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Adolescence and human development

Greydanus, Donald E, MD,Dr H.C. (2012). Adolescence and human development. International Journal of Child and Adolescent Health, 5(2), 95-117. Retrieved from https://search.proquest.com/docview /1726666418?accountid = 12381

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Abstract

Adolescence is the life-changing phase of human existence that begins as childhood ends and itself is finalized

by the onset of adulthood. This chapter sets the stage for the rest of this book by providing an overview of

adolescence that includes a review of normal psychosocial stages, adolescent sexual maturity stages, concepts

of sexuality, overview of health status of adolescents, and principles of caring for adolescents. Clinicians

privileged with the responsibility of caring for youth should serve as advisors of prevention and as committed

counselors to guide this precious cargo into the often turbulent times of adulthood. Youth of the second decade

of the 21st century will be responsible for caring for the world well into this and perhaps the next century. This

book is dedicated to these future ambassadors as they embark on this critical journey.

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Headnote

Abstract

Adolescence is the life-changing phase of human existence that begins as childhood ends and itself is finalized

by the onset of adulthood. This chapter sets the stage for the rest of this book by providing an overview of

adolescence that includes a review of normal psychosocial stages, adolescent sexual maturity stages, concepts

of sexuality, overview of health status of adolescents, and principles of caring for adolescents. Clinicians

privileged with the responsibility of caring for youth should serve as advisors of prevention and as committed

counselors to guide this precious cargo into the often turbulent times of adulthood. Youth of the second decade

of the 21st century will be responsible for caring for the world well into this and perhaps the next century. This

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book is dedicated to these future ambassadors as they embark on this critical journey.

Keywords: Adoiescence, human deveiopment, youth.

Introduction

Adolescence is the critical process in which the individuai ieaves the dependency of chiidhood and enters a

period in which dramatic changes occur, eventuaily resulting in what society identifies as aduithood. It is a

complex developmental time involving sociological, psychological, and physiological issues that initiates with

puberty and finalizes sometime in the third decade of life with central nervous system maturation. It is a unique

bridge which accepts the achievements and failures of childhood and sets in motion all changes necessary to

establish adulthood. The goal of this period is to develop an autonomous adult who is capable of functioning at

intellectual, sexual, and vocational levels acceptable to society.

We all have a stake in our adolescents, for they profoundly affect our present and will continue to affect our

future. Prevention and management of health problems in children and adolescents can prevent considerable

morbidity in adults. How we care for our children and youth says much about us as a global society, whether for

good or for i ll. How our children and adolescents are treated will determine much about the future of the world,

as the 21st century unfolds into its second decade-its own adolescence!

Terminology

According to United Nations Children's Fund (UNICEF) and the World Health Organization (WHO), the terms

child, adolescence, youth and young people have different meanings. For example, a child means every human

being below the age of eighteen years, unless, under the law applicable to the child, majority is attained earlier.

The period of adolescence refers to the second decade of life (ages 10-19), while youth refers to those between

the ages of 15 years and 24 years; young people refers to those between 10 and 24 years of age.

Demography of adolescent population

Today's generation of young people is the largest in human history. There are 1.2 billion adolescents (ages

10-19 years) in the world, which is over 20% of the world's population; there are one billion humans who are

between 15 and 24 years of age and about 50% of the world's population is now under 25 years old (1).

At the beginning of the 21st century in the United States there are over 300 million individuals, over 43 million

of whom are adolescents (ages 10-19-14% of the population) and over 60 million of whom are 10 to 24 year

olds (20%).

Despite the fact that the adolescent population in the United States is growing, the percentage of adolescents

representing the total population is constantly decreasing due to the aging of America. Hispanic, African

American, and Asian adolescent populations are rapidly increasing, when compared to Caucasian, English

speaking youth.

Normal adolescent sexuality stages

Adolescent psychosocial development is typically divided into three classic periods: Early (10-13 years of age).

Middle (14-16-1- years of age), and Late (17-2H- years of age) Adolescence (see tables 1-3). The young

adolescent resumes previously acquired interest in the development of interpersonal relationships. Typically, the

youth approaches this from a narcissistic viewpoint in which the individual's interest comes first and concerns of

others are not carefully considered. This "selfish" attitude starts with those of the same sex and extends to

those of the opposite sex during mid-adolescence. First, there is exploration of one's own body linked with

concerns of normality, and then comes the comparison with peers of the same gender. Interest in the opposite

sex usually eventually occurs.

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Considerable energy is spent acquiring social skills and friendships with same-sex individuals. Thus, boys tend

to develop groups of males who engage in various behaviors, as each member challenges the others in

diverse aspects of adolescence. Definitions of masculinity are tested and confirmed within such groups.

Homosexual experimentation and considerable false braggadocio about sexuality are quite common. Girls

tend to associate with a few very close girlfriends and then, to a lesser extent, deal with a larger cadre of

females. The extent of female masturbation and homosexual experiences is unknown, but is probably less

than that reported by males. Also, classic Freudian theory teaches that early adolescence Is the time for

reemergence of the Oedipus complex and, if normal sexual health is to occur, it must finally be resolved.

Middle adolescence is typically called the heterosexual stage, as youth acquire diverse experiences with the

opposite sex; these experiences can be quite short (even one or two days) and intensive.

During middle adolescence, depending on the youth's self-image, opportunity, and parental influence, there is

a normal sequencing of this heterosexual development. It begins with interest in the opposite gender, and is

followed by group dating, then by individual dating, and eventually by sexual intimacy.

