Chapter 1: Pubertal Growth and Maturation

Adolescents mature across the physical, cognitive, social, and cultural domains. “Puberty” is the term used to define the physical or biologic changes that occur in the early teen years. Cognitive changes allow the development of more complex thought patterns and in most adolescents the development of abstract thought. “Adolescence” is the term used to summarize the psychological and social changes that occur in conjunction with the physical changes. This chapter will review the expected process for normal pubertal growth and development.

Many adolescents become preoccupied with the biologic changes during puberty and have heightened concerns about whether these changes are normal. Often, adolescents use their peer group and images in the media as yardsticks for what is normal. With a basic understanding of the typical sequence and tempo of pubertal changes, the nurse can reassure the normally developing adolescent and refer those with atypical development for further evaluation.

Features of puberty

The reproductive system is controlled by the hypothalamic-pituitary-gonadal axis, which begins in the neurological system (the hypothalamus). The endocrine system is involved through the anterior pituitary gland. The cycle system is completed in the gonads (ovaries or testes). Puberty is the continuation of the maturation of the hypothalamic-pituitary-gonadal axis with the production of estrogen and testosterone, resulting in the ability to reproduce. The sequence of changes is similar and predictable for all people. There may be a wide variation in timing and tempo (when it starts and how long it takes). This variation is influenced by genetics, general health, nutrition, and environmental and socioeconomic factors.

The physical features of puberty include the maturation of the reproductive organs (ovaries, testes, and penis) and the development of the secondary sex characteristics (breasts, pubic and facial hair, testes, and penis). The body increases in height with the growth spurt and changes in composition through alterations in the distribution of fat. There is an increase in muscle strength and endurance for both males and females. All of these changes reflect the underlying hormonal changes.

Although individual adolescents may show great variation, the population as a whole has a predictable tempo for the physical changes of puberty. The typical ages for pubertal events in the United States are outlined below. Nurses working with adolescents who begin puberty outside of these typical age ranges should refer the adolescent for further evaluation.

Start of puberty

Boys: 11-12 years (range 9-14 years) — testicular growth and pubic hair
Girls: 10-11 years (range 8-13 years) — breast development and pubic hair

Growth spurt (maximum rate of growth)

Boys: 14 years (range 12-16 years)
Girls: 12 years (range 10-14 years)

Spermarche/menarche

Boys: 13-14 years (range 12-16 years) —first ejaculation
Girls: 12-13 years (range 10-16 years) —first menstrual period

Length of puberty

Boys: 3-4 years
Girls: 4-5 years

When evaluating pubertal development, the nurse must assess the sequence of pubertal events in addition to the tempo. Table 1 outlines the expected progression of pubertal changes. Variations in sequence and tempo suggest factors influencing pubertal maturation.

Table 1

The term “sexual maturity rating” (SMR) describes the typical progression of secondary sexual characteristics that occurs during puberty. The breast development in girls and testicular development in boys represents the function of the hypothalamic-pituitary-gonadal axis.  Table 2 outlines the physical features of the five sexual maturity ratings for males and females.

Table 2

Menstruation

Menarche, the first menstrual period, occurs at the end of Stage 3 or early in Stage 4. The growth spurt peaks just before menarche, and most girls will have one or two years of slow growth after the start of menstruation. The early menstrual cycles (period of time from the beginning of one menstrual flow to the beginning of the next menstrual flow) are often anovulatory and therefore irregular. This is a result of an immature hypothalamic-pituitary-ovarian axis. In general, the later menarche occurs, the longer the period of anovulation persists. Two-thirds of adolescent females will establish regular menstrual cycles by two years after menarche.¹ Normal menstrual bleeding lasts from two to seven days and occurs every 21-45 days. Oligomenorrhea (abnormally light or infrequent menstruation) early after menarche is generally of little concern unless it creates undue anxiety for the adolescent or her parents, which can ordinarily be allayed by explanation and reassurance. A careful examination should be done to reveal any physical abnormalities including signs of androgen excess and congenital defects of the genital tract.

Dysmenorrhea (painful menses) is not uncommon in adolescence, and the incidence increases as adolescents mature. At 12  years, the prevalence is reported at 38% and increases to 66%-77% by age 17.²  Primary dysmenorrhea is painful menses without any identifiable pathologic disorder. Primary dysmenorrhea is the most common cause of painful menses in adolescents. Secondary dysmenorrhea is defined as painful menses with a pathologic condition such as endometriosis, salpingitis, or congenital anomalies of the mullerian system.³

Typical complaints of the adolescent with dysmenorrhea are lower abdominal cramping and pain or discomfort. Systemic symptoms associated with dysmenorrhea include nausea and vomiting, fatigue, nervousness, diarrhea, and headache. Nonpelvic symptoms occur in about 50% of females with dysmenorrhea.³ The pain usually begins several hours before the appearance of visible vaginal bleeding and is most severe on the first day of menstruation. Symptoms may last from a few hours to a day or more but seldom exceed two to three days. The symptoms and degree of discomfort vary considerably from one person to another and from one period to another in the same person. The pain may be only a mild fleeting discomfort or so severe as to be incapacitating, requiring absence from school and activities.

A careful menstrual and sexual history is obtained in the initial evaluation of a young woman with dysmenorrhea. In addition, a careful review of gastrointestinal and genitourinary systems is necessary to rule out other causes. A complete gynecologic examination is indicated if the history is not consistent with primary dysmenorrhea or if the adolescent does not respond to medical therapy.

The treatment of choice for adolescents with dysmenorrhea is nonsteroidal anti-inflammatory drugs. NSAIDs block the prostaglandin synthesis, leading to a reduction in uterine activity and the prevention of pain.⁴ Antiprostaglandins are taken for only two to three days of the menstrual cycle. Prophylactic use of NSAIDs is efficacious when started one to two days before the onset of menses, about eleven days after ovulation. The relief appears to be a result of prostaglandin inhibition rather than analgesic effect. A variety of NSAIDs are available without prescription, such as ibuprofen and naproxen. The nurse should review correct dosing as many adolescents use subtherapeutic quantities of medication.

If pain is not relieved with NSAIDs or if the adolescent desires contraception, oral contraceptives are nearly always an effective treatment for dysmenorrhea.⁵ 

Transcutaneous electrical nerve stimulation (TENS), which hampers the perception of pain, has been found to be an effective nonpharmacologic treatment for dysmenorrhea but less effective than NSAIDs. There is not enough evidence to prove whether acupuncture is effective or not. Exercise is widely believed to alleviate dysmenorrhea, but careful research studies are not currently available to show a definitive relationship.

Additional pubertal changes

Acne

Over half of adolescents have acne, with many children having evidence of the disorder before the age of 10. The peak incidence is in mid-to-late adolescence, at age 16-17 in females and 17-18 in males. The disorder is more common in males than in females.⁶ After adolescence, the disease usually decreases in severity, but it may persist well into adulthood. Early acne occurs in the midface region (midforehead, nose, and chin) and later spreads to the lateral cheeks, lower jaw, back, and chest. The degree to which a person is affected may range from nothing more than a few isolated comedones to a severe inflammatory reaction. Acne is self-limited, but it can be a source of significant anxiety for an adolescent. Early treatment has been shown to reduce the severity of the disease.

