Chapter 16: School-Age & Adolescent Health Problems

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Welcome back to the Deep Dive.

We are back with another one of our Last Minute lecture installments.

We are!

And today we have a pretty massive mission ahead of us.

We are tackling Chapter 16 of Wang's Essentials of Pediatric Nursing, the 11th edition.

That is correct.

Yeah, we're leaving the, you know, the toddler years behind and stepping squarely into the really complex world of health problems of school -aged children and adolescents.

And just glancing at the source material, I mean, the scope here is,

well, it's huge.

We're not just checking growth charts and immunizations anymore.

Not at all.

We're talking about everything from bedwetting and acne to really, really heavy complex issues like suicide, eating disorders, and sexual assault.

It really is a pivotal shift in pediatric nursing.

I mean, when you're dealing with school -aged kids and teens, the focus moves from, you know, basic survival and physical growth to these really complex physiological and psychological deviations.

So the nurse's role has to change too.

It completely transforms.

Yeah, you have to be part detective, part counselor, and part clinician.

You're dealing with sensitive communication, privacy issues, family dynamics that are often strained by these very problems.

Feels like the stakes are just so much higher.

The problems aren't just ouchies anymore.

They're identity -defining issues for these kids.

Absolutely.

So our goal today is to give you, the learner, that audio shortcut to this chapter.

We're going to break it down system by system, just like the text does, but we really want to focus on the clinical application.

Why is this matter for practice and what are the specific red flags we need to catch?

And we have a lot of ground to cover.

We'll start with elimination disorders, which are way more common than people think, then move into a massive section on behavioral and mental health, touch on dermatology, reproductive health, and finally, we'll wrap up with nutrition and eating disorders.

Let's just get right into it then.

Section one covers something that I think causes a lot of silent stress in households.

Elimination disorders,

specifically enuresis and encopresis.

Let's start with enuresis, which is just the clinical term for bedwetting.

Now, the text is very specific about the criteria here because you really need to distinguish a medical issue from just, you know, normal development.

Right.

We're not talking about a three -year -old having an accident.

Exactly.

To be diagnosed with enuresis, the child has to be at least five years old.

And it's not just a one -off event, is it?

There's a frequency criteria.

Yes.

It has to be repeated urination into the bed or clothing at least twice a week for at least three months.

And once you establish that, you have to classify it.

You have monosymptomatic enuresis, which is, well, it's just the bedwetting and nothing else.

Then you have non -monosymptomatic, which is a bit more complex.

That includes other symptoms like urgency, frequency, or even daytime incontinence.

And I remember reading about primary versus secondary classifications.

That distinction seems really vital for a nurse taking a patient history because it points you toward totally different causes.

Oh, it's critical.

Primary enuresis just means the child has never been dry for an extended period.

They just haven't mastered nighttime bladder control yet.

Okay.

So that's more developmental.

Right.

But secondary enuresis is the one that really makes our ears perk up.

This is when a child established continence, they were dry for months, maybe years, and then they suddenly started wetting the bed again.

Which is always a red flag.

When I see secondary enuresis, my mind immediately goes to what changed?

Is it a UTI?

Is it new onset diabetes?

Is it stress or some kind of trauma?

You're spot on.

You have to rule out physical causes first.

Before we even talk about behavior, we check for structural disorders, urinary tract infections, neurologic deficits, and you mentioned diabetes polyuria.

That increased urine output is a classic sign of type 1 diabetes.

So no jumping to conclusions.

Never.

We need a clean medical workup before we go any further.

Now there was a formula in the text that I thought was super handy for assessing if a child's bladder is even anatomically large enough to hold a night's worth of urine, the functional bladder capacity calculation.

It's a great clinical nugget.

The formula is just the child's age plus two equals their capacity in ounces.

Simple enough.

So if you have a six -year -old patient, six plus two is eight.

Their bladder capacity is roughly eight ounces.

And the text notes that what 10 to 12 ounces is usually required to hold a full night's urine production.

Exactly.

So our six -year -old only has an eight ounce capacity.

They're physically set up to fail if they sleep through the night.

Precisely.

And just explaining that to parents is a huge part of the nursing intervention.

It helps frame the problem as physiological.

His tank is just too small rather than, you know, he's being lazy or it's willful misbehavior.

That's a huge shift in perspective.

So if the anatomy is normal, but the bed -wetting persists, how do we treat it?

