory-based adolescent studies that have examined the efficacy of these medications in reducing cravings and/or withdrawal symptoms, and/or studies that have assessed the tolerability of medications for smoking cessation in adolescent smokers. It provides information on the pharmacologic action of each medication, the efficacy of each medication for adolescent smoking cessation, the tolerability of each medication based on reported adverse events, and compliance with the medication protocols. Thirteen relevant articles were identified and included in the review. Nicotine patch (NP), nicotine gum, nicotine nasal spray, bupropion, and varenicline have been studied in adolescent smokers. The adverse events reported in the studies on pharmacology for adolescent smoking suggest that the side effect profiles for nicotine replacement therapy, bupropion, and varenicline are similar to those reported in adult studies. There is some evidence of efficacy of NP and bupropion at the end of treatment (efficacy of varenicline has not been assessed), but none of the medications included in this review were efficacious in promoting long-term smoking cessation among adolescent smokers. It is noted that many of the study protocols did not follow the recommended dose or length of pharmacotherapy for adults, rendering it difficult to determine the true efficacy of medication for adolescent smoking cessation. Future efficacy studies are warranted before recommending pharmacotherapy for adolescent smoking cessation.
View details for Web of Science ID 000301274700003
View details for PubMedID 22248234
View details for PubMedCentralID PMC3319092
Assessing teen smoking patterns: The weekend phenomenon
DRUG AND ALCOHOL DEPENDENCE
2012; 120 (1-3): 242-245
Adolescent cigarette smokers may have more daily variability in their smoking patterns than adults. A better understanding of teen smoking patterns can inform the development of more effective adolescent smoking cessation interventions.Teen smokers seeking cessation treatment (N=366) reported the number of cigarettes smoked on each day of a typical week. A paired t-test was used to examine differences between weekday (Sunday-Thursday) and weekend (Friday-Saturday) smoking. Main effects and interactions for race/ethnicity and gender were assessed using a 2-way ANOVA for the following variables: typical weekly smoking, average weekday smoking, average weekend smoking, and difference between weekday and weekend smoking. Scheffé post hoc tests were used to analyze any statistically significant differences.There was significantly more weekend smoking compared to weekday smoking, p<0.001. The difference in weekday versus weekend smoking levels was larger for females than for males, p<0.05. Hispanics reported less typical weekly smoking, p<0.001, less weekday smoking, p<0.001, and less weekend day smoking, p<0.01, compared to Caucasians and multi-racial teens. There was no difference in weekend day versus weekday smoking by race/ethnic background.Using a more detailed assessment of smoking quantity captures patterns of adolescent smoking that may lead to more effective smoking cessation interventions.
View details for DOI 10.1016/j.drugalcdep.2011.07.014
View details for Web of Science ID 000299499800037
View details for PubMedID 21885211
View details for PubMedCentralID PMC3245765
Anaphylaxis From Depot Medroxyprogesterone Acetate in an Adolescent Girl
OBSTETRICS AND GYNECOLOGY
2011; 118 (2): 443-445
Anaphylaxis postinjection of depot medroxyprogesterone acetate (DMPA) has been rarely reported in adult women.A 16-year-old girl developed anaphylaxis after receiving 150 mg of DMPA intramuscularly. She previously had received four injections of DMPA without any adverse reactions, including two earlier doses from the same lot number. She initially was treated in the clinic and was stabilized in the emergency department, with full recovery. She subsequently underwent allergy testing, which was inconclusive, and decided to use the copper intrauterine device for ongoing contraception.Anaphylaxis, a rare complication of DMPA, can occur even if a patient had no adverse reactions from previous injections from the same lot number.
View details for DOI 10.1097/AOG.0b013e318213cd49
View details for Web of Science ID 000293115000013
View details for PubMedID 21768848
Withdrawal symptoms over time among adolescents in a smoking cessation intervention: Do symptoms vary by level of nicotine dependence?
2009; 34 (12): 1017-1022
Nicotine dependence may be expressed differently in teens than in adults. Thus, it may not be sufficient to build diagnostic and cessation treatment strategies for teens based on adult-derived clinical and research data. This is the first study to prospectively examine the development of withdrawal symptoms by level of nicotine dependence among adolescent smokers. Forty-seven adolescent smokers completed nicotine withdrawal symptoms measures during 10 weeks of cessation treatment. Nicotine dependence was assessed at baseline using the mFTQ. Change in withdrawal symptoms over time by level of nicotine dependence was examined via mixed model ANOVA. Nicotine withdrawal in daily adolescent smokers was strongly and prospectively associated with the level of nicotine dependence. Craving was rated as the most problematic symptom at the baseline assessment. The results of this study may help guide the development of future research on diagnostic and cessation treatment strategies for teens.
