FAMILY NURSING
Health Problems of Adolescents
Learning objectives:
· Explain the importance and timing of physiological development in adolescence.
· Discuss the importance of psychosexual, psychosocial, cognitive, and moral development in adolescence.
· Discuss the impact that school, peers, work, and leisure time have on adolescent development.
· Describe the major developmental tasks of adolescence, and discuss why they are important for the transition to adulthood.
· Discuss several nursing interventions for effectively working with adolescents.
· Discuss several health promotion and screening activities related to adolescence and the appropriate nursing interventions.
Between childhood and adulthood, individuals experience the unique developmental period known as adolescence (ages 12-21), when young people begin to focus on who they are, how they are similar to or different from those around them, and what they want to become when they reach adulthood. It is a time of exploration, excitement and discovery, and sometimes confusion and despair).
Adolescence is second only to infancy in the amount of change individuals encounter physiologically and psychosocially. In order to effectively identify issues and problems commonly seen in adolescence, and consequently deliver appropriate and individualized nursing care, it is important to consider the physiological, psychosexual, psychosocial, cognitive, and moral transformations occurring during this time, as well as changes in adolescents’ rapidly expanding social context, including the family, school, and peers.
The concept of an adolescent stage of development is actually a relatively recent phenomenon. During the late 19th century our economy began to change from agricultural to industrialized; as a result, an unskilled workforce made up largely of children and adolescents became much less important to the labor market. This shift created a new and increasingly distinct segment of the population, which was not considered to be made up of either children or adults.
Adolescence consists of early, middle, and late periods. Each is distinguished by several different aspects of adolescents’ lives and constitute the ages of 12-14, 15-17, and 18-21 years. Another way to differentiate these periods relates to physiological development: prepubertal (early), pubertal (middle), and postpubertal (late adolescence). A third way relates to the level of education – early, middle, and late adolescence are associated with middle school, high school, and post-high school.
PHYSIOLOGICAL DEVELOPMENT
The physiological changes occurring during adolescence are extensive, do not occur in isolation, and have an impact on the adolescent’s psychosexual, psychosocial, and cognitive development. These changes also affect the experiences adolescents have with family members, peers, and others in their social world, as well as their own body image and selfesteem.
Clarification of two terms, commonly associated with this period is needed, however, before discussing the actual physiological changes occurring. Puberty is the state of physical development (between ages 12 and 16 for males and ages 10 and 14 for females) when secondary sex characteristics begin to appear, sexual organs mature, reproduction first becomes possible, and the adolescent growth spurt starts (Steinberg).
Adolescence begins with puberty and ends when the individual is physically and psychologically mature and able to assume adult responsibilities. The age when puberty begins and how long adolescence lasts varies individually and crossculturally (Jolley & Mitchell, 1996; Turner & Helms, 1995).
In the past, these terms have been used interchangeably even though their meanings are different. Before puberty, the primary hormone regulating growth is somatotropin, also called growth hormone. However during puberty, the gonadal hormones are responsible for many of the significant physiological changes seen in various body systems (Katchadourian, 1977).
Musculoskeletal System
During the adolescent growth spurt (AGS), which lasts about 4.5 years (Gallahue & Ozmun, 1995), the body assumes an adult appearance. Girls may begin their spurt as early as 7.5 or as late as 12 years of age, whereas boys typically begin their growth spurt by age 13. During the AGS, there is rapid acceleration in weight and height gain: boys gain 12-14 lb and grow 3-6 inches; girls gain 8-10 lb and grow 2.5-5 inches. The AGS is not uniform; weight begins to increase first, followed in 4-6 months by a rapid increase in height (Tanner, 1990). The age of onset, intensity, and duration of the AGS varies from individual to individual, and differs for boys and girls (Figure 12-2).
Typically, height begins increasing in early adolescence for females and in midadolescence for males. Females achieve peak height velocity (PHV), the maximum annual rate of growth in height during the AGS, at about 11 years of age, or 6-12 months before menarche. Very few females grow more than 2 inches after menarche. Males reach PHV at about age 13, after axillary and mature pubic hair appears, and growth of the penis and testes begins (Malina & Bouchard, 1991). Most males do not grow in height after 18 or 20 years of age. See Figures 12-3 and 12-4 for linear growth curves during childhood and adolescence.
Weight increases for adolescents tend to follow the same growth curve as height. Peak weight velocity (PWV), the period when weight gain is the most rapid, is greater for males than females, and occurs simultaneously with PHV (Malina & Bouchard, 1991). PWV for females occurs about 6 months after PHV. Females frequently are heavier than their male counterparts during the AGS and tend to weigh more than males until about age 14, when their weight gain begins to level off. Weight gain in adolescent males is due primarily to increases in muscle mass and height, whereas in females, it is due primarily to increases in fat and height (Gallahue & Ozmun, 1995). Males continue gaining weight until about 22 years of age (Dacey & Travers, 1996; Turner & Helms, 1995).