I know the text mentioned alarms, which I admit sounded a bit old school.

Old school, but effective.

Bed -wetting alarms are actually considered first -line therapy.

They use a little sensor that detects moisture and immediately sets off an alarm to wake the child.

So it's a conditioning thing.

It's all based on conditioning.

We're trying to teach the brain to respond to the sensation of a full before the wedding happens.

But, and this is a big warning for parents, it requires immense patience.

Why is the dropout rate so high?

Because it just disrupts everyone's sleep.

I mean, the alarm goes off, the kid wakes up, the parents wake up, you have to change all the sheets.

It can take weeks or even months to condition the brain.

Families often just get so tired of the interrupted sleep and they quit before it can work.

So if the alarm fails or the family just can't handle the sleep deprivation, then we turn to pharmacology.

What's the go -to drug?

The most common one is desmopressin, often called DDAVP.

It's a synthetic analog of vasopressin.

The antidiuretic hormone.

Exactly.

It tells the kidneys to hold onto water.

So essentially DDAVP tells the kidneys to produce less urine overnight and it works fast, often, immediately.

That sounds like a miracle cure, but I'm assuming there's a catch.

The catch is a very high relapse rate.

It treats the symptom, not the underlying cause.

Once you stop the medication, the bedwetting very often comes right back.

I also saw imipramine listed as a second -line drug, but it came with a whole laundry list of warnings.

Yes, Tofrenil.

It's a tricyclic antidepressant.

We don't really use it for depression much anymore, but it has these anticholinergic effects that help with bladder retention.

However, it carries a real risk of cardiac side effects, specifically arrhythmias, and it is very, very dangerous in overdose.

So we generally avoid it unless it's absolutely necessary.

So at the end of the day, what's the most important nursing intervention?

Parental reassurance.

Bar none.

We have to tell them.

Do not punish the child.

Scolding and shaming only increase their anxiety and make the problem worse.

Okay, let's move to the other side of elimination and coprasis.

This is the repeated passage of stool into inappropriate places.

Right.

The criteria here is a child older than four and it's happening at least once a month for three months and almost always this is tied to constipation.

This is where we get into that vicious cycle the text describes.

I think this is so counterintuitive for a lot of people.

It starts with a painful bowel movement, right?

It does.

A child has a hard, painful stool.

Maybe they were dehydrated, maybe it's diet related, it hurts.

So what do they do?

They decide, I'm not doing that again.

And they start to withhold their stool.

They tighten up the sphincter.

And the stool just sits there.

It sits in the colon, the body reabsorbs water from it, and it just becomes harder, larger, and even more painful to pass.

And as it sits there, the rectum physically stretches out.

Exactly.

The rectum is a muscular tube.

It stretches and the nerves in the rectal wall lose that sensation of, I need to go.

The child literally stops feeling the urge to defecate.

So then what happens?

Eventually, liquid stool from higher up in the colon leaks around that hard impacted mass.

So parents see soiled underwear, they see liquid, and they think the child has diarrhea.

That is such a key distinction.

If you treat it like diarrhea giving anti -diarrheals, you'll make the impaction so much worse.

You're just sealing the blockage in.

You're just making a bigger problem.

You have to treat the impaction first.

So management starts with the clean out.

We use enemas or strong laxatives like polyethylene, glycol, Miralex to clear that blockage.

And after they're cleared out.

Then we move to maintenance.

Dietary fiber, hydration,

and crucially bowel retraining.

The nursing intervention for bowel retraining seemed really practical.

It wasn't just go to the bathroom more.

No, it's all about physiology.

You instruct the family to establish a routine where the child sits on the toilet for 10 to 15 minutes after meals.

Why after meals?

It takes advantage of the gastrocolic reflex.

When the stomach fills, the colon naturally wants to empty and you give them a foot stool.

Being stable with their knees higher than their hips helps relax the pelvic floor muscles.

Again, positive reinforcement.

Always stickers for sitting and trying, not just for success.

Stickers, not shame.

I like that.

Let's pivot now to section two.

Behavioral and neurodevelopmental disorders.

We have to talk about ADHD.

Attention deficit hyperactivity disorder.

Yes, this is one of the most common neurodevelopmental conditions we see.

It refers to degrees of inattention, impulsiveness, and hyperactivity that are developmentally inappropriate.