Such intimacy runs an individual course including hand-holding, superficial versus "serious" kissing, petting,

oral sex, anal sex, and/or vaginal coitus. This relationship is also described as narcissistic (generated from

self-interest) and deeply embedded in resolution of the Oedipus or Electra complex. Late adolescence is

normally the time to begin consideration of available adult lifestyles.

The Process of CNS maturation

Brain cells consist of neurons and glia; the latter support and nourish the neurons. After the billions of central

nervous system (CNS) cells are developed by late fetal l ife, CNS pruning and differentiation occur in an

aggressive fashion in the young child and young adolescent. Approximately three-fourths of the brain growth

in weight occurs by age 2 years, while CNS maturation continues throughout childhood and adolescence; this

includes axon myelination, a process increasing the efficiency and speed of nerve conduction. The ability of

CNS cells to adapt to challenges is called plasticity; another process is the pruning or sculpting of these cells

starting in late fetal life and accelerating in the young child and young adolescent. The excessive number of

CNS cells that develops in fetal life is reduced by the process of apoptosis (programmed cell death) in which

cells are destroyed; as the hormones of puberty are increasing, apoptosis accelerates, leading to massive

death of neurons and the removal of half of the cortical synaptic connections.

Puberty

Puberty is a very significant neurobiological event that has profound effects on the growth and development of the individual. Parents and clinicians devote much time observing and seeking to modify the CNS

maturational changes in children that Intensify with the effects of genital and CNS maturation in adolescents.

In early adolescence the brain undergoes significant changes under the influence of pubertal hormones, such

as estrogen and testosterone. There is considerable growth of the brain, including the central nervous system

areas which direct impulsivity and social behavior. Other parts of the body also undergo profound change

(Table 4). Eventually, an adult-like individual appears who soon will be taking his or her place in society. Many

potential problems, medical and/or psychological, await this youth as s/he heads towards the independence of adulthood.

The exact trigger for puberty is not yet clear, but it involves central nervous system (CNS) maturation with

reduced hypothalamic sensitivity to gonadal steroids by changes in the GnRH pulse generator; there is also

adrenal gland maturation. The progression (see table 5) through puberty is predictable, but there is

considerable variation in its onset, timing, tempo, and in the magnitude of its changes (see table 6). There

are five stages of pubertal development due to hypothalamic-pituitary-gonadal maturation, called Sexually

Maturity Ratings (SMR) or Tanner Stages (see tables 7 and 8; figures 1 and 2).

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Eventually there is a rise in gonadotropins (Follicle Stimulating Hormone [FSH], Luteinizing Hormone [LH])

sex hormones (i.e., estrogen, testosterone), adrenal gland steroids, growth hormone, insulin-like growth

factors (IGFs or somatomedins) and other hormones. Thelarche (breast budding or SMR 2) is the first

clinical evidence of puberty in females, developing between 6 and 14 years of age, typically between 11

and 12 years of age; menarche (onset of menstruation) usually follows in 1 to 3 years in SRM 4, often

between 12 and 13 years of age (range of 10 -17 years). The first clinical event of puberty (SMR 2) in the

male is enlarged testicles (over 4 mL or 2.5 cm in diameter) and scrotal thinning; ejaculation is seen at

SMR 3 and fertility at SMR 4.

The growth spurt results in the final 25% of the adult height and is an early pubertal event in females

(SMR 2) often at age 11.5 years and a late pubertal event in males (SMR-4), typically at age 13.5 years of

age; the average growth spurt lasts 24 to 36 months. Those who have early (precocious) or late (delayed)

puberty can experience considerable psychosocial consequences. For example, the female and male who

develop much sooner than peers, may be subjected to sexual behavior (including abuse) much earlier than

peers.

Puberty stimulates more interest in sexuality in the growing and rapidly changing adolescent. Young teen

males may be concerned about spontaneous erections, nocturnal emissions, and same-sex sexual

experimentations.

Males may also be concerned about the development of gynecomastia, or the usually transient

development of breasts noted in as many as two-thirds of SMR 2-3 males. Though usually resolved in 12 to

18 months, gynecomastia may cause confusion about male identity and intense anxiety when undressing

in front of peers in physical education classes. Reassurance from the trusted clinician about the benign

nature of this phenomenon is very helpful to the male, though temporary release from situations of

showers with naked peers may be necessary; surgery is also necessary in some situations of persistent

gynecomastia, large breasts, or severe psychosocial stress. Females may be worried about vaginal

discharge (estrogen-stimulated "physiologic leukorrhea"), nocturnal sexually-oriented sex dreams,

homosexual interests (including sexual experimentation), and pressure from peers and society to be

sexually active (also seen in the male as well!).

Both males and females may be concerned with the effects of acne vulgaris, body odor, seborrheic

dermatitis, and other dermatologic effects of puberty. Crushes on non-parental figures are common in both

sexes, and include interest in teachers, youth leaders, coaches, and others. If adults misinterpret these

"crushes", sexual abuse may result with potentially profound negative consequences for this adolescent.

The influence of parents to these changes of puberty and that of the family's religious teaching have

profound effects on how adolescents deal with these emerging concepts of human sexuality.

Sexual behavior

Sexuality (see table 9) is a complex phenomenon involving interaction between one's a) biologic sex; b)

core gender identity (sense of maleness and femaleness); c) gender role behavior (nonsexual as well as

sexual). Sexuality is also a basic yet profound recognition that humans need other humans and that this

human capacity to give and receive love represents a natural continuum from birth to death. As sexuality

develops, the success or failure experienced by the child and teenager has much to do with eventual

success or failure as an adult (2).