View details for DOI 10.1016/j.addbeh.2009.06.014
View details for Web of Science ID 000270472500005
View details for PubMedID 19647373
View details for PubMedCentralID PMC2739258
Ethical issues in research with homeless youths
Annual Meeting of the Society-for-Adolescent-Medicine
WILEY-BLACKWELL. 2008: 365–72
This paper is a report of a study to document researcher, healthcare provider and programme administrators' experiences with ethical issues in research with homeless youths in North America.While there are legal and ethical guidelines for research with adolescents and with vulnerable populations in general, there are no specific guidelines for the ethical conduct of research with homeless youths.Using a web-based questionnaire, healthcare and social service providers, programme administrators and researchers working with homeless young people throughout the United States of America and Canada were surveyed in 2005. The survey group consisted of 120 individuals; a total of 72 individuals completed the survey. Survey questions included experiences with using incentives in research with homeless youths, consent and experiences with ethics review boards. Numerical data were analysed using frequencies and cross-tabulations. Text data were analysed qualitatively.Researchers doing mental health and/or substance use research tended to use money as a research incentive, whereas healthcare providers and programme administrators tended to use non-monetary incentives. The majority of respondents reported using written consent for research from homeless youths, including minors. Respondents reporting difficulties with ethics review boards were mainly involved with intervention research.Consensus is needed from a variety of stakeholders, including homeless youths and service providers, on use of various types of research incentives for different types of research, as well as use of consent for homeless youths who are minors.
View details for Web of Science ID 000255138400010
View details for PubMedID 18426461
- Ethical Issues in Research with Homeless Youths. Journal of Advanced Nursing, 2008; 62 (3): 365-72.
- The Relationship Between Homeless Youth and Juvenile Delinquency Journal of Child and Adolescent Social Work 2008; 25 (4)
Major depression among adolescent smokers undergoing treatment for nicotine dependence
2004; 29 (8): 1517-1526
This is the first study to examine the prevalence and effects of major depression (MDD) in a sample of adolescent smokers (N = 211) undergoing treatment for nicotine dependence. We assessed MDD at baseline and end of treatment with the mood disorders portion of the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV). Eleven percent of participants reported a history of MDD (6% of males and 21% of females). Study variables did not distinguish those with and without a history of MDD. End of treatment abstinence rates and relapse rates were similar in both groups. Two participants (1%), both female, experienced onset of MDD during the treatment. The findings provide further evidence that MDD is a comparatively common disorder among children and adolescents and that clinicians should monitor and be prepared to respond to depression that may emerge during the treatment of nicotine-dependent adolescents.
View details for DOI 10.1016/j.addbeh.2004.02.029
View details for Web of Science ID 000224464000002
View details for PubMedID 15451121
Randomized clinical trial of the efficacy of Bupropion combined with nicotine patch in the treatment of adolescent smokers
JOURNAL OF CONSULTING AND CLINICAL PSYCHOLOGY
2004; 72 (4): 729-735
Adolescent smokers (N = 211) were randomized to 1 of 2 groups: (a) nicotine patch plus bupropion SR (sustained release; 150 mg per day) or (b) nicotine patch plus placebo. Group skills training sessions were conducted each week by research staff. Abstinence rates at Weeks 10 and 26 were as follows: (a) patch plus bupropion, 23% and 8%, (b) patch plus placebo, 28% and 7%. Despite the lack of a treatment effect, a large majority of adolescents in both treatment groups reduced their consumption to a few cigarettes per day or less and maintained this reduction over time. Similarly, an examination of survival curves revealed that by the end of treatment many had managed to avoid a return to daily smoking. These findings are encouraging and suggest new avenues for research. For example, treatments of the kind examined in this report, augmented by extended maintenance therapies, may yield higher long-term success rates.
