INTRODUCTION AND OVERVIEW

The essence of good adolescent healthcare consists of:

Adolescent health falls outside biological paradigms, clinical medicine and its usual classifications, and outside the classic distinctions between physical and mental health, between medical and social aspects of health, and between curative and preventive care. Adolescent healthcare is a bio-psychosocial field, one which, by its very nature, requires an integrative approach.

While young people are often considered a relatively healthy population group, current indices are poor for at least 20–30% of young people. Their health problems are mainly psychosocial and, certainly in clinical settings, likely to be overlooked. Young people are notoriously reluctant to seek services to address these social and psychological self-concerns.¹,² They are also involved in health risk behaviours earlier than in past generations. Many engage in behaviour that threatens their health and wellbeing, and there is increasing evidence that many problem behaviours in young people are interrelated. Young people with conduct disorders, for example, are also likely to engage in tobacco, alcohol and substance use, to engage in high-risk sexual behaviour and to experience academic failure.³

A note about terminology: the term young person refers to someone aged 12–25 years. The word adolescent will be used where it is more appropriate to refer specifically to the developmental processes occurring during these years.

NORMAL ADOLESCENT DEVELOPMENT

Adolescence has been described as:

Adolescence begins with the onset of puberty and ends with the acquisition of adult roles and responsibilities. It is characterised by rapid change in the following domains:⁵

THE EXPERIENCE OF PUBERTY

Puberty involves the most rapid and dramatic physical changes that occur during the entire lifespan outside the womb. Average duration is about 3 years and there is great variability in time of onset, velocity of change and age of completion. Height velocity and weight velocity increase and peak during the growth spurt.

The classic milestones of puberty are determined by Tanner’s sex maturity ratings. Tanner’s staging system is based on breast, genital and pubic hair changes, with Stage 1 being prepubertal and Stage 5 adult (Figs 56.1, 56.2 and 56.3).⁶ In girls, peak height velocity usually occurs at Stage 2–3 (around 12 years) and menarche (initiation of menstruation) at Stage 4. In boys, peak height velocity occurs at Stage 3–4 (14 years) and semenarche (initial ejaculation) at Stage 3.

FIGURE 56.1 Tanner stages of pubic hair development in girls

FIGURE 56.2 Tanner stages of breast development in girls

FIGURE 56.3 Tanner stages of pubertal development in boys

The experience of puberty is to have a changing body that feels out of control. Feelings of helplessness or persecution are common and may not abate until about 12 months after the growth spurt has ended. The typical irritability, moodiness and occasional aggressiveness, sexual arousal and unpredictable behaviour of the early adolescent are largely due to hormonal changes. Puberty tends to be conceptualised as a biological event, with emotional and psychological ‘side effects’. However, puberty may also be regarded as a cultural phenomenon, with each young person’s experience being influenced by the cultural milieu in which it occurs. In many cultures, for example, an event such as menarche remains somewhat taboo, while changing body shape for girls and boys may bring high levels of anxiety in our image-driven society.

The psychosocial impact of the timing of puberty affects girls and boys differently.

For those who mature earlier than average:

• boys seem to benefit—more relaxed, independent, self-confident and physically attractive

• girls seem to be disadvantaged—seen as less popular, appear withdrawn, less positive body image, lack confidence

• both are more likely to engage in more adult behaviours, although they tend to be physically rather than cognitively ready, associating with older peers.

For those who mature later than average:

• boys seem to be disadvantaged—less well liked and viewed as anxious, overly talkative and attention seeking

• girls seem to benefit—regarded by peers and adults as physically attractive, lively, sociable and leaders at school.

Physical, cognitive and psychological changes may be ‘out of sync’. For example, an early-developing, mature-looking girl may be psychologically immature and vulnerable.

NEURODEVELOPMENT