That phrase, developmentally inappropriate, seems to be doing a lot of heavy lifting there.

It is the key.

All six -year -olds are hyper sometimes.

All teenagers are impulsive.

ADHD is diagnosed when these behaviors actually interfere with social and academic functioning.

It's affecting their grades, their friendships, their home life.

And the diagnosis isn't just a quick blood test.

Oh, no.

It's a multidisciplinary evaluation.

We need reports from parents, from teachers, from clinicians.

We're looking for consistency across different settings.

A child who is hyper at home, but a perfect angel at school, usually doesn't have ADHD.

There might be something else going on.

Once diagnosed, we often look at pharmacologic therapy.

The stimulants, which always seems so paradoxical to parents giving a stimulant to a hyperactive child.

How do you explain that?

It does sound completely backward,

but drugs like methylphenidate Ritalin or Lisdex amphetamine, they work by stimulating specific areas of the brain, particularly the frontal lobes, which are responsible for inhibition and focus.

So they stimulate the brakes.

That's a great way to put it.

They stimulate the brakes, essentially.

They help the child filter out all the distractions so they can focus on one thing.

But like any medication, they come with side effects that nurses really need to monitor.

The big ones are appetite loss and sleep disturbances.

These drugs can absolutely kill a kid's appetite, which over time can affect their growth velocity.

And then there's also the risk of abdominal pain and headaches.

The text had that critical thinking case study about a boy named Johnny that illustrated this perfectly.

He was doing better in math.

He was making friends.

The meds were working, but he completely stopped eating his lunch.

Right.

That is a classic scenario.

The clinical reasoning there is that the medication is peaking right around lunchtime and it's suppressing his hunger signals.

So what do you do?

The nursing intervention isn't to stop the med but to adjust the routine.

We advise giving the medication with or immediately after breakfast.

And then we emphasize nutritious high -calorie snacks in the evening when the medication starts to wear off and the appetite returns.

You have to work around the side effects.

And there's a quality indicator mentioned, Table 16 .1.

We can't just prescribe and say, good luck.

No, absolutely not.

The standard of care is very strict follow -up.

Children prescribed these meds need a visit within 30 days and at least two more visits within the first nine months.

We have to monitor their blood pressure, their height, and their weight to make sure they're growing safely.

Let's touch on PTSD quickly.

I think we often assume this is only for adults or, you know, combat veterans.

But the text highlights it in school -age children.

Children are very vulnerable to trauma.

And in kids, the response often comes in phases.

The first phase is that intense arousal fight or flight.

Then about two weeks later, you might see the second phase, defense mechanisms.

The child might just seem numb or in denial.

Which might look like they're over it to an untrained observer.

Correct.

And that's the danger zone where things can get buried.

Then hopefully they move to the third phase, which is coping and conscious processing.

Our role as nurses is to facilitate play and expression to help them process that stress.

If those phases are prolonged or if they seem stuck, we need a professional referral.

Speaking of anxiety, there's a specific condition called school phobia.

This isn't just a kid playing hooky or faking a cold.

No, this is a genuine anxiety reaction.

We see sudden somatic symptoms, vomiting, headache, severe abdominal pain that happens specifically on school mornings.

It's Monday morning, tummy hurts.

Saturday morning, totally fine.

Exactly.

The physical pain is real, but the cause is anxiety.

And the management might surprise some people.

The primary goal is school attendance.

We need to get them back to school immediately.

That feels a little harsh.

Why not let them stay home until they feel better?

Because the longer they stay home, the harder the reentry becomes.

Staying home reinforces the avoidance behavior.

It actually validates the anxiety.

We might use a reentry protocol, like starting with half days, but we do not validate the avoidance.

We have to break that cycle.

That's tough love, but it makes sense.

Moving into section three,

the mental health crisis.

This is heavy.

Depression, suicide, and substance abuse.

Childhood depression is really tricky because it often doesn't look like adult sadness.

In adults, we look for a low mood.

In kids, it often presents as irritability, withdrawal, solitary play, or again, those somatic complaints, stomach aches, sleeping issues.

The text mentions a black box warning for the medications used to treat this.

Yes, for SSRIs, there is an increased risk of suicidal ideation, especially in the first two to four weeks of treatment.

So just like with ADHD, monitoring is non -negotiable.

We cannot just give them a script and see them in six months.

Which leads us directly to suicide.