In societies around the world coital behavior initiates during the adolescent years. In the United States,

millions of sexually active youth produce approximately 757,000 pregnancies in females 15 to 19 years of

age and over 9 million sexually transmitted diseases each year in those 15 to 24 years of age; this includes

an estimated 6,610 cases of HIV/AIDS in 15-24 year olds (3). This well-known, classic annual YRBS report

repeatedly identifies that almost half of all high school students have had sexual (coital) experience (3). In

addition, 34.2% are currently sexually active (i.e., had had sexual intercourse during the 3 months

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preceding the survey), nearly 39% of currently sexually active students had not used a condom during

their last coital activity, and 2.1% had ever injected an illegal drug. The 2009 YRBS (3) notes that nearly

20% of surveyed high school students have smoked cigarettes during the 30 days before the survey.

The YRBS reports (3) have noted that nationwide, 6% are coitally active before age 13 (9% in males

and 4% in females), and 14% of youth have four or more partners (17% of males and 12 % of

females). Though over half of youth are sexually experienced, marriage does not occur on average in

the United States until age 25 for the female and 28 years for the male. Youth who have experience with

more than one partner usually practice serial monogamy-having one partner and then moving on to

others, but usually one at particular time. There is an increased coital rate with increased drug/alcohol

use and those engaged in survival sex (I.e., prostitution or slavery). The topics of substance abuse

disorders, sexually transmitted diseases, and adolescent pregnancy and are discussed in chapters 9,17,

and 19 respectively.

Homosexuality

As already noted transient attraction to and sexual experimentation with members of the same sex may

occur during early puberty. Some adolescents go through a phase of homosexual behavior and proceed

toward a heterosexual behavior pattern; other adolescents learn to perceive homosexuality as a life

pattern for themselves. Sexual behavior, whether heterosexual or homosexual, places adolescents at

risk for sexually transmitted diseases. However, adolescents with persistent homosexual attraction and

sexual behavior additionally have to cope with typical societal aversion to homosexuality that may place

them at risk for other psychosocial and medical problems.

Though there has been considerable research about the etiology of homosexuality, controversy remains.

In 1973 homosexuality was removed as a diagnostic category by the American Psychiatric Association,

and in 1980 it was removed from its Diagnostic and Statistical Manual of Mental Disorders (DSM-III); it

is not present in the DSM-IV edition (4). In 1975 the American Psychological Association officially

adopted this concept that homosexuality itself Is not a psychiatric or psychological disorder. The 10th

revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10)

states "Sexual orientation alone is not to be regarded as a disorder" (5).

This view reflects a change In the perception of homosexuality on the part of most researchers from a

pathological disorder to a variant of normal human sexuality.

Prevalence

A variety of sexual orientations have been described since the ground-breaking work of Kinsey and

colleagues (6,7), who surveyed over 5,000 adult males and 6,000 adult females in the 1930s and 1940s in the United States. This research concluded that 4% of adult males and 2% of adult females are

exclusively homosexual in their sexual fantasy and sexual behavior; also, these researchers concluded

that 50% of these adult males had a homosexual experience before puberty, 37% had at least one such

experience leading to orgasm, and 10% were homosexual for at least 3 years after puberty. Table 10

lists the Kinsey scale used to rate sexual orientation in adults. Other researchers conclude that 2% of

adult males are exclusively homosexual while 3% are bisexual, that 3% of adult females are sexually

active with other females since their teen years, and nearly 7% of adult females in the United States are

involved in same-sex sexual activity after age 15 years (8-9). Troiden (10,11) has outlined 4 stages in

the development of a gay identity (see table 11).

Caring for the GLBT youth

Clinicians must also understand that gay, lesbian, bisexual, and transgendered (GLBT) youth often have

limited access to health care. These youth may experience considerable stress in identifying a gay or

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lesbian sexual orientation and identifying this to family and peers. Parents may be quite distressed

and fearful of society's reaction to this declaration. Clinicians should comprehend that homosexual

youth have increased risks for depression, suicide attempts/completions, eating disorders, alcohol

and drug abuse (including club drugs), sexually transmitted diseases (including HIV), violence-related

injuries (including homicides), homeless lifestyle, and other psychological as well as medical

problems.

A caring, non-judgmental clinician can be of considerable help to youth struggling with issues of

sexuality, whether homosexuality, heterosexuality, or both. The GLBT youth may present to the

clinician with a variety of concerns, including seeking information about homosexuality, STDs

(including fears of having STDs and seeking relevant information), psychosocial difficulties (family,

school, significant other(s), personal problems, vocational concerns, or religious conflicts), various

psychosocial problems, various medical disorders, substance abuse issues, or legal problems

(including prostitution) (12,13).

The adolescent sex offender

The sexual victimization of children or other individuals by adolescents has become a serious, yet

often ignored problem in our society. Adolescents under the age of 18 years account for 20% of

arrests for all sexual offenses (excluding prostitution), 2030% of rape cases, 14% of aggravated

sexual assault offenses, and 27% of child sexual homicides. More than 46% of the sexually

aggressive adolescents began their deviant behaviors before the age of 12. About 0.5% of all

adolescents are ever arrested for violent crimes of which sexual offending represents a small subset.

Known offenders represent only a fraction of the number of actual cases of child and adolescent

sexual abuse.

Health status of adolescents

Approximately one-third of youth have a chronic illness or disability (with a duration > 3 months),

including 6% who have illnesses that limit daily activity (12-15). Behavioral issues and potential

complications of such difficulties on adolescent growth and development should be considered by

those interested in adolescent health care. Nearly three-quarters of this group have one health

condition, 21% have two, and 9% have three or more. Current research suggests that 13% to 18%

of American children and adolescents have a special health care need. Approximately 90% of children

with severe illness reach age 20 in developed countries, and the impact of chronic illness on the lives

of these children and adolescents is considerable.