The etiology of acne is multifactorial. Research has demonstrated a familial link to acne vulgaris, with a high concordance of severe acne and increased sebum secretion among monozygotic twins. Premenstrual flares of acne occur in the majority of females, suggesting a hormonal cause.⁶ Scientific studies do not demonstrate a clear association between stress and acne; however, adolescents commonly cite stress as a cause for acne outbreaks. Cosmetics containing lanolin, petrolatum, vegetable oils, lauryl alcohol, butylstearate, and oleic acid can increase comedone production. Exposure to oils in cooking grease can be a precursor to acne in adolescents working over fast-food restaurant hot oils. There is no known link between dietary intake and the development or worsening of acne lesions.

Acne is a disease of the pilosebaceous unit, which consists of the sebaceous glands and hair follicles. Acne is most commonly found on the face, chest, upper back, and neck because of the large quantity of sebaceous glands located on these skin areas. The three pathophysiologic factors that have the greatest influence on acne development are excessive sebum production, comedogenesis, and the overgrowth of Propionibacterium acnes.⁷

Acne presents as comedones, inflamed pustules, or cystic lesions. Identifying the type of acne helps in choosing the correct treatment modality. Comedogenesis (formation of comedones) results in a noninflammatory lesion that may be an open comedone (blackhead) or a closed comedone (whitehead). Inflammation occurs with the proliferation of P. acnes, which draws in neutrophils causing inflammatory papules, pustules, nodules, and cysts. Scarring is a result of the process in which macrophages digest the inflamed skin and the normal dermis.

Successful management of acne requires patience and persistence on the part of the adolescent. Unlike many dermatologic conditions, the acne lesions resolve slowly, and improvement may not be apparent for at least six weeks. The multifactorial causes of acne necessitate a combined approach for successful treatment.

Improvement of the adolescent’s overall health status is part of the general management. Adequate rest, moderate exercise, a well-balanced diet, reduction of emotional stress, and elimination of any foci of infection are emphasized as part of general health promotion. Gentle cleansing of the face with a mild soap once or twice daily is usually sufficient. For some adolescents, hygiene of the hair and scalp appears to be related to the clinical activity of acne. Acne on the forehead may improve if an adolescent brushes his or her hair away from the forehead and shampoos more frequently.

Topical retinoids such as tretinoin (e.g., Retin-A) are the only medications that effectively interrupt the abnormal follicular keratinization that produces microcomedones, the invisible precursors of the visible comedones. Retinoids are recommended as the first-line treatment for most forms of acne.⁸ Retinoids can be extremely irritating to the skin, and adolescents must be educated to use a retinoid product correctly. Creams are less irritating than gel formulations, which are less irritating than a liquid. The patient should be instructed to use a pea-sized dot of medication; this total amount is applied on three main areas of the face and gently rubbed into each area. The medication should not be applied until at least 20-30 minutes after washing to reduce the burning sensation. The daily use of a moisturizer helps diminish the drying effects of retinoid treatment. Sun exposure should be avoided and sunscreen applied daily because the skin will become photosensitive from the medication and severe sunburn may occur. Applying the medication at night and using a sunscreen with an SPF of at least 15 in the daytime provide protection.

Topical benzoyl peroxide (such as Benzac) is an antibacterial agent that inhibits the growth of P. acnes. Benzoyl peroxide is effective against both inflammatory and noninflammatory acne. The medication is available as a cream, lotion, gel, or wash. Benzoyl peroxide soaps are convenient because they can be applied in the shower and will help treat acne on the chest and back. Patient education about the bleaching effect of the peroxide on sheets, bedclothes, and towels is helpful. The adolescent can be reassured that his or her skin will not be beached. By gradually increasing the strength and frequency of application, the adolescent can help the skin adjust to the drying effects of the medication.

When the acne consists of inflammatory lesions in addition to comedones, a topical antimicrobial agent may be prescribed. Topical antimicrobials combined with benzoyl peroxide are more effective than topical antimicrobials alone. Retinoids in combination with antimicrobials also improve the penetration of these topical agents and are the only way to address three of the pathogenic causes of acne: keratinization, P. acnes, and inflammation. The use of combination topical antimicrobial products will help prevent the development of antibiotic-resistant strains of acne.⁸ The nurse should encourage patience when treating acne; the adolescent should not expect to see improvement until after six weeks of treatment. The adolescent and parent should be told that acne will reoccur if treatment is not continued; that is, the treatment does not cure the chronic condition.

Systemic antibiotic therapy is initiated when moderate to severe acne does not respond to topical treatments.⁶ Oral antibiotics are considered extremely safe even when given for years as part of acne treatment. Tetracycline, erythromycin, minocycline, doxycycline, clindamycin, and trimethoprim-sulfamethoxazole are oral antibiotics commonly used to treat acne. Resistance to antibiotics may develop, especially with tetracycline and erythromycin. Resistance can be prevented with judicious use of oral antibiotics and avoidance of topical antibiotics in combination with oral treatment.

Females with mild to moderate acne may respond to topical treatment with the addition of an oral contraceptive pill. Oral contraceptive pills reduce the endogenous androgen production and decrease the bioavailability of the woman’s circulating androgens. Research has demonstrated that combination oral contraceptive pills containing levonorgestrel, gestodene, and desogestrel as the progestin have effectively decreased acne in women.⁹

Isotretinoin (Accutane), a very potent and effective oral agent, is reserved for severe, cystic acne that has not responded to other treatments.⁹ Adolescents with multiple, active, deep dermal, or subcutaneous cystic and nodular acne lesions are treated for 20 weeks. Dry skin, dry eyes, dry mucous membranes, nasal irritation, decreased night vision, photosensitivity, arthralgia, and headaches may occur. Adolescents receiving this medication should be monitored closely for depression, depressive symptoms, and suicidal ideation.¹⁰ Isotretinoin is absolutely contraindicated in pregnant women because of its severe teratogenic effects. A negative pregnancy test must be documented before starting treatment with isotretinoin in female patients. Sexually active young women must use an effective contraceptive method during treatment and for one month after treatment. Patients receiving isotretinoin should also be carefully monitored for elevated cholesterol and triglyceride levels.⁹

Gynecomastia

Gynecomastia is the benign bilateral or unilateral breast enlargement that occurs in young boys during puberty. Approximately half of adolescent boys have transient gynecomastia, which usually persists for less than a year and is nearly always resolved by three years.¹¹ Fatty breast enlargement can be difficult to differentiate from true gynecomastia, especially in obese males. When the onset of gynecomastia is prepubertal or at SMR 5, the adolescent should be evaluated for adrenal or gonadal tumors, liver disease, or Klinefelter syndrome. Gynecomastia may also be drug induced; calcium channel blockers, cancer chemotherapeutic agents, histamine-2 receptor blockers, anabolic steroids, and oral ketoconazoles have all been shown to cause the disorder. The use of marijuana may also cause gynecomastia.¹²

Treatment usually consists of reassuring the adolescent and his parents that the changes are benign and temporary. The adolescent may benefit from the knowledge that it occurs in more than 50% of his peers.¹¹ If gynecomastia persists or is extensive enough to cause embarrassment, plastic surgery is indicated for cosmetic and psychological considerations. Administration of testosterone has no effect on breast development or regression and may even aggravate the condition.

Vision

The onset or worsening of myopia is common during the teenage years as a result of the growth spurt. Other than myopia, new eye problems in this age group are rare. Vision screening is usually performed in the school by nurses. The main goal is to detect new refractive errors. Adolescents with vision changes are referred for corrective lenses as appropriate.

