ADOLESCENCE

CHARMIE DUNGCA-ARRIBE, MD DPPS

Adolescence
10 20years
Young people who undergo rapid changes in
body structure and physiologic, psychologic &
social functioning social functioning
Hormonesset thisdevelopment
Adolescence
Adolescenceisincreasinglyrecognizedasalifeperiodthat
poses specific challenges for treatingdisease &promoting
health.
Specialized communication skills are needed to take an
accuratehistory, bearinginmindnewLIFEDOMAINSnot
applicable to children (sex & drugs) and adding
communication&engagement of thefamilytothestandard
adult consultation.
Adolescence
Factors that profoundly affect the development
course:
Gender
Subculture
Physical stressor
Social stressor
Adolescence
PRIMARYCHALLENGESOFADOLESCENCE:
Theachievement of biological &sexual maturation
Thedevelopment of personal identity
Thedevelopment of intimatesexual relationshipswithan Thedevelopment of intimatesexual relationshipswithan
appropriatepeer
Establishment of independence&autonomyinthecontext
of sociocultural environment
Adolescence
Distinct periods:
EarlyAdolescence(10 13)
MiddleAdolescence(14 16)
LateAdolescence(17 20)
Pubertal development follows a predictable
sequence
Developmental tasks of adolescents
(an overview)
Duringadolescenceyoungpeoplewill:
Negotiatepuberty&thecompletionof growth
Takeonsexuallydimorphicbodyshape
Develop new cognitive skills (including abstract thinking Develop new cognitive skills (including abstract thinking
capacities)
Developaclearer senseof personal &sexual identity
Develop a degree of emotional, personal & financial
independencefromtheir parents
Psychosocial Development
(an overview)
The physical changes that signal the start of adolescence
occur alongsidepsychological &social changesthat markthis
periodasacritical stageof becominganadult
Freuds psychosexual development, viewed adolescence as
recaptitulation of the development of sexual awareness in recaptitulation of the development of sexual awareness in
infancy.
Piagets cognitive development, sees the development of
abstract thinkingabilitiesasmakingpossiblethetransitionto
independent adult functioning
Psychosocial Development
(an overview)
PSYCHOLOGICAL CHANGES:
Early adolescence abstract thinking is the ability to use
internal symbolstorepresentreality
Abstract thinkingenablesteenerstothink hypotheticallyabout
thefutureandassessmultipleoutcomes. thefutureandassessmultipleoutcomes.
It is important to the therapist to know whether the young
person has a poorly or well-developed capacity for abstract
thinking, as this capacity is essential for informed consent to
treatmentandbeabletomanageillnessregimenindependently
Psychosocial Development
(an overview)
SOCIALCHANGES:
Adolescenceistheperiodwhereindependenceisachieved.
There is a change in the balance of independence and
dependencewithother partsof theteenerssystem(parents,
peers, community, &HCP). peers, community, &HCP).
Timingof thesechangesdependsoncultural expectationsof
theenvironment wherethepersonlives.
Psychosocial Development
(an overview)
SOCIALCHANGES
Knowledgethat hasbeenhandeddownbyadultsisof little
value.
Adolescents may strongly believethat no other person can
haveaclear understandingof howayoungpersonfeels haveaclear understandingof howayoungpersonfeels
Physical Development
(an overview)
Thechangesfromprepubertytofull reproductive
capacity maketakeas little as 18 months to as
longasfiveyears.
Thecommonest clinical concernsabout puberty Thecommonest clinical concernsabout puberty
are: particularlyinboys.