View details for DOI 10.1037/0022-006X.72.4.729
View details for Web of Science ID 000222924600020
View details for PubMedID 15301658
- Medical complications of eating disorders: An update JOURNAL OF ADOLESCENT HEALTH 2003; 33 (6): 418-426
Children and adolescents with eating disorders: The state of the art
2003; 111 (1)
Eating disorders in children and adolescents remain a serious cause of morbidity and mortality in children, adolescents, and young adults. The working knowledge of pathophysiology, recognition, and management of eating disorders continues to evolve as research in this field continues.This article builds on previous background and position papers outlining issues relevant to the care of the adolescent patient with an eating disorder.The eating disorder special interest group from the Society for Adolescent Medicine recognized the need to update the state of the art published guidelines for the care of the adolescent patient with an eating disorder. This article was a multidisciplinary, group effort to summarize the current knowledge of best practice in the field.This article summarizes newer findings on pathogenesis and etiology, prevention and screening, risk factors, nutritional issues, care from the primary care clinician's perspective, appropriate use of a multidisciplinary team, and issues of managed care and reimbursement.Primary prevention combined with early recognition and treatment helps decrease morbidity and mortality in adolescents with eating disorders.
View details for Web of Science ID 000180135200016
View details for PubMedID 12509603
- Children and Adolescents With Eating Disorders: the State of the Art. Pediatrics 2003; 111 (No. 1): e98-108.
- Medical Complications of Eating Disorders: An Update. Journal of Adolescent Health 2003; Volume 33 (No.6): pp. 418-26.
Adolescents with eating disorders - Primary care screening, identification, and early intervention
NURSING CLINICS OF NORTH AMERICA
2002; 37 (3): 537-?
The identification and treatment of eating disorders in adolescents is a challenging and time-consuming commitment. Early identification and treatment requires a multi-disciplinary team of health care professionals and provides an improved prognosis for these complex conditions. Nurses in all levels of practice are in ideal positions to influence early detection through careful screening (identification of risk factors, patient history, and physical exam), close follow-up, and prompt specialty referral with disease progression.
View details for Web of Science ID 000177752300014
View details for PubMedID 12449011
Do adolescent smokers experience withdrawal effects when deprived of nicotine?
EXPERIMENTAL AND CLINICAL PSYCHOPHARMACOLOGY
2001; 9 (2): 176-182
This is the first controlled prospective study of the effects of nicotine deprivation in adolescent smokers. Heart rate and subjective withdrawal symptoms were measured over an 8-hr period while participants smoked normally. Seven days later, participants were randomized to wear a 15-mg (16-hr) nicotine patch or a placebo patch for 8 hr, and they refrained from smoking during the session. Those wearing the placebo experienced a decrease in heart rate across sessions and an increase in subjective measures of nicotine withdrawal. Those wearing the active patch also reported significant increases for some subjective symptoms. Expectancy effects were also observed. The findings indicate that adolescent smokers experience subjective and objective changes when deprived of nicotine. As in previous research with adults, expectancies concerning the effects of nicotine replacement also influenced perceptions of withdrawal.
View details for Web of Science ID 000170981800009
View details for PubMedID 11518093
Epidemiology of herpes simplex virus type 2 infections in a high-risk adolescent population
JOURNAL OF ADOLESCENT HEALTH
1996; 18 (6): 384-386
The seroprevalence of infection with type 2 herpes simplex virus (HSV-2) was determined in 135 adolescents detained in a juvenile detention facility. A total of 16% of enrollees were seropositive for HSV-2. Age of onset of sexual intercourse, number of lifetime partners, frequency of condom use, and history of sexually transmitted diseases did not predict HSV-2 seropositivity.
View details for Web of Science ID A1996UT29800003
View details for PubMedID 8803729
- Unique Considerations for Treating Eating Disorders in Adolescents and Prevention Intervention. Topics in Clinical Nutrition 1996; 12 (1): 79-85.
NEIGHBORHOOD-BASED TOBACCO ADVERTISING TARGETING ADOLESCENTS
WESTERN JOURNAL OF MEDICINE
1995; 162 (6): 514-518
Adolescent tobacco use remains a serious problem, and adolescents may be particularly receptive to the glamorous images tobacco companies use in advertisements. A relatively new form of neighborhood-based outdoor advertising, the illuminated bus-stop-shelter billboard, was studied to determine tobacco companies' use of this medium. We hypothesized that in 2 distinct San Francisco, California, neighborhoods, 1 predominantly white and the other mostly Latino, we would find a predominance of tobacco advertising on these billboards in both neighborhoods, that tobacco advertisements would be more prevalent in the minority Latino neighborhood, and that tobacco advertising would target adolescents in both neighborhoods. Each bus-stop-shelter billboard advertisement in the study areas from April 1992 to March 1993 was recorded. The type and frequency of products advertised and qualitative content of tobacco advertisements were analyzed. Adolescents' possible exposure to these advertisements was noted. Our main outcome measures were the percentage of tobacco advertising, possible adolescent exposure to this advertising, and themes of the tobacco advertisements. About 10% of all bus-stop-shelter billboard advertisements in each area promoted tobacco use. Possible exposures to these advertisements were greater in the Latino neighborhood because of a greater adolescent population. Qualitative analyses of tobacco advertisements suggested that adolescents are the primary targets. We urge physicians and educators to explicitly address this form of tobacco advertising, and we urge a ban on neighborhood-based tobacco advertising.