Summary

Puberty affects many parts of the body. The changes are predictable in sequence and tempo. These dramatic physical changes are accompanied by significant cognitive and emotional changes. Understanding the physical changes is an essential foundation to understanding the psychological and social changes that occur during adolescence.

Chapter 2: Psychosocial Development

Along with the physical changes during puberty, adolescents experience dramatic cognitive and emotional changes. Adolescence is often described as a period of storm and stress; however, the majority of young people progress through the social developmental period trouble free.¹ But unlike the predictable physical development of puberty, the social and emotional development of the adolescent is more asynchronous, with wide variability in individual progress.

Most adolescents move from concrete thinking to the development of abstract thought processes.² This allows the young person to think beyond the present and consider the future. These changes in the quality of thinking, coupled with physical, social and emotional changes, give rise to a form of egocentrism. This may result in a rather self-centered, but not necessarily selfish, view of the world. There are four major types of egocentrism exhibited during adolescence: the imaginary audience, the personal fable, overthinking, and apparent hypocrisy.

Abstract thinking allows teens to wonder what others are thinking about. Coupled with their own preoccupation with the physical changes of puberty, this new thinking ability creates for them the notion that everyone is thinking about the same thing they are: namely themselves. This gives rise to the concept of the imaginary audience. In other words, “Everyone must be looking at me and thinking about me because that’s what I’m doing.” The young girl who has a pimple on her nose may feel that it’s the first thing that everyone sees when looking at her.

The personal fable is the concept that the laws of nature do not apply to oneself and that one’s thoughts and feelings are unique. Examples of the personal fable could include a boy’s belief that his first love is different and forever or a girl’s belief that that she won’t get pregnant, especially the first time, or that she won’t get a sexually transmitted disease if she has unprotected intercourse. In the latter example, the girl’s limited coping will cause her to come to the conclusion that something terrible cannot possibly happen, and she may continue the risky behavior.

Overthinking involves making things much more complicated than they really are. An example is the adolescent who gets her hair cut and determines her friend no longer likes her because the friend didn’t comment on the haircut.

Apparent hypocrisy is the notion that rules apply differently to the adolescent than they do to others. For example, an adolescent may feel that she should have free access to her parents’ computer while complaining that her parents are invading her privacy when they enter her room.  All these newly developing cognitive abilities, along with the emotional and physical changes of puberty, accentuate an adolescent’s feelings of uniqueness. This usually peaks during early adolescence and may frustrate and bewilder parents and providers.

These new thinking abilities make adolescents keen observers of the world and in particular adult behavior, which causes some of the conflicts that develop between teens and parents. Adolescents begin to consider values, and their new abstract thinking ability allows them to begin to challenge and question the values of the family.  Adolescents begin to understand concepts of good and evil and human nature. They realize that not all adults and authority figures are good people. They develop an awareness of the contradictions between what is said and what is done.

Developmental tasks

There are five developmental tasks adolescents have to achieve during the transition from childhood to adulthood. Adolescents achieve mastery of these tasks within their family, peer group, school, and community.

1. Identity development — discovering and understanding who they are as an individuals, experimenting with different personalities, achieving personal understanding and recognition from others and society regarding their uniqueness as individuals.
2. Autonomy or independence — becoming self-governing individuals by becoming less emotionally dependent on their parents, increasing independent decision-making, and establishing a personal code of values and morals.
3. Intimacy — forming close and caring relationships with other people. Friendships move beyond shared activities and interests to open, honest, loyal exchanges of confidences, in other words, trusting and loving relationships.
4. Sexuality — expressing sexual feelings and enjoying physical contact with others, and incorporating sexuality into a developing sense of self. This includes resolving questions about sexual values/morals and behaviors.
5. Achievement — being successful and competent members of society.  This depends on school achievement, evaluations of their own competencies, and the direction and advice they receive from parents, teachers, and friends.

Adolescent development is divided into three age-based groups: early adolescence (10-14 years); middle adolescence (15-18 years); and young adult (19-21 years).

Early adolescence (10-14 years)

During early adolescence, young people become extremely conscious of their bodies as they adjust to the vast physical changes of puberty. They begin to spend more time in front of the mirror seemingly self-absorbed with their appearance. The question most on the early adolescent's mind is “Am I normal?” Physical changes, especially the onset of secondary sex characteristics, increase anxieties about menstruation, wet dreams, masturbation, and size and appearance of breasts or penis.¹

Early adolescence is often a period of loneliness as teens begin to renegotiate relationships with parents and other significant adults while not yet comfortable in the adolescent subculture. Wide mood swings, shifting from what appears to be euphoria to sadness within a matter of minutes, are common. Young teens explore the meanings of these feelings and develop coping skills. This period is the young person’s first experience with the joys and pitfalls of independence.

The early adolescent begins to prefer to spend more time with friends than family. This is a normal and healthy step toward maturity, and a first stride towards independence. Decisions made about appearance largely depend on how friends look. The assertion of newly discovered independence is much easier when it is a group decision. Early teens become overly sensitive and critical of their appearance as well as the appearance of others. The peer group the adolescent chooses to be with and what that group does is an important determinant of risk behavior.³

Close, usually same-sex friendships provide a safe environment for young adolescents to experiment with new roles — a cheerleader, an athlete, a musician, a scholar, etc. — which is a significant part of identity development. Friendships also provide opportunities to develop and apply relationship skills such as compromise, conflict resolution, disappointment, and forgiveness, which are vital for intimacy. Close relationships with “best friends” are the context in which early teens practice trusting people outside of the family and where they learn how to be that trusted person for someone else. Contact with the opposite sex most often occurs in groups during early adolescence. These group experiences allow for opportunities to make decisions about behavior and values.

As an early teen’s thinking abilities develop, he or she spends a lot of time daydreaming to practice this new-found skill. In spending quiet time alone with their thoughts, early teens can plan their futures, imagine themselves in different roles, think about what really matters to them, and envision how they can make a difference. They set idealistic vocational goals, which change frequently. One day a teen may want to be an engineer, the next day a hairdresser or baseball player. Early teens need opportunities to discover where they excel and to experience what it feels like to make a contribution.

During early adolescence there is a desire for privacy. Young teens spend more time in their rooms alone listening to music, playing video games, or talking on the telephone. They are asserting independence from the family and spending time developing their sense of self. All teens need this opportunity, which can be a challenge for members of large families or those living in small homes.

One means of demonstrating independence and asserting a new role in the family is to challenge parental authority. The adolescent may become more argumentative and disobedient, refuse to do chores, and want to renegotiate family rules and expectations. In fact, with their increasing cognitive development and changing physical and social expectations, teens have more conflicts with their parents in early adolescence than at any other time during adolescence.

Early adolescents begin to develop their own value system and may experiment with value systems other than the ones they have learned from their families. This process affects the accomplishment of all the developmental tasks. Developing one’s own value system gives a teen the opportunity to experience autonomy and identity development, to resolve questions about sexual values/morals, to prioritize intimacy in relationships, and to determine what it means to be successful in life.

Sexual feelings begin to emerge in early adolescence. Masturbation, dirty jokes, lewd remarks to others, an interest in watching explicit sexual scenes in the media or looking at magazines with naked people are all part of understanding sexual feelings and deciding how to behave as a sexual person. The type of sexual experimentation may vary greatly depending upon the adolescent’s peer group and subculture. A small minority of early adolescents may have experimented with sexual intercourse.