DELAYEDPUBERTY
SHORTSTATURE
Physical Development
(an overview)
CAUSESOFDELAYINPUBERTY:
Constitutional delayof growth&puberty(boys)
Poor nutrition
Chronicillness
Eatingdisorders
Severepsychosocial stress
Disorder of hypothalamic-pituitary-gonadal axis
Physical Development
(an overview)
CAUSESOFEARLYPUBERTY:
Familial
Obesity(girls)
Benignnormal variantsof pubertal timing:
Isolatedtherlarche(earlybreastdevelopment)
Prematureadrenarche(earlypubichair development)
CNSabnormalities
Gonadotropinindependentprecociouspseudopuberty
EARLY ADOLESCENCE
AGES 10 13 YEARS
Early Adolescence
BIOLOGICDEVELOPMENT
PUBERTY isthebiologicprocessinwhichachild
becomesanadult.
Changesnoted: Changesnoted:
Appearanceof secondarysexcharacteristic
Increasedtoadult size
Devt of reproductivecapacity
Early Adolescence
6y/ o adrenal productionof androgen
Underarmodor
Faint genital hair (adrenarche)
LH(luteinizinghormone)
FSH(folliclestimulatinghormone)
Rise progressively thru middle adolescence
without dramaticeffect
Early Adolescence
Rapidpubertal changesbegin:
Increased sensitivity of the pituitary organ to
GnRH
Pulsatilereleaseof GnRH, LH, FSHduringsleep Pulsatilereleaseof GnRH, LH, FSHduringsleep
Increasesinthegonadal androgens/ estrogens
Early Adolescence
The resulting sequence of somatic & physiologic
changes giverise to theSexual Maturity Rating changes giverise to theSexual Maturity Rating
(SMR) or theTanner Stages.
Early Adolescence
SMRstagesarenot perfectlysynchronized
Pubichair
Breast Breast
Genital development
Boys Girlsdevelopment
SMR for girls
SMR
stage
Pubic hair Breast
1
preadolescent preadolescent
2
Sparse, lightly
pigmented, straight,
medial border of the
labia
Breast & papilla elevated
as a small mound,
diameter of areola
increased labia increased
3
Darker, beginning to
curl, increased in
amount
Breast & areola enlarged,
no contour separation
4
Coarse, curly,
abundant, less than in
adult
Areola & papilla form a
secondary mound
5
Adult feminine triangle,
spread to medial thigh
Mature, nipple projects,
areola part of a general
breast contour
SMR for boys
SMR
stage
Pubic hair Penis Testes
1
none preadolescent preadolescent
2
Scanty, long,
lightly pigmented
Minimal
change/
enlargement
Enlarged
scrotum, pink,
texture altered
3
Darker, starting to lengthens Larger
3
Darker, starting to
curl, in small
amount
lengthens Larger
4
Resembles adult
type but less
quantity, coarse,
curly
Larger, glans &
breadth
increase in size
Larger, scrotum
dark
5
Adult distribution,
spread to medial
thigh
Adult size Adult size
SMR FOR FEMALES
SMR FOR MALES
EarlyAdolescence
In girls, the 1
st
visible sign of puberty & the
hallmark of SMR2istheappearanceof breast budin
between8 12yrsold
Mensestypicallystart 2years later, duringSMR3-4
aroundthepeakof highvelocity
Early Adolescence
In boys, the 1
st
visiblesign &hallmark of SMR2 is
testicularenlargement, beginningat9yrsold.
FollowedbypenilegrowthduringSMR3
Theleft testisnormallyislower thantheright. Theleft testisnormallyislower thantheright.