A very heavy topic, but the text gives us a very specific assessment tool, the SLAP mnemonic.

Can you break that down for us?

This is a tool every single nurse needs to memorize.

It assesses immediate risk.

So S is for specificity.

Do they have a specific plan?

Saying I wanna die is very different than saying I am gonna take all of my mom's pills tonight.

Okay, S for specificity, what's L?

L is for lethality.

Is the method they chose deadly.

A firearm is more lethal than taking 10 aspirin.

Right, an A.

A is for accessibility.

Do they have access to the means?

Is the gun in the house?

Are the pills in the medicine cabinet?

And finally, P?

P is for proximity.

When do they plan to do it?

Is it tonight or just someday?

That is so clear.

So if you have a specific lethal plan with access and the proximity is tonight, that is a code red emergency.

It requires immediate intervention, yes.

And there's a specific nursing alert in the text that honestly gave me chills.

It says to watch out for a sudden lift in mood.

If a deeply depressed teen suddenly becomes energetic and happy, do not assume they are cured.

Why not?

Because it might mean they've made the decision to end their life.

The decision itself brings a sense of relief and resolution.

The internal conflict is over.

So you must take all threats and all sudden changes very seriously.

What about substance abuse?

It feels like the landscape here changes every few years.

It really does.

We still see alcohol and tobacco, of course, but vaping is the new giant in the room and opioids.

For the nurse, there are really two lanes, acute care and prevention.

In acute toxicity, the priority is always respiratory support, especially with opioids or CNS depressants.

But prevention is where we can do the most good by identifying risk factors like peer pressure or family history.

Let's shift gears to section four, dermatology,

specifically acne vulgaris.

And before anyone rolls their eyes, the text makes it very clear.

This is not just a skin thing.

Not at all.

It's the most common skin problem in adolescence and the psychosocial impact is massive.

It affects body image, self -esteem, social interaction.

We cannot minimize it.

So what's actually happening under the skin to cause it?

It's a combination of a few things.

You have follicular hyperkeratosis.

So the hair follicle gets plugged with dead skin cells.

Then you have excess sebum or oil production.

And finally, the bacteria P -acnes.

And figure 16 .1 in the text shows the difference between open and closed comedones.

Right.

An open comedone is a blackhead.

It's open to the air.

So the melanin oxidizes and turns black.

It is not dirt.

Scrubbing it won't wash the black away.

A closed comedone is a whitehead.

And then, of course, you have the inflammatory pustules.

So let's walk through the therapeutic ladder.

Where do we start with treatment?

General care first.

Gentle cleansing.

The text specifically says do not scrub.

Scrubbing just damages the ductal walls and can spread the inflammation under the skin, making it worse.

OK.

So no scrubbing.

Then what?

Topicals.

Yes.

Usually retinoids like cretinoin or retin -a.

These normalized keratinization, they basically keep the follicles open so they don't plug up.

And the patient education here is critical.

Vital.

You have to tell them.

Apply it at night because it causes photosensitivity.

You will get sunburned very easily.

And use a pea -sized amount.

More is not better.

It just irritates the skin.

And if that doesn't work, we add systemic antibiotics like doxycycline.

But for the severe cystic acne, we bring out the heavy hitter.

Isotretinoin or Accutane.

This is a powerful, powerful drug.

It inhibits sebum production very effectively.

But the side effect profile is serious.

The biggest concern is that it is highly teratogenic.

Meaning it causes severe birth defects.

Severe birth defects, yes.

The nursing priority here is huge for female patients.

But what does that involve?

There's a program called IPL Beach.

Female patients must be on two forms of birth control.

They have to sign a pledge that they will not get pregnant.

We also have to monitor for depression and suicidal ideation linking back to our previous topic.

And we check cholesterol and triglycerides because the drug can elevate blood fats.

It's a very serious commitment.

Okay, moving on to reproductive health.

Let's split this by biological sex, starting with the males in section five.

The big emergency here is testicular torsion.

This is when the spermatic cord twists on itself, cutting off the blood supply to the testicle.

Time is testicle, as they say.

What are the signs?

Sudden severe scrotal pain.

Nausea and vomiting are very common because the pain is so visceral.

And on exam, the testicle will be in a high and horizontal position because the cord has shortened as it twisted.

Any other signs?

Yes.

The chromastoric reflex where the testicle pulls up when you stroke the inner thigh will be absent.