Demographic information on specific illnesses in the United States include statistics such as: a) over

one million have asthma, b) one million teenagers have epilepsy, c) >100,000 present with diabetes

mellitus, d) eight million present with refractive errors (myopia, hyperopia or astigmatism) - including

a 100,000 with partial or limited vision, and e) over one million present with significant hearing loss.

The overall i llness prevalence in the 10 - 17 age group is 315 per 1,000. Prevalence rates for youth,

ages 10 - 17 include 130.3 per 1,000 teens suffering from respiratory allergies, musculoskeletal

disorders- 20.9, asthma -46.8, headaches (frequent, severe) - 45.8, heart disease - 17.4, deafness

and hearing loss - 17.0, blindness and vision impairment -16.0, speech defects - 18.9 and diabetes -

1.5 (16). Approximately 10% of youth each have hypertension, recurrent migraine headaches, and

severe dysmenorrhea. ?ver 80% of youth develop acne vulgaris, and the majority have dental

problems, particularly dental caries. Estimates are that the average 15 year old youth has 10

"diseased" teeth (decayed, filled or missing).

Research indicated that 25% of adolescent females have an eating disorder, whether bulimia nervosa,

anorexia nervosa, or obesity; this includes 1% of youth with anorexia nervosa and as many as 5%

with bulimia nervosa. Twelve percent of American adolescents are obese (with a Body Mass Index

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[BMI] >95th percentile on the relevant Centers for Disease Controi and Prevention [CDC] curves

according to age and sex), whiie > 20% are overweight or at risk for obesity (BMI >85th

percentile). Underlying issues in the increase in obesity and overweight over the past 30 years

include a reduction in physical activity along with a precipitous rise in calorie dense foods that are

eaten in preference to healthy foods that are often quite expensive. The annual evaluation of

adolescents should include a recording of their height, weight, sexual maturity rating, and Body

Mass Index (BMI). These measurements should become part of the youth's record (electronic

medical record or EMR) for two reasons. First, the individual youth's physician can use this

information to evaluate and manage issues in regard to the patient's obesity; second, this

information can be compiled with an eye to evaluating the magnitude of this problem for the youth of the world.

Some of the factors leading to the decline in exercise of youth over the past 3 decades include use

of video games, computers, cable television, and movies; also, there are public as well as private

transportation systems and employment opportunities that do not require great amounts of

physical exertion. Since increased weight gain is due to excess calorie intake, it is inevitable that

those consuming similar or greater amounts of food compared to prior generations, but expending

less energy, will have greater weight gain. The US 2009 YRBS notes that during the 7 days prior to

the survey, nearly 78% of high school students had not eaten fruits and vegetables 5 times or

more per day, 29% had drunk soda or pop at least one time per day, and nearly 82% were not

physically active for at least 60 minutes per day on all 7 days before the survey (CDC YRBS, 2010).

Unfortunately pharmacologic agents are not yet useful in the treatment of eating disorders

(17,18).

Mental health

One fifth to one-third of disability in adolescents (10-18 years) is caused by mental disorders

(psychosocial, behavioral, developmental or psychiatric). Major depression increases with age and

is noted in 9 of every 1000 preschool children, 20/1000 of school-aged and nearly 50/1000 adolescents-the latter is a rate similar to that found in adults. In childhood depression, there is a

1:1 male to female ratio; in adolescents and adults, there is a 1:2 male:female ratio. Depression

can lead to a number of adverse events, as reflected in Table 12, and can be found with a number

of co-morbidities as well, including anxiety disorders, substance abuse disorders, and disruptive behavior disorders. Mental health of the world's children and adolescents is worsening with

increase in overall stress, psychosomatic symptoms, school dropouts, substance abuse, wars,

homicide, suicide and other forms of violence so prevalent in the the 21st century world milieu.

Youth violence

Violence remains a tragic and significant cause of physical and psychosocial morbidity among

adolescents in the United States and the world. According to the United States Department of

Education, in schools there were 188,000 incidents of physical attacks not involving weapons,

11,000 fights involving weapons, and 4,000 incidents of sexual assaults (Greydanus, 2006, 2009).

The 2009 YRBS survey reported (3) that nearly 20% of high school students were bullied during

the 12 months prior to the survey and 5% skipped school at least one day out of safety concerns

(3). In an average month, there are 525,000 attacks (including shakedowns, and robberies), and

125,000 threats against teachers in United States public secondary schools. Approximately 5,000

teachers suffer actual physical harm in a given month. The 2009 YRBS reported (3) that 31.5% of

high school students were involved in a physical fight during the 12 months prior to the survey and

6.4% attempted suicide.

A vast majority of children and adolescents (especially inner city youth [70-95%]) have witnessed

a violent act such as robbery, stabbing, shooting, murder, or domestic violence. African Americans

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and other minority ethnic groups experience a disproportionate share of violence. Young African-

American females are 4 times more likely and African-American males 11 times more likely to be

killed than Caucasian teenagers. The 2009 YRBS reported (3) 17.5% carried weapon to school

(5.9% a gun), 41.8% drank alcohol, and 20.8% had used marijuana during the 30 days prior to

the survey. Risk factors for being involved in violent incidents are drug abuse (including

marijuana and alcohol) and the developmental difficulty of youth to realize future consequences

of their actions. Violence in school is often highlighted in the media, following unfortunate events

such as shooting incidents in schools.

The medical costs as a result of violence are enormous. In the long run it is less expensive to

prevent youth violence than to treat its lifelong consequences.