Middle adolescence (15-18 years)

During middle adolescence, parental concerns peak as adolescents argue and renegotiate independence issues such as setting curfews, going to a party or a movie, and driving. The early teen asserted autonomy by picking fights with his or her parents. The middle adolescent is now using new thinking skills and independence to navigate the world without parents. This is a period of increasing anxiety for parents as they recognize the significant influence of the outside world. Parents often respond by attempting to pose more limits on the adolescent. This increase in parental anxiety often contributes to the conflicts experienced during middle adolescence.

Physical development is nearing completion for the middle adolescent. There is less concern about bodily changes, but increased interest in making the body more attractive. In a quest for autonomy and independence, middle adolescents defy the limits of their bodies and may have periods of excessive physical activity followed by periods of lethargy.

Middle adolescence is the essence of adolescence and its subculture. A peer group connection during middle adolescence provides a means to accomplish the developmental tasks of the period. Peer group involvement is intense and includes establishing a dress code, communication style, and code of conduct, all behaviors that contribute to identity development, autonomy, intimacy, and achievement. Middle adolescents tend to be more “non-adult,” preferring to live in parallel to the adults around them as opposed to the anti-adult behavior seen in early adolescence.

Sexual drives emerge, and the development of a sexual identity comes into clearer focus as middle adolescents begin to explore their ability to attract a partner. Frequently, physical urges precede emotional maturity, and social pressure to experiment with sex is great. Increasing concern about peer acceptance and limited experience can lead to unhealthy risk-taking and behavioral experimentation.³ These behaviors might include smoking, use of alcohol, sexual activity, and drinking and driving. Parents need encouragement to monitor activities and friends; this is particularly challenging because the adolescent spends more time away from home.

Middle adolescents develop more realistic vocational goals as they begin to realize their strengths and limitations. Adolescents lacking adequate environmental and economical resources may have a limited range of vocational opportunities. For those who are physically or cognitively challenged, additional guidance may be necessary to realistically assess their strengths and limitations.

Young adult  (19-21 years)

Late adolescents relate more to individuals than the peer group as a whole through the achievement of emotional autonomy. Selection of a romantic partner is based on individual preferences and less on the opinions and values of the peer group. Teens are now perfecting more advanced relationship skills of intimacy such as honest sharing and unconditional support and forgiveness. Young adults also have a more mature understanding of their sexual identity.

Behavioral autonomy is achieved, as late adolescents are capable of understanding the consequences of actions and behaviors. They have developed value autonomy demonstrated by a rational and realistic conscience with refinement of moral, religious, and sexual values.⁴

Vocational goals are generally achieved during late adolescence. Skills for future employment are obtained through post-secondary education, apprenticeships, or on-the-job training. This is a time of excitement and anxiety as the young person makes the final separation from the family. The late adolescent begins to relate to the family as an adult. The search for autonomy is moving from an adamant need for independence to a realization of the importance of interdependence.

Nursing implications

A general understanding of the developmental tasks of adolescence provides a framework for assessing the individual adolescent. Although no individual adolescent will fit exactly into the description of the phases and tasks as outlined, most will follow the general patterns. Nursing interventions and teaching strategies are most successful when they take into consideration the developmental level rather than just the chronological age of the individual or group of adolescents served.

Parents generally lack a clear understanding of adolescent cognitive and social development. The nurse can play an important role in explaining normal adolescent development to help parents understand adolescent behaviors. For example, parents’ fears about the lonely early adolescent who appears to have trouble negotiating friendships can often be allayed when placed in the framework of normal adolescent development.Understanding the impact of egocentrism will relieve the parents’ fears that their child is uniquely self-centered.

Chapter 3: Nutrition During Adolescence

Adequate nutrition is essential to support the dramatic physiological changes that occur during adolescence.  During this period, the adolescent will likely gain about 20% of his or her adult height and 50% of adult weight.

The rate of linear growth accelerates with puberty and at its peak is second only to the growth of an infant. The total nutrient needs are greater than at any other time in the life cycle.¹ 

Nutrition is also critical to the adolescent’s psychosocial development. Nutrition is a prime arena for adolescents to assert their autonomy; they have opportunities to control what, how, where, and when they eat.

It is an important vehicle for developmental mastery. Emotional maturity allows adolescents to develop their own value systems and make their own decisions about food.

Adolescents begin to spend more time eating with friends than with family, thus, there is the inherent opportunity to make good and bad food choices.

Many influences on eating behavior originate outside the home. By adolescence, the average child has likely seen more than 100,000 food commercials, most advertising high-fat foods and simple carbohydrates.² Adults can play a major role in encouraging adolescents to form reasonable eating habits by giving them greater responsibility and choice within a range of nourishing foods. Just as they learn about management of money and job responsibility, teens should learn to adequately nourish themselves by having opportunities to purchase and prepare healthy meals for themselves and others.

The emotional and cognitive changes that occur during this time will influence adolescents’ need to explore with food just as they influence the need to experiment with drinking, smoking, and sex. With encouragement, adolescents can be creative with menu planning and food selection. When nutritional choices threaten or interfere with health or lead to life-compromising outcomes, nurses need to intervene.

Body mass index

Body mass index is an anthropometric index of weight and height that is defined as body weight in kilograms divided by height in meters squared. BMI is sex- and age-specific for children ages 2-20 years old. BMI is a screening tool useful for identifying people who are underweight or overweight. BMI is not a diagnostic tool. For example, a muscular, athletic adolescent may have a high BMI for his or her age or high weight-for-stature. To determine whether the adolescent has excess fat or is overweight, a complete assessment is needed that may include triceps skinfold measurements, family history, weight history, and assessments of diet, health, and physical activity.

Dietary education materials are readily available through the U.S. Department of Agriculture’s new MyPyramid. This interactive and individualized tool replaces the 1992 Food Guide Pyramid. MyPyramid.gov is the access point for this food guidance system. Health care providers can print useful handout materials or encourage adolescents to explore the easy-to-use website. The website includes the recommended daily total intake of each food group by age and sex. Serving sizes for all food types are shown graphically as well as described in weight or volume.  Adolescents require more servings from the bread, cereal, rice, and pasta group than adults do. Growth is rapidly occurring during this time and must be supported by adequate calories. Nine to eleven servings from the grain group should meet the energy needs of most teenagers. High-fiber grain products, such as whole wheat bread, brown rice, cereal, and potatoes, are good choices from this group. These foods provide carbohydrates, the body’s primary fuel source, and are necessary in greater amounts for teens who are active in athletics.³

Fruit and vegetable intake is often low for teenagers and adults, particularly the nutrient-rich dark green and orange vegetables. Fruits and vegetables are naturally low in calories and offer a wide array of health benefits. Knowledge of the health benefits of fruits and vegetables influences the choice of which foods are eaten. Many adolescents eat foods prepared away from home, which are much less likely to include fruits and vegetables. Educational efforts to improve fruit and vegetable consumption must include the parent because teens are usually not responsible for buying the household groceries.

Four servings from the milk, yogurt, and cheese group are necessary to support optimal bone growth and to build bone mass. Many teenagers, females in particular, do not meet the minimum requirement for calcium. A large percentage of the bone mass is acquired in the two years surrounding the onset of menses.⁴ Many people mistakenly think milk products are fattening despite the widespread availability of non-fat and low-fat dairy foods. Leafy-green vegetables are also an excellent source of calcium. Many foods such as orange juice, cereals, and breads have been fortified with calcium for those who do not consume dairy products. Weight-bearing exercise also contributes to the development of bone mass. About 90% of adult bone mass is established by the time an adolescent finishes her growth spurt.⁵ Therefore, teens must consume adequate calcium while they are growing.