And the intervention?

Surgery, immediately.

There is a very, very short window of opportunity, usually less than six hours.

TM twisted and saved the organ.

On the flip side, there's a condition that's benign but causes a ton of anxiety, gynecomastia.

Right, breast enlargement in boys.

It happens to about 50 % of boys during puberty.

And it's usually transient, lasting less than a year.

So the nurse's role is mostly reassurance.

Mostly reassurance.

Let them know they aren't turning into a girl.

It's just a normal hormonal fluctuation.

But if it persists, we do have to rule out things like tumors or anabolic steroid use.

I saw a brief mention of varicosalat, too.

Yes, the bag of worms feeling in the scrotum.

It's an enlargement of the veins.

It's important to note because it can cause infertility later in life due to the increased temperature in the test dice.

Now for female reproductive health in section six.

Specifically, amenorrhea.

The absence of menses.

We distinguish between primary, so no period by age 14 without secondary sexual characteristics or by 16 even with them.

And secondary, which is when periods stop after they've already been established.

And the number one cause of secondary amenorrhea.

Pregnancy, always.

Even if the patient denies sexual activity, you must rule out pregnancy first.

And other causes.

Oh, stress, polycystic ovary syndrome or PCOS or what we call the female athlete triad.

That combination of excessive exercise and low body weight that causes the body to just shut down reproduction to save energy.

Then there's dysmenorrhea.

Painful menses.

I feel like this is so often dismissed, but for many teens, it's truly debilitating.

It is.

And primary dysmenorrhea has a biochemical basis.

It's caused by prostaglandins.

These are chemicals that cause the uterus to contract to shed its lining.

Too many prostaglandins means severe cramps.

And that explains the treatment.

Exactly.

That's why NSAIDs, like ibuprofen, are the first line treatment.

They are prostaglandin inhibitors.

They work better than Tylenol here because they target the actual mechanism of the pain.

We also recommend heat and regular exercise.

And it's crucial to distinguish that from vaginal infections, right?

Yes.

Adolescents often have something called physiologic lucaria.

A clear or whitish discharge that is totally normal.

But if it has a foul odor, causes itching, or is colored, then we need to investigate for infection.

Which segues perfectly into section 7, sexual health and STIs.

The text covers the major players.

Chlamydia, gonorrhea, HPV.

Chlamydia is the most common.

And the scary part is that it is often asymptomatic, especially in females.

A girl can have it and feel totally fine.

But it's not fine.

It's not fine at all.

If left untreated, it can ascend the reproductive track and cause pelvic inflammatory disease, or PID.

And PID isn't just a temporary infection.

No, it causes scarring in the fallopian tubes.

This is a major cause of infertility and ectopic pregnancies later in life.

That's why the standard of care is to screen all sexual active females under the age of 25.

The goal is prevention of future heartache.

And gonorrhea often tags along with chlamydia.

The clap, yes.

Co -infection is very common.

So if we find one, we often treat for both just to be safe.

Then there's HPV.

And we have a vaccine for this now.

The human papillomavirus.

It can cause genital warts, but much more importantly, it causes cervical cancer.

The vaccine is recommended at age 11 or 12.

And parents sometimes push back on that age saying, my kid isn't having sex.

Which is exactly why we vaccinate them then.

The goal is to vaccinate before sexual debut.

It's a cancer prevention vaccine.

It works best if the immune system is primed before it ever encounters the virus.

We also need to touch on adolescent pregnancy.

The text highlights the risks, not just socially, but physically.

Physically, the adolescent pelvis might not be fully grown.

This can lead to something called cephalopelvic disproportion.

Basically, the baby's head won't fit through the birth canal.

That's a huge risk.

It is.

There's also a higher risk for PIH pregnancy -induced hypertension or preeclampsia.

And nutrition is critical here because you have a growing fetus competing with a growing mother for nutrients.

It's a metabolic tug of war.

The final part of this section is sexual violence.

The text mentions the SANE nurse.

The sexual assault nurse examiner.

This is a highly specialized role.

If a teen comes in reporting an assault, the nursing priorities are very, very specific.

And the most difficult instruction to give is do not let them bathe, shower, or change their clothes.

That sounds incredibly hard.

The first instinct is to want to wash it all away.

It is.

But washing destroys the DNA evidence.

We have to preserve that.

