Adolescent Development and Health 471can represent underlying disease or abnormalities, or consti-
tutional delay, but it can also result from drug use (e.g.,
heroin), stress, weight loss (e.g., with anorexia), or intense
exercise. Serious female athletes have substantially higher
rates of amenorrhea„up to 18% of recreational runners, 50%
of competitive runners, and 79% of ballet dancers (note that
dancers both diet and exercise strenuously). Among predis-
posing factors are training intensity, weight loss, changes in
percentage of body fat, and younger age of onset of intense
training (Neinstein, 1996b).
Amenorrhea is of concern primarily because loss in bone
mineral density (BMD) can begin soon after amenorrhea de-
velops. For example, female athletes have low levels of es-
trogen and thus are at higher risk for osteoporosis and stress
fractures (Neinstein, 1996b). The vast majority of bone min-
eralization in adolescent girls is completed by age 15 to 16,
and loss of bone density can have signi“cant long-term con-
sequences. For example, most adolescents who recover from
anorexia nervosa before age 15 can have normal total body
BMD, but regional BMD (lumbar spine and femoral neck)
may remain low; the longer the weight loss persists, the less
likely it is that BMD will return to normal (Hergenroeder,
1995).
Amenorrhea is usually reversible with weight gain or, for
athletes, lessening the intensity of exercise. At a minimum,
amenorrheic girls should be treated with increased calcium
intake and lifestyle intervention. There is substantial contro-
versy regarding the use of hormone-replacement therapy,
which is generally considered for girls who do not gain
weight or reduce activity after six months. Who should be
treated and the extent of bene“t for BMD are questions that
remain unresolved (Neinstein, 1996b). The optimal interven-
tion would be behavioral rather than medical. This physical
disorder is both prompted by attitudes and behavior, and
treatable by changes in attitudes and behavior. However,
while intervention with eating disorders has been studied ex-
tensively, there has been no systematic study of intervention
with athletes, despite awareness that athletes are more likely
to engage in various health risk behaviors than are non-
athletes (Patel & Luckshead, 2000) and that competitive
female athletes are at particular risk for loss of bone density.
Short statureis considered present when a child falls
below the third percentile (Neinstein & Kaufman, 1996) or
the “fth percentile (Delamater & Eidson, 1998) on the nor-
mal growth chart. Most instances represent normal variants,
re”ecting familial short stature and/or constitutional growth
delay, while some cases are due to underlying pathology. A
variety of behavioral and psychological problems has been
reported for children and adolescents with short stature
(Delamater & Eidson, 1998); not surprisingly, the effects of
stature are more evident in adolescence than in childhood.
For example, a longitudinal study of 47 children with short
stature (Holmes, Karlsson, & Thompson, 1985) reported
an age-related decline in social competence that began in
early adolescence; this appeared to be related to fewer friend-
ships and social contacts. Allen, Warzak, Greger, Bernotas,
and Huseman (1993) found increased behavior problems and
decreased competence, compared with nonclinical norms,
only for older children (age 12 and above); measures of per-
sonality, self-concept, anxiety, and social competence corre-
lated signi“cantly with the magnitude of the discrepancy in
height, compared with normal peers. Sandberg, Brook, and
Campos (1994) reported parent ratings of social competence
and behavioral and emotional problems: Compared with both
nonclinical norms and with girls of short stature, boys were
less socially competent and evidenced more behavioral and
emotional problems (particularly with regard to internalizing
disorders). In the same study, boys• self-report indicated
lower social competence and decreased self-concept in ath-
letic and job competence; this was particularly evident for
older boys. A study of 311 children and adolescents with
short stature resulting from four different disorders and a “fth
group representing normal variation (Steinhausen, Dorr,
Kannenberg, & Malin, 2000) reported that behavioral prob-
lems were a function of short stature per se, with no signi“-
cant differences found for diagnostic category.
Just as short stature is particularly problematic for boys,
concern about excessive growth ortall statureappears to be
most evident for girls. The differential diagnosis includes
familial tall stature, excess growth hormone, anabolic steroid
excess, hyperthyroidism, and various pathological syn-
dromes. When there are no abnormal causes for tall stature, the
decision regarding medical treatment is dependent on the pa-
tient•s (and family•s) perception of what height is •excessive.Ž
Treatment with estrogen will slow the rate of growth until
skeletal growth (epiphyseal fusion) is completed and hormone
supplements can be discontinued. Treatment is currently
begun later than was previously recommended (Neinstein &
Kaufman, 1996); intervention is delayed until a girl is at least
age 9 or 10, puberty has begun, and she is at 5.5 feet tall.
Side effects of hormonal treatment of girls appear to be
mild and no adverse long-term consequences have been re-
ported. Because boys are rarely treated for tall stature, only
one study (Zachman, Ferrandez, & Muurse, 1976) has re-
ported the effects of treatment with testosterone. Side effects
appeared more signi“cant than those for girls, including
weight gain, acne, edema, and decreased testicular volume; all
appeared to resolve after therapy ended. There are no reports
of psychosocial effects of excessive stature either for male or
female adolescents.