It is estimated that 3% of the total United States medical expenditure goes to treat

interpersonal violence-related injuries annually (12-15). Firearm injuries cost between $1.4 and

$4 billion annually for direct treatment. Because of lifelong effects of serious firearm injuries,

another $19 billion are lost in indirect costs such as loss of future earnings. The direct costs to

treat domestic violence related injuries are estimated to be $44 million annually, and that for

child abuse about $500 million annually (12,13).

Mortality

Violence accounts for about 75% of deaths in youth 15 to 24 years of age. In 2005, the total

number of death for adolescents, 15-19 years of age, was 13,706. (66.1 deaths per 100,000 for

adolescents, 15-19 years old) (12). The leading causes of death are motor vehicle crashes

(30%), other unintentional injuries (16%), homicide (16%), and suicide (12%) (3). Although

the death rate of American youth has been declining during the past years, violence - related

deaths increased over the last quarter of the 20th century, with a 400% increase in motor

vehicle accidents, a 400% increase in homicide rates, and a 600% increase in suicide rates (12).

The leading cause of adolescent deaths is accidents, most of which are car crashes; many of

these involve the use of drugs, especially alcohol. About 40% of lethal vehicle accidents are

related to substance use. In contrast the leading causes of mortality among those at or over 25

years of age are cardiovascular disease (59%) and cancer (24%) (3).

Homicide and suicide

Mortality rates increased for adolescents from the early 1960s to the late 1980s; these rates

have stabilized since then, except for an increase in African-American maies, due to increased

homicide rates. The mortality rate for firearm homicide rates for black males is 11 times greater

than for white males; white males were more than twice as likely as black males to commit

suicide with firearms. Risk factors for youth committing suicide are the following: maie gender,

homosexual or lesbian sexual orientation, access to fire guns, past psychological distress or

suicidal attempt, substance abuse and family history for suicide and/or depression.

In general, homicide is more likely to occur in the inner city in the US than suicide, while suicide

is more prevalent in suburban America. Approximately four to five thousand teens commit

suicide each year out of 30,000 annual suicides from all age groups; the suicide rate in 15 to 24

year olds is over 13 per 100,000 in contrast to 5.2 in 1960 (12-15). In 2001 the suicide rate for

15-19 year olds was 7.9 (versus 2.7 in 1950) and 12.0 for 20-24 year olds (versus 6.2 in 1950).

Suicide is the second leading cause of death for white males 15-24 years of age and third cause

overail for those 15-24 years of age; chronic illness is a factor in some of these cases.

Motor vehicle accidents

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Thirty percent of deaths in 15 to 20 year olds result from motor vehicle crashes (MVAs), the

number one cause of deaths among teens (12). In 2002, more than 5,000 adolescents were

killed in MVAs and approximately 482,000 were injured. Fourteen percent (7,975) of all

drivers involved in fatal crashes (56,543) were 15-20 years old, and 16% (1,801,000) of all

drivers involved in police-reported crashes (11,368,000) were young drivers. In 2002, the

motor vehicle traffic death rate for males was nearly twice the rate for females, and the

firearm death rate among males was eight times that for females (12). According to the YRBS

(CDC), 11.1% of high school students (8.5% female; 13.6% males) had rarely or never worn

seat belts when riding in a car or truck driven by someone else, and 28% had rarely or never

worn a helmet when riding a motorcycle. During the 30 days prior to the survey, the 2009

YRBS reported (3) 28.3% of high school students rode in a car or other vehicle driven by

someone who had been drinking alcohol. In 2001, the economic cost of police-reported

crashes involving drivers age 15 to 20 was about $42.3 billion (12).

A number of factors influence driving-associated morbidity and mortality. For the adolescent

driver, psychosocial development and inexperience contribute to increased risk-taking and

dangerous driving behavior. Alcohol-related factors are of special significance. Miles driven per

week, truancy, drug abuse, and number of evenings out are all positively associated with

driving-after drinking behavior, whereas positive academic performance and religiosity reduce

this deadly behavior. The United States National Flighway Traffic Safety Administration notes

that 30% of Americans will be involved in an alcohol-related crash at some point in their lives

(13). In 2005, 39% of deaths from MVAs were alcohol-related accidents; 21% of drivers

15-20 years of age who were killed in these crashes were legally intoxicated (12).

Abuse

There are approximately 3 million reported annual cases of abuse in those under age 18 years

of age; reported cases of maltreatment are subdivided into neglect in 63%, physical abuse in

18%, sexual abuse in 10%, emotional or psychological abuse in 7%, and medical neglect in

2% of total cases (13). Research notes that 15.4 per 1,000 teenagers aged 12-17 report

being victims of violence in 2004. Sexual abuse was noted in 13% of females and 7% of

males in the eighth and tenth grades. Only 30% of cases are reported to the authorities and

in >75%, the abuser is no stranger to the victim (e.g. a family member, a friend, or a social

acquaintance). Forced coital behavior is reported in over 70% of sexually active females

under age 14 years, 60% for those under age 15 years. Exposure to pornography and

strangers on the Internet may lead to sexual abuse as well. A study in the United States

concluded that 27% of adult females and 16% of adult males report a history of sexual abuse

(13). Children and adolescents who are subjected to violence and abuse may become adults

with serious sequelae, including diverse mental health disorders.

Dating violence

The majority of high school students receive unwanted sexual comments or actions at school-

including being the object of lewd comments or jokes and being touched or grabbed, among

other behaviors. Studies suggest that the majority of female youth eventually become victims

of some violence while dating. This may be physical, verbal and/or sexual in nature. As many

as 60% of adolescents experience dating violence and this involves youth from all ethnic

groups and socioeconomic strata. Studies with college students note dating violence in 36%

of the males and 59% of the females (12). Acquaintance or date rape may be the cause in

60-70% of adolescent assaults. Over 7% of high school students report being forced to have

sexual intercourse (3).