Obesity

Recent data from the National Center for Health Statistics indicate that approximately one in five children in the U.S. and Puerto Rico are overweight.⁶ Obesity in adolescents remains one of the most challenging and frustrating diseases to treat. Children with a BMI at or above the 95th percentile, with or without complications, should undergo intensive evaluation and treatment.⁷ The highest prevalence rates are among children of  lower socioeconomic status and from certain ethnic groups (e.g., Hispanic and American Indian youth and African-American adolescent females).  About 70% of obese adolescents will become obese adults; this increases to 80% if the parent is overweight or obese.⁸ The etiology of obesity is multifaceted: genetic, environmental influences, and inactivity. Complications of obesity include orthopedic disorders, hypertension, dyslipidemias, sleep disorders, gallbladder disease, heart disease, insulin resistance, and diabetes. The most immediate consequence for overweight youth is social discrimination that is associated with lower self-esteem and depressed affect.

In addition, any adolescent with a two or more unit increase in BMI during the previous year; a family history of obesity, hypertension, heart disease, and diabetes mellitus; or a significant concern about his or her weight should receive an in-depth medical assessment. The treatment goal during the growth periods for overweight adolescents is to maintain the current weight while growing normally in height.

Obesity treatment focuses on health rather than appearance. A problem for today’s youth is learning how to balance food intake with fitness to maintain a stable, healthy weight. Lifestyle changes including healthy eating, a reduction in dietary fat and concentrated sweets, and gradual targeted increases in physical activity with a reduction in sedentary activities are the components of a successful weight-loss program. Dietitians providing outpatient counseling aim for a 1-2 pound weight loss per week.¹  Weight control should be considered a lifelong process. Sustainable programs focus on gradually changing the family’s physical activity and eating habits. This requires the involvement of the parents or guardians in the nutrition counseling process.

Exercise should be built into regular routines for families. The popularity of television and computer and video games has made a sedentary lifestyle the norm. Adults need at least 30 minutes of moderate physical activity most days; children and adolescents should get at least 60 minutes. Nurses can advocate for daily, quality physical education in all school grades and healthy food choices at school.

Anorexia and bulimia

Harmless fads that come and go are part of the teen years. But the effects of fad diets can be permanent. Pressure to be thin from friends or parents — or the media — can push a teen into trying to diet to lose weight when it is not necessary.  Fad dieting can keep teens from getting adequate nutrition with a resulting negative effect on growth. The consequence could be an eating disorder; anorexia nervosa and bulimia nervosa are the two most common.⁸

The signs and symptoms of eating disorders typically fall into three categories: behavioral signs, emotional signs, and physical signs. Some behavioral signs are the following of a restrictive diet, preoccupation with the type of food rather than the amount, restricted fat content, weight preoccupation and frequent weight checks, meals spent away from family, excessive bathroom time, and excessive exercise. Physical symptoms include weight loss, menstrual irregularities or cessation, fatigue, dizziness, abdominal pain, bloating, hair loss, dental changes, and sleep disturbances. The teen may also experience a wide range of emotions such as perfectionism, sadness, irritability, anxiety, frequent complaints about appearance, and expressions of worthlessness. The medical complications that follow an eating disorder can include delayed growth and development, osteoporosis, gastrointestinal problems, dental changes, cardiac abnormalities, and suicide.

The precise cause of anorexia nervosa is not known; a combination of biological, psychological, and social factors underlies the etiology. Specific populations appear to be more at risk for developing an eating disorder because of their focus on thinness. This includes athletes (especially gymnasts, figure skaters, and runners), dancers, models, college students, and teens in general.  Some factors that contribute to the development of eating disorders are genetic predisposition, vulnerable personality, societal pressure to be thin, upper/middle socioeconomic status, frequent dieters, someone who has experienced major life changes, and the onset of puberty.  The peak age of onset for anorexia nervosa is 13-18 years. 

The diagnostic criterion for anorexia nervosa is:¹⁰

• A refusal to maintain minimum normal weight
• An intense fear of gaining weight
• Disturbed body image and self-esteem
• Amenorrhea

The diagnostic criterion for bulimia nervosa is:¹⁰

• Recurrent binge eating more than twice a week for more than three months
• Purging, exercising, or fasting to prevent weight gain
• Self-esteem determined by body shape and weight
• Body weight may be low, normal, or high

The treatment of eating disorders is complex; effective treatment requires a long-term, multidisciplinary team approach. At the time of diagnosis, the goal is to replace the nutritional stores and may require hospitalization and careful monitoring. Long-term therapy generally involves individual and family therapy. Co-existing conditions are common, particularly obsessive compulsive disorder and substance abuse.

Nutrition for the adolescent athlete

Ideally, adolescents develop exercise habits that last throughout their lifetimes.  Everyone should participate in some kind of physical activity that he or she enjoys.  The basic elements of fitness are cardiorespiratory function, muscular strength, endurance, and flexibility. Fortunately, a number of teens are involved in school athletics. Athletes require specific nutritional support to maintain normal growth and physical maturation in spite of the increase in physical demands on the body.  The amount of additional energy required will depend on the intensity, the duration, and the type of exercise.  

The best nutrition for teen athletes is to eat three meals daily at established times, with appropriate snacks, and a variety of foods ensuring adequate nutrient intake.  Additional energy is best utilized if it is supplied as complex carbohydrates. High levels of protein are counterproductive and can lead to dehydration and increased calcium losses. Nutritional supplements are not necessary for the adolescent with adequate food consumption.

To support normal growth, teens should maintain their weight at an optimal level over the long run, rather than manipulating weight weekly or seasonally, which may occur with adolescents competing in certain sports like wrestling and rowing.¹¹  Anabolic steroids taken to increase weight and muscle mass can stunt growth and disturb development of secondary sex characteristics. Those who repeatedly gain and lose weight rapidly through drastic dietary and related manipulation may develop lifetime unhealthy eating habits.

Fluids are an important and often overlooked nutrient for teen athletes. Adequate hydration controls the body temperature and is necessary for all body functions. Thirst is not a good indicator of fluid needs.  A person can lose up to 2 quarts of fluid before he or she is thirsty, and thirst can be quenched before fluids are replenished. Adequate hydration can be obtained with 1 cup of water every 15 minutes, two hours before activity with continuation during an event. After the event, 2 cups of water should be consumed for every pound lost during participation. Replacement of electrolytes can be accomplished with balanced meals. Sports drinks have been found to be beneficial only in events consisting of more than 90 minutes of continuous activity or as a method to increase the sensation of thirst to encourage young athletes to drink enough fluid for adequate hydration.¹²

The young female athlete may be at risk for adverse reproductive effects of inadequate food intake. The most common clinical indications of potentially detrimental effects of exercise on an adolescent's reproductive cycle include 1) delayed menarche, 2) anovulation associated with dysfunctional uterine bleeding, and 3) oligomenorrhea or amenorrhea with hypoestrogenic states.¹³ Researchers have not been able to identify the exact mechanism of these menstrual changes. The most probable cause is at the hypothalamus level as a result of an imbalance of the amount of energy in (food) compared to the energy out (exercise).¹³

Amenorrhea is so common among female athletes that it is misinterpreted as normal by athletes, coaches, and some health care providers.  Adolescents who exercise intensely with menstrual bleeding more frequently than every 21 days or at intervals of 35 to 120 days are likely to have chronic anovulation. These young women usually produce estrogen but have inadequate levels of progesterone. Unopposed estrogen can lead to endometrial hyperplasia and theoretic risk of endometrial adenocarcinoma.¹³

Any adolescent athlete with amenorrhea requires medical evaluation to rule out other causes of the menstrual changes and to assess for disordered eating.¹³ Sometimes a trial of decreasing the intensity or duration of exercise and improving nutrition will relieve irregularities. Careful evaluation by a health care provider who specializes in treating eating disorders as well as athletes is essential.