40 65% of boys may experience unilateral or
bilateral breast hypertrophy at SMR3 d/ t excessive
estrogenicstimulation
Early Adolescence
<10%of boys, will havegynecomastiasufficient to
causeembarrassment &social disability
Breast swelling of <4cms in diameter will have a
90%chanceof spontaneousresolutionwithin3yrs 90%chanceof spontaneousresolutionwithin3yrs
Early Adolescence
Gynecomastia:
Presenting later in puberty, occurring in the prepubertal
period, occurring in the absence of signs of pubertal
development maybepathologic
work up medications (H2 blocker, psychotropics) drugs work up medications (H2 blocker, psychotropics) drugs
(anabolic steroid), medical history (Klinefleter syndrome,
testicular failure, thyroiddse, tumor)
Early Adolescence
Growthaccelerationbegins in early adolescence but
peakgrowthvelocitiesarenot reacheduntil SMR3-
4
Boystypicallypeak2 3yearslater thangirls, and Boystypicallypeak2 3yearslater thangirls, and
continuetheir linear growthfor 2-3 yrs after the
girlshasstopped
Early Adolescence
Asymmetricgrowthspurtbeginsdistally
Enlargement of thehands&feet
Followedbythearms&legs
Finallythetrunk&chest
Youngadolescentslookgawkybecauseof this
Elongation of the optic globe often results to
nearsightedness
Early Adolescence
COGNITIVE&MORALDEVELOPMENT
Formal logical thinking(abstract thought)
Abilitytomanipulatealgebraicexpressions, reason
from known principles, weight many points of from known principles, weight many points of
view, thinkabout processof thinkingitself
Early Adolescence
Whenemotional stakesarehigh, adolescentsmay
regress to more concrete operational &/ or
magical thinking
Transition fromconcrete to formal operations Transition fromconcrete to formal operations
follows fromquantitativeincrease(of knowledge,
experience & cognitive efficiency) rather than
qualitativereorganizationof thinking
Early Adolescence
Cognitive development differs by gender, as girls
developearlier thanboys
Development of moral thinking roughly parallels
cognitivedevelopment.
Youngchildrenviewtheir relationshipwithadultsin Youngchildrenviewtheir relationshipwithadultsin
termsof power &fear of punishment
Preadolescentsbegintoperceivetheright &wrongas
absolute&unquestionable.
Punishment or rewards must be fair, otherwise
adolescentsmaycomplainor becomeangry
Early Adolescence
SELFCONCEPT
Self consciousness increases exponentially in
responsetosomatictransformation
Self awareness at this age centers on external
characteristics,vs. introspectionof later adolescence
Early Adolescence
Elkindsimaginaryaudience
Feelsthat everyoneelseisstaringat them
Media has profound influence on an adolescents
senseof identity senseof identity
Approximately7hours/ daymediaexposure
Girlsdevelopdistortedsenseof femininity, risk to
viewthemselvesasoverweight &mayleadtoeating
disorders
MEDIA influence
Early Adolescence
(cont.) onself-image&media
Boys similarly may have masculine confusion
leading to self-doubt, insecurity, misleading
conceptionsabout malebehavior conceptionsabout malebehavior
Early Adolescence
RELATIONSHIPS(family, peers, society)
Young teens become less interested in parental
activity & more interested in the peer group,
typicallyof thesamesex typicallyof thesamesex
Seekmoreprivacy, leadingtofamilydiscord
Stylisticchangesaccordingtopeer group
Early Adolescence
BELONGINGisall important
In one-to-one friendships, boys & girls differ in
important ways
Femalefriendshipcentersonsharingconfidences Femalefriendshipcentersonsharingconfidences
Malerelationshipsfocus moreon sharedactivity &
competition
Early Adolescence
ONSEXUALITY
Includes not only sexual behaviors but also
interests, fantasies, sexual orientation, attitude
towardssex, awarenessof sociallydefinednorms towardssex, awarenessof sociallydefinednorms
It isnormal tocomparethemselveswithothers
Early Adolescence
ONSEXUALITY
Inboys, ejaculationoccursfor the1
st
timeduring
masturbation, thennocturnal emissionsandmay masturbation, thennocturnal emissionsandmay
beacauseof anxiety
IMPLICATIONS ON THERAPISTS
In interviews, parents are interviewed prior to the
adolescent toprevent underminingthechildstrust.