The SANE nurse performs the exam, collects the evidence, does testing for STIs, and offers prophylactic antibiotics and emergency contraception.

But the emotional support being completely non -judgmental that's the foundation of all of that care.

Right.

Final stretch.

Section 8.

Nutrition and eating disorders.

Let's start with obesity.

The text uses BMI as the standard.

Overweight is the 85th to 95th percentile.

Obese is anything over the 95th percentile for their age and sex.

And the goal for treatment in kids?

Surprise me.

It's not necessarily lose 20 pounds.

Right.

For growing kids, the goal is often weight maintenance.

If they can just stay the same weight while they grow two inches taller, their BMI will naturally drop.

We don't want strict calorie restriction that could stunt their growth.

So it's about lifestyle change.

It's about family -wide change.

Box 16 .5 gives a great protocol for this.

Assess, set an agenda, assess motivation, summarize, and follow up.

It focuses on behaviors, not just numbers on a scale.

And it mentions comorbidities, too.

Yes.

Type 2 diabetes, hypertension, sleep apnea, fatty liver disease.

These used to be considered adult diseases, but now we're seeing them in teenagers all the time.

But on the complete other end of the spectrum, we have anorexia nervosa and bulimia nervosa.

Anorexia is characterized by a refusal to maintain a healthy weight, severe restriction, and a very distorted body image.

It's often about control.

Bulimia involves binging, followed by some kind of compensatory mechanism purging, laxatives, or excessive exercise.

It's often more chaotic.

And there's a screening tool mentioned.

The Esquiel of Questionnaire.

Yes.

It's a really quick way to flag potential issues.

So, S, do you make yourself sick because you feel uncomfortably full?

C, do you feel you've lost control over how much you eat?

Okay, S, C.

Have you lost one stone, which is about 14 pounds in a three -month period?

F, do you believe you are fat when others say you are too thin?

And finally, F, does food dominate your life?

And two or more yes answers is a major red flag.

A very strong indicator of a likely eating disorder, yes.

And physically, what are we looking for in a patient with anorexia?

The body is essentially slowing down to survive.

So you see bradycardia, a slow heart rate, hypotension, and hypothermia.

You might see lanugo, that fine downy hair growing on their back and arms to try and keep the body warm because they've lost their insulating fat.

And for bulimia.

Look for the Russell sign calluses on the knuckles from where their teeth have been rubbing against the hand during induced vomiting.

There is one massive nursing alert here regarding treatment.

Re -feeding syndrome.

This sounds so contradictory that eating again could actually be dangerous.

This is a life or death concept.

When a severely malnourished patient starts eating again, their insulin spikes.

This drives electrolytes, specifically phosphorus, out of the blood and into the cells.

So their blood levels of phosphorus just plummet.

They plummet.

And phosphorus is required for energy production for ATP.

Without it, you get muscle weakness, seizures, and cardiovascular collapse.

So you can't just give them a cheeseburger and cheer?

Absolutely not.

You have to re -feed very slowly and monitor their electrolytes, especially phosphorus, constantly.

It's a very delicate medical process, not just a dietary one.

Wow.

Okay.

That brings us to the end of chapter 16.

That was a marathon.

It really was.

But if you think about the trajectory, we've covered the things that really define the adolescent experience.

The awkwardness of puberty, the pressure of school and peers, the awakening of sexuality, and that struggle for identity and control.

So if we had to sum it up for the learner, what's the big takeaway?

The nurse dealing with this age group has to be an investigator.

You're looking for the hidden depression behind the stomach ache.

You're looking for the eating disorder behind the healthy eating kick.

You're looking for the abuse behind the silence.

And you're an educator, teaching them that acne isn't dirty, that periods shouldn't be agony, and that asking for help is brave.

Exactly.

You are the safe harbor in a really stormy time of life.

Here's a final thought to leave you with.

We talked about how ADHD meds can suppress appetite and how anorexia is a battle for control.

Think about how those two might overlap.

If you have a teen with ADHD who is being treated with stimulants and they start losing a lot of weight,

is it just the side effect?

Or have they discovered that their medication helps them achieve an anorexic goal?

Where is that line between side effect and abuse?

Something to mull over?

That is a fascinating and frankly disturbing connection.

Always, always dig deeper.

Thanks for diving deep with us.

Good luck with your studies from the last minute lecture team.

See you next time.