Adolescents need to learn potential signs that their dating partner may be too aggressive and

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may resort to violent means to control the relationship. Concerns in this regard should be

raised under these circumstances: a partner prevents the teen from associating with

friends, becomes jealous with minimal (if any) reason, becomes upset with the teen for

little or no reason, uses any means of violence in the relationship, always apologizes for

being mean or violent, induces sadness in the teen when with him/her, or uses drugs

(including Rohypnol, GBH) when dating. Youth and their parents need to be educated that

these are warning signs and to avoid dating or to stop dating such individuals. Adolescents

should know that violent dating partners become violent spouses and live-in sexual

partners.

Runaway and homeless youth

It is estimated that there are several hundred thousand adolescents who run away from

home and are homeless in the United States. The Runaway and Homeless Youth Act (Title

III of the Juvenile and Delinquency Prevention Act) defines runaways as "juveniles who

leave and remain away from home without parental permission." Some are "situational

runaways" who briefly leave home (i.e., a day or so) after arguing with a parent or

guardian. Others are "throwaways" who have parents who abandon them, ask them to

leave or severely abuse (neglect) them- forcing them to leave home. Some youth have no

or very limited family contact and have lived in different foster homes or institutions; these

"systems youth" eventually leave to live on the street.

The most detailed United States Government study looked at 40 urban counties and

included 430 shelters; this study estimated there were 253,600 homeless children and

youth under age 16 years; this included over 9,000 living in cars, abandoned buildings, bus

terminals and others areas (12). Others estimate that there are over 450,000 runaways

and 127,000 throwaways (13). There are also several hundred thousand youth who live

with their families, but lack access to a conventional dwelling or residence. Homeless youth

are subject to many dangers of the street-physical/sexual abuse, substance abuse,

sexually transmitted diseases, various medical disorders and others. Their main medical

treatment is usually through the emergency room, if they receive any care at all.

Incarcerated youth

There are over 800,000 youth in jail-like facilities in the United States that include

detention centers, lockups, jails, or others. They have various health care needs and often

are not eligible for health care coverage (12). Over 75% of these youths have health care

problems which need to be addressed. They represent a very vulnerable and high-risk

group of youth in America. They have skin, vision, and dental problems, in addition to a

high prevalence of tuberculosis and sexually transmitted diseases (including HIV/AIDS).

Multiple psychosocial issues are noted in these youth including depression, anxiety, other

behavioral or psychiatric disorders, and abuse (sexual, physical, others).

Caring for adolescents

In addition to acute visits, clinicians should provide a preventive evaluation on an annual

basis for all adolescents in their practice. Sometimes much of the visit may focus on

obtaining a complete medical history while a comprehensive physical examination may be

important at another visit. The purpose of the annual evaluation is to see how the

adolescent is doing with regard to important aspects of his/his life including questions

regarding the home, education, nutrition (looking for eating disorders including obesity),

physical activities, drug use, safety concerns, depression, suicidality, and sexuality. The

clinician can serve as an advisor to the adolescent at a time when s/he may not wish to

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share such details with parents. Principles of preventive services for adolescents are

outlined in a number of available documents including Bright Futures (19), the American

Medical Association's GAPS (20) and the US Preventive Services Task Force (USPSTF)

from the Office of Disease Prevention and Health Promotion, U.S. Department of Health

and Human Services (21). Table 13 provides a list of issues to be addressed both in a

questionnaire and/or in direct questioning. Main points of health history, examination,

and questions are summarized in tables 13-15. Start with neutral questions (i.e., "How

is school going?" or "How are you getting along with family members?") before getting

to potentially sensitive questions, such as "Are you using illicit drugs?" or "Are you

having sex?" It is important for the clinician to develop active listening skills that can be

sharpened with repeating some of the comments from youth back to them by

paraphrasing what you have heard-"If I heard you correctly, you said that,

many techniques that clinicians can learn to help communicate with youth, such as: "If

you had three wishes, what would they be?"

There are

Involvement of parents

Involving parents as much as possible is usually recommended when health care

professionals work with youth. However, some teenagers wil l seem more eager than

others to talk alone to a health care professional. Young adolescents (11-13 years of

age) often prefer the assistance of parents, but late adolescents (17 years and older) do

not, and middle adolescents (14 to 16 years) typically place the health care provider in

the very delicate situation of needing to balance between relating to both parents and

youth. In general, the very young teenager, the critically ill, and those with intellectual

disability (22) do need active parental involvement. Some youth are in an emancipated

status in which the youth is in an independent state, as noted in Table 16.

Emancipated youth may be dealt with by clinicians apart from parental involvement. In

the United States, there is the Mature Minor Doctrine, a non-legal concept in which

youth are labeled as mature minors capable of receiving health care without parent's

permission; this usually applies to those who are at least 15 years of age who are

cognitively capable of providing their own informed consent regarding their health care

(see table 16).

Confidentiality

When possible, confidentiality must be carefully approached and provided. Some

adolescents are considered emancipated to make health care decisions on their own (see

table 16). Young concrete-thinking teenagers are especially eager for health information

but may be unable to provide detailed answers. A questionnaire focusing on health

issues may be helpful in this regard, in addition to interviews with parents and teens. In

general, documenting data from as many sources as possible is extremely helpful in

evaluating complex situations that involve diverse family dynamics, as well as individual

personality complications and complex, Gordian medical and/or psychiatric conditions.