Interviews&PEs, HCPshouldkeepinmindthat
physical maturationcorrelateswithsexual maturity physical maturationcorrelateswithsexual maturity
Psychological development correlatesmoreclosely
withchronological age
IMPLICATIONS ON THERAPISTS
Physical examinations of adolescents require consideration of
privacy&personal integrityaswell asrequiringadditional skills
suchasPubertal Assessment
For effectivetreatment inadolescence, MDsandtherapist need
to knowabout adolescent development if they areto manage
adeptlyissueson: adeptlyissueson:
Adherence(compliance)
Identity
Consent&confidentiality
Relationshipsbetweenyoungpeople&their families
IMPLICATIONS ON THERAPISTS
Bids for autonomy are normal (avoiding family
activity, demanding privacy, increasing
argumentativeness)
Risktakingislimitedtoearlyadolescence
Discipliningthroughnegotiationiscritical
IMPLICATIONS ON THERAPISTS
Children&adolescentsraisedbyparentswhouse
negotiation as part of child rearing have more
positive outcomes than those raised by positive outcomes than those raised by
authoritarian&permissivestyles
MIDDLE ADOLESCENCE
AGES 14 16 YEARS
MIDDLE ADOLESCENCE
BIOLOGICDEVELOPMENT:
Growthacceleratesabovetheprepubertal rateof 6-7
cm/ year
Ingirls, growthspurt peaksat 11.5y&thenslowsto
astopat 16y
Inboys, growthspurt startslater, peaksat 13.5y&
slowstoastopat 18y
MIDDLE ADOLESCENCE
BIOLOGICDEVELOPMENT:
weight gainparallelslinear growth, withadelayof several
months, adolescentsseem1
st
tostretchout thenfill out
Pubertal weight gainaccountsfor approx 40%of adult Pubertal weight gainaccountsfor approx 40%of adult
weight.
MIDDLE ADOLESCENCE
BIOLOGICDEVELOPMENT:
Musclemassincreases
After several months: increasedinstrength
Boysshowgreater gainsinbothmass&strength Boysshowgreater gainsinbothmass&strength
MIDDLE ADOLESCENCE
BIOLOGICDEVELOPMENT:
LEAN BODY MASS, approx 80%in prepubertal
child, increasesinboysto90%and decreases ingirls
to75%assubqfatsaccumulate to75%assubqfatsaccumulate
Bone maturation correlates closely w/ SMR bec
epiphyseal closureisunder androgeniccontrol
MIDDLEADOLESCENCE
BIOLOGICDEVELOPMENT:
Wideningof theshouldersinboysandof thehipsin
girlsisalsohormonallydetermined
Doublinginheart size&lungvolumecapacityfrom Doublinginheart size&lungvolumecapacityfrom
preadolescentnorms
BP, bloodvolume&hematocrit rise(particularlyin
boys)
MIDDLE ADOLESCENCE
BIOLOGICDEVELOPMENT:
ACNE & BODY ODOR androgenic stimulation of the
sebaceous&apocrineglands
Physiologicincreaseforsleepinessmaybemistakenfor laziness Physiologicincreaseforsleepinessmaybemistakenfor laziness
MIDDLE ADOLESCENCE
BIOLOGICDEVELOPMENT:
Sexual maturation is dramatic, menarche is
achieved in 30%of girls by SMR3 and 90%by
SMR4 SMR4
Menarcheusuallyfollowsapprox1year after the
growthspurt begins
MIDDLE ADOLESCENCE
BIOLOGICDEVELOPMENT:
Timingof menarcheappearstobedeterminedby:
Genetics
Adiposity Adiposity
Chronicillness
exercise
MIDDLE ADOLESCENCE
SEXUALITY:
Datingbecomesanormativeactivity
Sexual activityisdeterminedby:
Biologicmaturation Biologicmaturation
Social pressures
High testosterone & lowreligiosity together may
predictwhichboysbecomessexuallyactive
MIDDLE ADOLESCENCE
SEXUALITY:
Homosexual experimentationiscommon&does
not necessarily reflect a childs ultimate sexual
orientation orientation
Many adolescents worry that they might be
homosexuals&dreadbeingfoundout. Asaresult