The Female Athlete Triad is a term first used by the American College of Sports Medicine in 1992 to describe three conditions that often occur together in female athletes: amenorrhea, osteoporosis, and disordered eating.¹⁴ Recognition and treatment of the triad in its early phases leads to better outcomes. Coaches, athletes, and parents need to be educated about the disorder, its symptoms, and risks for the athlete.  All female athletes should be screened at the pre-participation physical with a careful diet and menstrual history.  Treatment involves a decrease in the intensity of training and a gradual increase in caloric intake.

It is essential for nurses to evaluate the nutritional status of adolescents. Some adolescents appear to be overly vigilant about nutrition and food intake while others appear to lack interest or concern. Nutrition programs and interventions are most effective when they are developmentally appropriate and include the family. It is beneficial to enlist the support of a dietitian when counseling adolescents on weight loss, sports nutrition, and eating disorders.

Chapter 4: Risk and Resiliency

What do you do when faced with an adolescent who is entering into his or her first romantic relationship? You understand that developing intimacy and autonomy are important developmental steps for the adolescent, but you also know that close relationships may lead to sexual intimacy, unplanned pregnancies, and sexually transmitted infections. Do you advise the teen to “just say no” or do you consider each adolescent individually and try to determine the most appropriate intervention?

Adolescence inherently challenges youth to make decisions that can result in risky behavior. Risk factors are characteristics that increase the likelihood that adverse outcomes will occur. Examples include poverty, family conflict, parental mental illness, and early pubertal maturation. The adverse outcomes are risk behaviors such as smoking, unprotected intercourse, substance abuse, emotional distress, and school failure. Risk factors and behaviors may interfere with an adolescent’s transition to successful young adulthood.¹

Stress is universal and a driving force toward risky behaviors. It is the reaction to stress that determines coping ability. Resiliency is the ability to recover from or adjust to misfortune or change. Some of the most useful coping skills are based on flexibility: the ability to reframe a situation to find additional meaning and problem-solve alternative solutions. One is not either “resilient” or “not resilient.” It is the circumstance as well as available resources that allow resiliency in one instance and failure to cope in another. Nurses can play a role in shoring up the resources for an adolescent to enhance resiliency.

Researchers have identified some of the individual-specific assets that seem to protect adolescents. Resiliency experts believe that a positive, strength-based approach to adolescents reduces risk and produces more successful adults. Each of these characteristics has been shown to increase the ability of teens to deal with stress and to navigate successfully through adolescence:²

• Strong verbal and communication skills help teens connect with others, share their thoughts and feelings, and make them marketable in the workplace.
• An easy temperament is thought to be a positive protective factor. The adolescent with an easy temperament is even tempered and adaptable. This improves the teen’s ability to cope with disappointment, frustration, and day-to-day problems.
• Problem-solving capabilities allow youth to look for alternative solutions, to understand their role in the world, and to be accountable for their actions. Critical thinking and analysis are important components of problem-solving, from dealing with friendships to making important decisions about the consequences of risky behavior.
• Humor, the ability to laugh at oneself, is essential. It is closely tied to being able to put one’s own situation in perspective, as well as the situation of others.
• Empathy allows adolescents to understand and appreciate the experiences of others. It helps them connect with the world from another’s perspective.
• Spirituality provides protection against feelings of despair while providing youth with a sense of meaning and connectedness in the world and with others.

Fostering resiliency in youth requires an environment that allows them to meet their developmental tasks. Adults in the lives of teens play an important role in creating this environment. It is critical as a society that we see adolescents as a resource to develop, not a problem to be solved. Several key components to assure resiliency have been identified.³ The first is a sense of future. Lack of expectations for the future results in hopelessness. Adolescents need opportunities to display competence through achievements. Teens can achieve and succeed in a variety of situations. Academics are a traditional yardstick of achievement, but there are numerous other opportunities inside and outside of school for recognition of success. For example, in the workplace youth can learn life and vocational skills as well as responsibility and economic gain. Another component that must be fostered for teens is a feeling of usefulness. This can be achieved through opportunities for accountability, through community involvement, by contributing to the greater good, and through acquiring social skills.

To become resilient, young people need to have a sense of belonging, to feel loved, and to be secure. This most often comes from trusting adult relationships at home, at school, and in the community.  A sense of belonging allows teens to formulate their own value system by discussing ideas with others. It allows them to reflect upon the self in relation to others. They see themselves by looking outward. The final component for resiliency is a sense of power or control over fate. This is achieved by contributing to decisions that affect their lives. Teens with power enhance community programs, improve schools, and contribute to families. Teens with a sense of power are focused on the future because they have confidence that they can affect it.  Reducing risk and enhancing resiliency requires looking at the individual first rather than relying on textbook predictions. Consider where the teen is developmentally. Consider his or her cultural context. In other words, look at the whole picture.

Biological development can play a role in enhancing or compromising resiliency. Timing of pubertal changes is an important consideration. Early or late developers are at increased risk of engaging in risk-taking behavior as they try to fit in with their peers. When assessing developing teens, the nurse should identify and strengthen protective factors to balance the impact of the stress of early or late puberty.

Certain cognitive factors promote resiliency in an adolescent. Having at least an average IQ is associated with increased resiliency. People with problem-solving skills are more resilient, but teens lack decision-making experience. People are not born with the ability to make a decision; it is a skill that can be taught. In stressful, emotionally charged moments, teens are likely to regress to concrete thinking. Role-playing potentially stressful scenarios is an effective teaching strategy with teens because it allows them to make decisions while functioning at their cognitive best. They can then apply the same strategy when they experience these emotionally charged situations in their lives.

Self-esteem is both a protective factor and an outcome. During early adolescence, males and females measure themselves by physical attractiveness and peer acceptance. The self-esteem of early adolescent females decreases throughout junior high while males experience a rise in self-esteem.⁴ Teens with the perception of supportive parents are more likely to have a positive sense of self. Exposure to a variety of positive role models and participating in community service provide opportunities for positive identity development. Teens need to be involved in activities in which they feel competent and successful to incorporate those characteristics into their developing identity.⁵

Opportunities to develop and exercise autonomy meet the developmental tasks of adolescence and enhance resiliency. Through increasing independence teens learn consequences, develop skills in decision making, and learn their personal strengths and weaknesses. However, adult support and supervision are crucial. Parental monitoring and restricting unsupervised time are essential to reduce risk-taking behaviors. Emotional autonomy involves negotiating relationships, especially relationships with parents. Behavioral autonomy entails independent decision-making and acceptance of consequences. Value autonomy has to do with establishing a personal code of conduct or value system.