View details for Web of Science ID A1995RD94400004
View details for PubMedID 7618311
View details for PubMedCentralID PMC1022829
- EATING DISORDERS IN ADOLESCENTS - A POSITION PAPER OF THE SOCIETY FOR ADOLESCENT MEDICINE JOURNAL OF ADOLESCENT HEALTH 1995; 16 (6): 476-480
- EATING DISORDERS IN ADOLESCENTS - A BACKGROUND PAPER JOURNAL OF ADOLESCENT HEALTH 1995; 16 (6): 420-437
- THE USE OF NORPLANT AND DEPO-PROVERA IN ADOLESCENTS JOURNAL OF ADOLESCENT HEALTH 1995; 16 (5): 343-346
- ANOREXIA-NERVOSA PRESENTING AS A PERIPHERAL VASCULOPATHY IN AN ADOLESCENT MALE JOURNAL OF RHEUMATOLOGY 1995; 22 (3): 544-547
DO ADOLESCENTS UNDERSTAND WHAT PHYSICIANS SAY ABOUT SEXUALITY AND HEALTH
1992; 31 (10): 590-595
The high rates of adolescent sexual activity, often with adverse medical and social outcomes among minority females, prompted us to survey 160 girls between the ages of 13 and 18 concerning their knowledge of reproductive health terms, anatomy, and body functions. All were patients in a clinic in an inner-city hospital. We hypothesized that adolescents who were older, sexually active, and/or had received formal sex education would be better informed. We used a two-part, self-administered questionnaire. The first part focused on definitions of nine common medical and reproductive health terms; the second focused on definitions of unlabeled anatomic drawings of male and female genitourinary systems. The subjects' responses revealed their lack of information as well as a great deal of misinformation. No statistical differences in knowledge were found related to age, sexual activity status, or formal sex education. Many patients knew only nontechnical and slang terms and did not understand medical terms used by physicians in the clinic. Clinicians should not assume similar patients (minority and poor) know or understand their terminology and should use simple and, if necessary, explicit vocabulary.
View details for Web of Science ID A1992JU45500003
View details for PubMedID 1395365
ECTOPIC PREGNANCY IN ADOLESCENTS - A CLINICAL REVIEW FOR PEDIATRICIANS
JOURNAL OF PEDIATRICS
1990; 117 (5): 677-686
Pediatricians caring for sexually active female adolescents and young adults need to be aware of the history, symptoms, and signs of an ectopic pregnancy. A thorough history and physical examination, including the pelvic examination, as well as specific diagnostic tests such as repeated quantitative hCG measurements, and ultrasonography when indicated, are crucial to proper and early diagnosis of a nonruptured ectopic pregnancy manageable by laparoscopy. The key to early diagnosis is to include ectopic pregnancy in the differential diagnosis in any sexually active female patient who has abnormal vaginal bleeding or abdominal pain. With early diagnosis, close observation, and appropriate management, the outcome is more likely to be favorable, with minimal morbidity and risk of death.
View details for Web of Science ID A1990EH43900001
View details for PubMedID 2231199
TYMPANOSTOMY TUBE COMPLICATIONS AND EFFICACY IN CHILDREN OF A RURAL-COMMUNITY
WESTERN JOURNAL OF MEDICINE
1986; 144 (3): 318-320
In the pediatric group practice and the otolaryngologic practice of our rural community, 41 patients were seen in 1984 with 49 episodes of suppurative discharge after tympanostomy tube insertion. Streptococcus pneumoniae was the most common organism after upper respiratory tract infection. Staphylococcus or enteric organisms were most frequently encountered after bathing or swimming. Most patients regained hearing within normal limits. The benefits of tympanostomy tubes in terms of good hearing and reduced incidence of suppurative otitis media outweigh the risk of transitory suppuration for most patients.
View details for Web of Science ID A1986A480200005
View details for PubMedID 3962295
- DIAGNOSTIC UNCERTAINTY IN ATYPICAL KAWASAKI DISEASE, AND A NEW FINDING - EXUDATIVE CONJUNCTIVITIS PEDIATRIC INFECTIOUS DISEASE JOURNAL 1985; 4 (2): 210-211