homosexual dating&activity arerareinthisage
group
MIDDLE ADOLESCENCE
SEXUALITY:
Homosexual adolescents face increased risk of
isolation&depression
Sortsout other important aspectsof sexual identity Sortsout other important aspectsof sexual identity
Love
Honesty
propriety
MIDDLE ADOLESCENCE
SEXUALITY:
Datingrelationships superficial
Attractiveness
Sexual experimentation Sexual experimentation
Not yetintimacy
Tendtochoose1of 3sexual paths:
Celibacy
Monogamy
Polygamousexperimentation
MIDDLE ADOLESCENCE
SEXUALITY:
Most have some knowledge of the risks of
pregnancy, AIDS & other STDs, but knowledge pregnancy, AIDS & other STDs, but knowledge
doesnotconsistentlycontrol behavior
MIDDLE ADOLESCENCE
COGNITIVE&MORALDEVELOPMENT:
Formal operational
Questions&
analyzesextensively analyzesextensively
Questioningof moral conventionsfostersdevelopment
of personal codesof ethics
Such codes often appear to justify their sexual
appetitewhatI wantisright.
Inother cases, theymayembraceacodethat ismore
strict thanthatof their parents
MIDDLE ADOLESCENCE
SELF-CONCEPT:
Peer group exerts less influence over dress,
activities, &behavior
Oftenexperiment w/ different personae, changing
stylesof dress, groupsof friends, &interestsfrom
monthtomonth
MIDDLE ADOLESCENCE
SELF-CONCEPT:
Manyphilosophizeabout themeaningof their lives
&wonder,WhoamI?andWhyamI here?
Intensefeelingof turmoil &misery arecommon
and may be difficult to differentiate from
psychiatricillness
MIDDLE ADOLESCENCE
SELF-CONCEPT:
Girls tendto characterizethemselves&their peers
according to interpersonal relationships (I ama girl
withclosefriends) withclosefriends)
Boysasagroupmayfocusonabilities(I amgoodat
sports)
MIDDLE ADOLESCENCE
RELATIONSHIPS:
Pubertycommonlyresultsinstrainedrelationships
betweenadolescents&parents
As a part of separation, adolescents may become As a part of separation, adolescents may become
distant fromparents, redirectingemotional &sexual
energiestowardpeer relationships
MIDDLE ADOLESCENCE
RELATIONSHIPS:
As dating increases, the need to belong in the
samesexgroupsdeclines samesexgroupsdeclines
Physical attractiveness&popularity remain critical
factorsinbothpeer relationships&self-esteem
MIDDLE ADOLESCENCE
RELATIONSHIPS:
Childrenwithvisual differences, likeacleft lip, are
at risk for problems developing social skills & at risk for problems developing social skills &
confidenceandmayhavemoredifficultyestablishinga
satisfyingrelationships
MIDDLE ADOLESCENCE
RELATIONSHIPS:
Beginstothinkseriouslyabout what theywant todo
asadultswhichinvolves:
Self-assessment Self-assessment
Assessmentof theopportunitiesavailable
The presence/ absence of realistic role models, as
opposedto theidealizedonesof theearlier period,
canbecrucial
IMPLICATIONS ON THERAPISTS
Theneedfor anon-judgmental adult isappreciatedby
theseteeners:
Physical &sexual maturation
Changesinsexual behavior &identity Changesinsexual behavior &identity
Emotional distancefromparents
Waningpeer groupinfluence
Introspection
Growingcognizanceof lifeafter childhood
ADDITIONAL REFERRENCE
ABCof Adolescence, Adolescent Development 1
st
of 12
series.
DeborahChristie, RussellViner
BMJ volume330(Feb2005)
Forfar and Arneils textbook of Pediatrics. 6
th
edition.
Edinburgh: Churchill Livingstone, 2003:1757-68
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