Families

The family remains an important source of support for adolescents. However, it’s not just having a family that counts, but what goes on within the family. Some of the factors found to be helpful include:

• The teen’s perception of closeness and open communication with parents, which provides a sense of connectedness for the teen
• Parent availability at key times, such as after school and at the morning and evening meal, which fosters a sense of belonging and provides opportunities for discussion
• The teen’s perception of parental expectations about both school performance and sexual abstinence. These expectations need to be both implicit and explicit.
• Limited access to alcohol, drugs, tobacco, guns, and unsupervised time in the home¹

During puberty as the adolescent strives to become more autonomous, families experience some distancing. This results in increased conflict between the parent and teen that begins during early adolescence. Adolescence is generally more difficult for parents than teens. Teens are experiencing everything for the first time. They are totally self-involved and fairly oblivious to the impact that their actions have on their parents. Parents, on the other hand, have all the experience to “know what’s best” but very little control over the teen or the environment to make sure their teen does exactly what they want. The parents’ perspective can be very unsettling.

To achieve individuation and autonomy, teens require guidance. Parents move from the role of director to consultant, and nurses can help them with this transition.  As teens experience individuation (that sense of who they are as unique and separate from their family) and autonomy (the sense of being responsible for their own decisions), there is often increased closeness with parents. Nurses can reduce teen involvement in all risky behavior by supporting family functioning and communication.

Parenting styles can have a great impact on the adolescent’s behavior. Two variables are used to classify parenting styles: responsiveness, which is the degree to which parents respond to needs in an accepting and supportive manner; and demandingness, which is the extent to which parents expect and demand mature, responsible behavior. The authoritative parent has a high degree of both variables: warm but firm. Parents put a high value on the development of autonomy and self-direction, but they  maintain ultimate responsibility. 

Authoritative parenting requires a relationship with the child and the skills to have that relationship. Parents need encouragement to spend time alone with their teens, driving, taking walks in the park, and making dates with their teens. Since many parents are at a disadvantage in terms of knowing what to do, nurses can play an important role in filling in this information gap. By facilitating support groups and notifying parents about books and other resources with helpful information for parents of teens, nurses can pave the way for improved communication and parenting skills.

Peers

Peers are often the first source of information about other families’ values, norms, and expectations. This exposure to other family styles may cause teens to question their own family’s values and norms. These questions may fuel the challenges adolescents begin to express toward family norms, particularly related to expectations to participate in family activities.

The quality of peer interaction changes as teenagers mature. Early adolescents spend most of their time in small same-sex groups that then evolve into bigger, mixed-sex groups by middle adolescence. In late adolescence, teens are more comfortable and competent in one-on-one relationships. Friendship networks are strongly associated with resiliency. These networks are developed at school, through extracurricular activities, in religious organizations, and at work.

Early teens are more influenced by their peers than late teens. Fortunately, most teens are swayed by prosocial peer pressure, that is, peer pressure to conform to societal norms.

The quality of a teen’s peer relations is more important than the number of activities in which the teen is engaged. An adolescent who is involved in minimal extracurricular activities is inherently at no greater risk than a socially active adolescent if he or she is able to identify one or two key friendships. The adolescent who is unable to identify a close friend or feels he or she does not have enough friends is at risk.

The quality and nature of prior relationships affects the adolescent’s peer relationships. For instance, teens with secure connections to their parental figure tend to be more successful connecting to peers.  A child who has made friends and learned to share and play by the rules during early childhood is very likely to have successful peer relations in adolescence. Good peer relations in adolescence predict positive mental health at midlife.

Friendships provide tenderness and a secure attachment. A friend is a source of social acceptance, providing teens reassurance of their worth as well as support. Intimacy requires self-disclosure and sharing of private thoughts. Having a friend helps the adolescent learn to meet this important developmental goal. In addition, a friend serves as a partner in identity development. Friends are sounding boards for ideas, values, and plans.

Loneliness is to be expected in early adolescence, but it is difficult for all involved, both teens and their parents. Being involved with a peer group not only allays that loneliness, but provides a safety net from peer-rejection. The ability to make and keep friends is a critical social skill.  Young people who self-disclose appropriately, provide emotional support, and can manage disagreements are teens who are most successful at making and keeping friends.⁶

Adolescents are less likely to be involved in risk-taking behavior when their parents know their friends and peers.⁷ Parents with concerns about the values and activities of the peer group can find opportunities for their teen to make other friends. In other words, link them to other teens with pro-social values. The peer group is highly influential; for example, the strongest predictor of drug use is having friends involved in obtaining or using drugs.

Schools

Longitudinal research with adolescents has shown that school connectedness is associated with lower participation in every risk behavior studied, including sexual activity, substance use, and violence.¹ The overall size of the high school has been shown to be more important than the individual class size. The ideal high school has 600-1,200 students.⁸

Parental involvement in school is important; however, it is not a critical component of an adolescent’s perception of connectedness to school. Adolescents who perceive that their teachers are caring and that the school environment is free of prejudice or discrimination from peers have the highest level of school connectedness.

Schools serve many functions for adolescents, not the least of which is as their chief educational arena.  As the adolescent develops, the school is a source of identity development. The adolescent begins to see himself or herself as the student, the athlete, the musician, the clown, the truant, or any other label, which is incorporated into his or her developing identity.

Students are vulnerable at times of transition. The move from elementary to middle or junior high school can be difficult academically and socially.⁹ Students are not prepared for the dramatic changes in expectations for organization, peer negotiation, and self-advocacy. It is often in one of these transition years that teens have to repeat a grade and begin to experiment with alcohol, marijuana, and tobacco.

Teens who change schools often are at greater risk for decline in academic performance and are at increased risk for school failure and eventually dropping out. The most academically and socially vulnerable teens arrive with the most inadequate skills to cope with transition.

School curriculum can support adolescent resiliency. Comprehensive life skills training includes violence prevention, stress management, handling peer pressure, and the development of decision-making skills. A health-promoting environment motivates teens to adopt health practices. Appropriate health-related policies are most effectively determined through close collaboration among health professionals, educators, and the community. Examples of health policies are an all-inclusive ban on smoking on school grounds and at school functions, physical activity requirements for all students, and the elimination of soft drinks in vending machines and cafeterias. Adolescent autonomy and competency can be enhanced through student responsibility for developing and promoting health activities.

Employment

Adolescent employment can be a major step toward independence through the development of self-reliance. Employment provides the opportunity for teens to learn responsibility for time management, teamwork, and money management. But there are potential risks inherent in adolescent employment. The employment opportunities are restricted; teens are mainly employed in jobs where the work is monotonous and boring with little or no variability in tasks. The skills necessary for these jobs rarely relate to what teens are learning in school. The responsibilities of a job may restrict teens’ opportunities to participate in extracurricular or family activities.

Twenty hours a week is the maximum that teens should work during the school year. Employment for more than 20 hours a week is associated with substance abuse and a decline in school performance.¹ Employed adolescents work with older people, who are more likely to use substances than school peers, and work provides the financial means to obtain tobacco, alcohol, and other drugs of abuse.

Jobs that provide apprenticeships allow teens to form mentorship relationships and increase their connections to other adults in the community.  While parents and schools can make a significant contribution to the well-being of youth, it requires the energy of an entire community to make sure that adolescents feel valued and learn the skills needed for adulthood.

Nurses working with adolescents have an opportunity and responsibility to advocate for youth. Professionals can promote programs and policies that protect youth and lead to the healthy development of adolescents. Nurses can help create settings for youth in which they feel a successful future is a reality.

Chapter 5: Communication

Frequently, one of the biggest pitfalls in working with adolescents is not a lack of information but an inability to communicate effectively. Silent teens, angry teens, parents not involved or overinvolved, too much time, not enough time, sensitive and hard-to-talk-about topics, consent and confidentiality issues… all add to potential problems when talking to teens.  A trusted relationship with a clinician skilled in communication is a key component in helping young people become successful adults.