Health care professionals who deal with adolescents are presented with unique

challenges and responsibilities. A delicate balance must be struck between youth and

parents. Early adolescents as noted already, generally want more direct parental

involvement in the physician-patient relationship, while middle and late adolescents

generally seek much greater autonomy. Trying to deal effectively with both teen and

parent (guardian) can be difficult at best, especially if various complicating factors arise.

Encouraging youth to talk with their parents or guardians openly and even providing

them with examples of how to talk to their parents is an important part of the clinician's

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role.

Youth must be given some sense of confidentiality and shown that the health care

professional is not merely an unfiltered conduit of information from the youth to the

parent. These young patients must be given some reassurance that what they say will

be held in acceptable confidence. However, youth must also realize that there are

some limits to this aspect. Laws of each country specify what information must be

reported to parents, police, and other authorities. For example, individuals who are

severely depressed and threatening suicide or those presenting with a risk of physical

harm to others must not be allowed to go through with these serious issues untreated

and unchecked. Sexual or physical abuse of a minor is also an area governed by legal

mandates.

Clinical judgment is necessary in deciding whom to tell and how to handle such

problems. Specific documentation of these situations must be kept in the patient's

electronic medical files. In some states and countries, there are legal mandates

specifying who must be notified and in what time frame. However, appropriate health

care for youth should not be denied by the health care professional or insurance

managers because of insensitivity to well-known psychosocial issues of adolescence.

Immunizations

When caring for youth, a key part of preventive care is providing advice on keeping

this patient up-to-date with current Centers for Disease Control and Prevention or

World Health Organization guidelines on immunizations, an important aspect of

healthcare initiated by the English physician, Edward Jenner (1749-1823), in 1796

that has become one of the highest achievements of medical science in the 20th and

21st centuries (23).

Table 17 lists vaccines recommended for adolescents in the United States for 2011.

These recommendations are ever-changing as the immunization science evolves and

can vary from country to country. Travelers to different countries should be educated

regarding what vaccines are recommended in such travel and should adhere to these

guidelines from the Centers for Disease Control and Prevention (Atlanta, Georgia) and

the World Health Organization in Geneva, Switzerland.

For example, traveling youth from the United States may be advised to supplement

their immunization record with vaccines for typhoid, yellow fever, Japanese

encephalitis, rabies, cholera, and others.

Immunizations, like preventive care in general, should begin in childhood and

continue into adolescence on their inevitable journey to reach adulthood. Prevention

services can also focus on areas that the CDC has listed as leading causes of

morbidity and mortality among youth and adults, as listed in Table 18.

Counseling

Those who choose to be sexually active should have appropriate information about

contraception and STD protection. Advice should be provided in a friendly,

confidential, and safe manner. The attitudes and beliefs of clinicians can influence

their ability and willingness to provide counsel for teens regarding sexual orientation,

pregnancy, abortion, contraception, and STDs. Clinicians can introduce the subject of

sexuality into the doctor-patient communication on a regular basis and set the youth

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at ease while talking about sexuality. Youth may have a hidden agenda regarding

various aspects of sexuality, and clinicians should be attuned to this agenda. A

number of factors can compromise sexual health and careful screening will often

uncover these issues. Sexuality involves various family, legal, ethical, moral, and

religious issues and clinicians need training to be able to help youth in these areas

(2,2427).

Conclusions

Adolescence is the life-changing phase of human existence that begins as childhood

ends and itself is finalized by the onset of adulthood. This chapter sets the stage

for the rest of this book by providing an overview of adolescence that includes a

review of normal psychosocial stages, adolescent sexual maturity stages, concepts

of sexuality, overview of health status of adolescents, and principles of caring for

adolescents. Clinicians privileged with the responsibility of caring for youth should

serve as advisors of prevention and as committed counselors to guide this precious

cargo into the often turbulent times of adulthood.

Anticipatory guidance by clinicians is important to promote healthy sexuality

development in children as well as adolescents and to prevent complications (such

as unwanted pregnancy, STDs, abuse, others). Youth involved in abusive

relationships need the guidance of trusted clinicians and counselors to steer them

toward healthy adulthood. Counseling can encourage the growth of various

resiliency factors that promote healthy sexuality and healthy l iving, enabling these

youth to deal with adversities and to lead a productive adolescent as well as adult

life. These factors include a sense of belonging with other peers, acquiring a

healthy value system, receiving appropriate education (including sexuality

education), and learning to enjoy the fascinating phenomenon of life itself. Youth

need an adviser and a guide in l ife, one who can provide support and accurate

education in important facets of life, such as human sexuality as well as in specific

concepts of medical and psychological health. Sometimes the advice or counsel of

the clinician is not accepted initially; however, one can never predict when the

small seed of advice given to an adolescent now will take root later as the course of

his/her life as this 21st century unfolds. That is the challenge and promise of

adolescent medicine for those privileged to care for this important group of human

beings.

Acknowledgments

This paper is an adapted version of a chapter in the book "Adolescent medicine:

Pharmacotherapeutics in general, mental and sexual health" edited by Donald E

Greydanus, Dilip R Patel, Cynthia Feucht, Hatim A Omar, Joav Merrick and

published with permission by Walter de Gruyter, Berlin and New York.

References

[1] UNICEF Website. http://www.unicef.org/sowcOO /map/.htm

[2] Omar H, Greydanus DE, Tsitsika AK, Patel DR, Merrick J, eds. Pediatric and

adolescent sexuality and gynecology. New York: Nova Science, 2010.

[3] Centers for Disease Control and Prevention. Surveillance summaries. MMWR

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2010;59:SS-5.

[4] American Psychiatric Association. Diagnostic and statistical manual of mental

disorders, DSM-IV, 4th ed. Washington, DC: American Psychiatric Association,

2000.