Communication is not just words. Nonverbal communication can serve as an accurate reflection of feelings. It is relatively free of deception or distortion and may support, emphasize, or contradict the spoken communication. The following are some typical modes of nonverbal communication:

• Facial expressions 
• Eye contact
• Body posture
• Tone of voice
• Touch
• General appearance
• Silence

Verbal communication, like nonverbal communication, is open to interpretation depending on a person’s perception. Effective communication with adolescents requires the nurse to be attentive to the adolescent’s interpretation of the conversation. The developmental level of the adolescent and previous experience with the health care system influences perception and can lead to miscommunication. To increase effectiveness, it is necessary to respect the adolescent's individuality and meet the adolescent where he or she is developmentally, as an individual, and within his or her own culture. Respecting individuality is crucial for gaining trust.

Interviewing techniques

Establishing rapport sets the stage for the entire visit. The nurse should introduce himself or herself to the adolescent first and then the parent if present. Adolescents appreciate a demonstration of general interest in themselves; this can be done by a simple comment on appearance or enquiring about the teen’s day. Matching the pacing of the adolescent in conversation allows the adolescent to lead the interaction. Throughout the interview, rapport is enhanced when the nurse displays empathy toward the feelings and experiences of the adolescent.

The concerns of the adolescent should be taken seriously; allow the adolescent to express the problem initially, and then the nurse can expand and redefine the problem. Throughout the interview, the nurse can ensure mutual understanding through clarification and reflection back to the adolescent. For example, when asked a general question about his family, a 16-year-old boy might say, “My father is really strict; he is always telling me to do work around the house when I have other things I want to do.” The nurse may respond with reflection by saying, “It sounds like you get angry with your father when he prevents you from doing what you feel is important.” The adolescent can then either clarify what he actually feels or agree with this reflection.

Adolescent health care requires a careful balance of the alliance between the adolescent and parent while at the same time establishing boundaries. This requires the nurse to balance the attention displayed to both the adolescent and parent and ensure that each is heard and understood. 

Nonverbal techniques can enhance communication or serve as a barrier. The nurse should monitor his or her own reactions and body language throughout the interview. Matching language, voice, posture, and energy level of the teen and parent increases the comfort level for the patient. Subtle turns of the body can signal to the parent that the nurse is expecting an answer from the teen rather than the parent. Silence is often underused as a communication technique. When all else fails, used effectively, silence allows both the adolescent and the nurse to organize their thoughts. In the haste to complete an interview, nurses often underuse nonverbal communication techniques.

Conducting the interview    

Health care visits during adolescence are often the first opportunity for the young person to participate directly in the medical interview.  Attention to key interview points will enhance communication between the nurse and the young patient. When interviewing the adolescent, begin the interview with the adolescent’s presenting concern and expand from there, starting with least sensitive issues and moving toward the more sensitive issues. Always frame the interview questions within their proper context to help the adolescent understand why the information is important.

Ideally, more time is spent listening than talking. Realize that the adolescent is inexperienced in providing a health history and discussing health concerns. Allow the teen the time to describe the concern and avoid interruptions. The adolescent should lead the interview and gradually expand upon the problem. As the problem is defined, clarification and summarization ensures mutual understanding. Throughout the interview it is best to avoid writing, especially when discussing sensitive issues.

As adolescents share information about risk behavior, avoid the temptation to lecture, and maintain a neutral stance. An adolescent who discloses personal behavior is taking an emotional risk. A strength-based approach requires the nurse to consider the risk in the context of the young person’s life. Rather than only hearing what the adolescent is doing wrong and lecturing about behavior change, it is important to listen for what is right, as well. Through recognition of strengths the nurse can more effectively guide the adolescent to build new capabilities by means of these strengths.¹

One of the challenges inherent in adolescent health care is balancing the relationship and time spent with the parent and the adolescent. Balancing the care of the adolescent within the context of the family is the essence of family-centered care, be it in the school, the health care arena, or in the community. Clear boundaries should be established and efforts made to ensure that both the parent and adolescent have an opportunity to be heard.

Ground rules are established at the beginning of each health visit for adolescents. The discussion centers on the purpose of the visit from the perspective of both the teen and parent. The interviewer identifies what can be accomplished and a reasonable timeline.

Notify the adolescent and parent that more of the conversation may be directed toward the teen, as compared to a traditional pediatric or child setting.

Occasionally parents are not a part of the visit because of the practice setting, work schedules, or adolescent preference. Remain mindful of what information the parent may need about the visit. Parents are usually the source of support necessary to make the plan work. Always ask about the parent and call when necessary.

Consent and confidentiality

The traditional requirement that a parent give consent for medical treatment of a minor child is based on the principle of parental rights and the presumed incapacity of minors.² Parental rights is a time-honored principle that acknowledges parents as having the right to make decisions for their children while they are minors. The law has also generally presumed that minors are not competent to consent to medical care because they are immature and lack the legal capacity to enter into binding contracts. Numerous exceptions to the requirement for parental consent exist. The exceptions are based on the type of services being sought or the status of the minor. For example, parental consent is usually not required for a minor seeking care in an emergency or for the treatment of sexually transmitted diseases. Examples of minor status exceptions to parental consent may include married minors, minors in the military, and minors who themselves are parents.

Confidentiality refers to protecting the right of the individual to privacy. Confidentiality must be maintained for adults, generally defined as those 18 years of age. Numerous laws protect health care information. When nurses work with adolescents, both the adolescent and parent must be aware of their rights to privacy within the current health care setting. This may differ from setting to setting and is regulated by institutional policies and state and federal laws.

When considering reproductive health, there are differing opinions on allowing minors the right to consent and, therefore, confidentiality. Proponents of mandatory parental involvement believe it encourages abstinence; teens will abstain from sex if their parents are involved in the acquisition of contraception. Parental advocates also believe it is within the rights of parents to make health care decisions for their children.³

The argument for confidentiality is based on the premise that ensuring confidentiality for the minor is crucial to encouraging openness and access to care. Supporters of this view acknowledge that parental involvement is desirable and seek to work with the minor to include parents, but not at the expense of health care intervention.³

The parameters of confidentiality should be part of every initial health care visit. Ideally, the discussion occurs with the adolescent and parent or guardian together.⁴ Some health care settings follow children from infancy through young adult or into adulthood. These agencies need to establish the age at which separate interviews and the issues of confidentiality will be addressed. Traditionally, confidentiality is ensured except when the adolescent discloses information about suicide, homicide, or abuse. In these circumstances, the teen is informed that another adult needs to be involved. The adolescent does not have the option about disclosure but can decide how the information will be shared. The adolescent can tell the parent alone, the nurse can tell the parent, or they can tell the parent together.

Confidentiality policies should not be rigid. There are circumstances beyond the traditional situations of homicide, suicide, and abuse in which it is in the best interest of the adolescent to involve the parent. Each situation should be considered individually.  The developmental level of the adolescent plays an important role in the decision to encourage disclosure.⁵

Providing care to adolescents requires a general interest in adolescents; with that basic framework, nurses approaching adolescents in a sensitive, flexible, and developmentally and culturally appropriate manner will be effective. The ability to communicate effectively with teens improves with time and experience. With an awareness of personal biases and a trusted mentor or co-worker with whom to discuss challenging situations, the nurse can continue to grow and improve his or her ability to guide and support adolescents.