[5] International classification of diseases and related health problems, 10th

Revision (ICD-10). Geneva: WHO, 1992.

[6] Kinsey A, Pomeroy W, Martin C. Sexual behavior in the human male.

Philadelphia, PA: WB Saunders, 1948.

[7] Kinsey A, Pomeroy W, Martin C, Gebbard P. Sexual behavior In the human

female. Philadelphia, PA: WB Saunders, 1953.

[8] Diamond M. Homosexuality and bisexuality in different populations. Arch Sex

Behav 1993;22:291-310.

[9] Seidman SN, Rieder RO. A review of sexual behavior in the United States.

Am J Psychiatr 1994;151:330-41.

[10] Troiden RT. Becoming homosexual: A model of gay identity acquisition.

Psychiatry 1979;42:362-73.

[11] Troiden RT. Homosexual Identify development. J Adoles Health Care

1989;9:105.

[12] Greydanus DE, Patel DR, Pratt HD, eds. Essential adolescent medicine. New

York: McGraw-Hill, 2006.

[13] Greydanus DE, Patel DR, Pratt HD, Calles J, eds. Behavioral pediatrics, 3nd

Ed. New York: Nova Science, 2009.

[14] Greydanus DE, Tsikika A, Hutchins E, Patel DR. Adolescent health. In:

Wallace HM, Green G, Jaros KJ, eds. Health and welfare for families in the 21st

Century. Third ed. Sudbury, MA: Jones Bartlett Publishers, 2007:289-314.

[15] Greydanus DE, Patel DR, Reddy VN, Feinberg AN, Omar HA, eds. Handbook

of clinical pediatrics: An update for the ambulatory pediatrician. Singapore:

World Scientific, 2010.

[16] Newacheck PW, Rising JP, Kim SE. Children at risk for special health care

needs. Pediatrics 2006;118:334-42.

[17] Greydanus DE, Bricker LA, Feucht C. Pharmacotherapy for obese

adolescents. Pediatr Clin North Am 2011;58(1): 139-53.

[18] Golden NH, Attia E. Psychopharmacology of eating disorders in children and

adolescents. Pediatr Clin North Am 2011;58(1): 121-38.

[19] US Maternal and Child Health. Website: http://www.brightfutures.org

[20] Guide for Adolescent Preventive Services. Website: www.ama-

assn.org/amal/pub/upload/mm/39/gapsmono. pdf

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[21] Office of Disease Prevention and Heaith Promotion, US Department of

Health and Human Services. Website: http://www.ahrq.gov/clinic

/uspstfix.thm

[22] Patel DR, Greydanus DE, Omar HA, Merrrick J, eds. Neurodevelopmental

disabilities. Dordrecht, Germany: Springer, 2011.

[23] CDC. Ten great pubiic heaith achievements. United States, 2001-2010.

MMWR 2011;60(19):619-23.

[24] Ford C, English A, Sigman G. Confidential health care for adolescents:

Position paper for the Society for Adolescent Medicine. J Adolesc Health

2004;35:160-7.

[25] Greydanus DE, Feinberg AN, Patel DR, Homnick DN, eds. The pediatric

diagnostic examination. New York: McGraw-Hill, 2008.

[26] Levy JA. Not an HIV cure, but encouraging new directions. N Engi J Med

2009;360(7):724-5.

[27] World Health Organization Press Release. WHO/64. Sexually transmitted

diseases: three hundred and thirty-three million, new curable cases in 1995.

Geneva: World Health Organization, 1995.

Submitted: September 01, 2011. Revised: November 10, 2011. Accepted:

November 20, 2011.

AuthorAffiliation

Donald E Greydanus, MD, Dr HC (ATHENS)*

Department Pediatrics and Human Development, Michigan State University

College of Human Medicine, Michigan State University/Kalamazoo Center for

Medical Studies, Kalamazoo, Michigan, United States of America

Correspondence: Professor Donald E Greydanus, MD, Pediatrics and Human

Deveiopment, Michigan State University Coilege of Human Medicine,

Pediatrics Program Director, Michigan State University/Kaiamazoo Center for

Medical Studies, 1000 Oakland Drive, Kalamazoo, MI 49008-1284 United

States. E-mail: [email protected]

Details

Subject Teenagers;

Birth control;

Prevention;

Society;

Child development;

Adults;

Children & youth;

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Age;

Population;

Apoptosis;

Nervous system;

Sexuality;

21st century;

Narcissism

United States—USLocation

Name:

World Health Organization

NAICS:

Company / organization

923120

Adolescence and human developmentTitle

Greydanus, Donald E, MD, Dr HCAuthor

Publication title

International Journal of Child and Adolescent Health; Hauppauge

Volume 5

2Issue

Special Issue: Adolescence and HealthSupplement

Pages 95-117

Number of pages 23

2012Publication year

Publication date 2012

Nova Science Publishers, Inc.Publisher

Place of publication Hauppauge

Country of publication United States, Hauppauge

Medical Sciences—PediatricsPublication subject

ISSN 19395930

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e-ISSN 23740833

Scholarly JournalsSource type

EnglishLanguage of publication

Document type Feature

References; Tables; IllustrationsDocument feature

1726666418ProQuest document ID

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/1726666418?accountid = 12381

Document URL

2012

Last updated 2015-10-26

ProQuest CentralDatabase

Bibliography Citation style: APA 6th - American Psychological Association, 6th Edition

Greydanus, Donald E, MD,Dr H.C. (2012). Adolescence and human

development. International Journal of Child and Adolescent Health, 5(2), 95-117. Retrieved from https://search.proquest.com/docview /1726666418?accountid = 12381

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