Diet, gastric motility, exercise, socioeconomic status, lifestyle, and hereditary factors affect adolescent weight gain. Significant changes also occur in skeletal size, muscle mass, skin, and adipose tissue. Full bone length is first reached in the extremities and moves inward. Trunk growth begins with lengthening and widening of the hips, especially in females, then involves broadening of the chest and shoulders, especially in males. Males have greater arm and leg length relative to trunk size and delayed skeletal ossification as compared with females. Supporting muscles grow more slowly than the skeletal system, and large muscles develop faster than small muscles, resulting in the characteristic lank)’ or awkward look of some adolescents. Feet and hands grow out of proportion to the body, resulting in decreased coordination (Katchadourian, 1977). However, fine motor coordination improves as adolescence progresses. The period of greatest muscular development does not occur until a year after the PHV, and in males it continues into late adolescence. Muscle mass doubles and strength increases for males during this period (Katchadourian, 1977). Endurance increases for both genders, especially with fitness training. Subcutaneous fat decreases in males and increases in females. In males, fat is deposited more commonly on the trunk, whereas in females, it is deposited over the thighs, buttocks, and breasts.
Sebaceous glands increase in size as they become active for both genders (Murray & Zentner, 2001; Steinberg, 2001). Eccrine and apocrine glands mature as well, leading to increased amounts of and a distinct odor to perspiration. Perspiration is also now secreted in response to emotional stimuli. The skin becomes darker, and the texture thickens and toughens in males. Females, on the other hand, develop soft, smooth-textured skin, with fine hair growing on the cheeks and upper lip (Katchadourian, 1977).
Genitourinary System
Secretion of neurohormonal releasing factors by the hypothalamus stimulate the anterior pituitary gland to release follicle-stimulating hormone (FSH) and luteinizing hormone (LH). In females, FSH stimulates ovarian follicle growth and estrogen production. Estrogen causes breast changes, including enlargement and darkening of the nipple, growth and development of the reproductive organs (vagina, uterus, ovaries), and growth and darkening of pubic and axillary hair. Estrogen also promotes epiphyseal maturation, which in turn inhibits long bone growth. LH initiates ovulation and formation of the corpus luteum, which then produces progesterone. Progesterone prepares the uterus to accept a fetus and maintain a pregnancy (Katchadourian, 1977).
In males, FSH is responsible for sperm production and maturation of the seminiferous tubules. LH promotes testicular maturation and testosterone production. Testosterone causes the musculoskeletal system changes discussed earlier and promotes growth and development of the male reproductive system. It also stimulates epiphyseal maturation, which then inhibits long bone growth (Katchadourian, 1977).
These reproductive hormones are also responsible for the predictable sequence of the appearance of secondary sexual characteristics, that occur during puberty. The age when the changes occur and the rate of progression through the sequence varies. In fact, cross-cultural studies show the onset of these secondary sexual changes varies with environmental conditions, race and ethnicity, geographical location, and nutrition (Eveleth & Tanner, 1990). This sequence of secondary sexual characteristics has been divided into five stages, called the Tanner stages. For females, the stages describe breast and pubic hair growth. For males, the stages describe growth of the testes, penis, scrotum, and pubic hair. The first visible sign of female sexual maturation is breast development, which may not be symmetrical. This is followed by growth of pubic hair, which begins on average between 11 and 12 years of age, and is complete by about age 14 (Katchadourian, 1977; Marshall & Tanner, 1969).
Breast development and pubic hair growth for females is described in Appendix F. Figure 12-5 illustrates the approximate timing of development changes in females. In females, menarche (first menstrual period) indicates puberty and sexual maturity. Most adolescent females are ambivalent about menarche; they are happy for the proof they are women, yet view it as a burden since they are unable to control their bodies. Often, the response reflects feelings about growing up and femininity, and can be influenced by messages and attitudes of peers and parents.
Even though regular menstrual cycles and ovulation typically begin 6-14 months after menarche, adolescent females can become pregnant after their first menstrual period. Menarche occurs about 2 years after breast development starts and after the AGS peaks. The exact time menarche begins, however, varies among populations and is influenced by nutrition, exercise, weight, breast development, health, metabolism, heredity, stress, depressive affect, family relations, and other environmental influences (Brooks-Gunn, 1988; Gallahue & Ozmun, 1995; Graber, Brooks-Gunn, & Warren, 1995; Moffitt, Caspi, Belsky, & Silva, 1992; Warren, Brooks-Gunn, Fox, Lancelot, Newman, & Hamilton, 1991).
The average age of menarche in North America (12.88 years in Caucasian girls, and 12.16 in African American girls) has remained stable over the past 45 years (Herman-Giddens et al, 1997). However, in developed countries throughout the world during the past 150 years, the average age of menarche had decreased about 3 months per decade until the 1980s; this was probably due to better nutrition and overall health (Tanner, 1991).
For males, puberty and sexual maturity are initially indicated by growth of the penis and testes, spermatogenesis, and seminal emissions. The first ejaculate, however, usually does not contain mature sperm, and occurs about 1 year after the penis begins its adolescent growth. Testicular enlargement begins between 10 and 13 years of age and is usually complete by age 18 (Katchadourian, 1977; Marshall & Tanner, 1970).
During this time, it is not uncommon for one side of the scrotum to grow faster than the other; 60% of males experience transient breast enlargement (gynecomastia), and many after the age of 14 experience nocturnal emissions (loss of seminal fluid during sleep). These situations can be disturbing, and adolescent males may have uncomfortable and embarrassing feelings related to the changes their body undergoes during this period. They are sensitive to suspected deviance and constantly compare their body and appearance to their peers. Teens can also be reassured that as they get older, their body will slim down and fat will be redistributed.
Cardiorespiratory System
The heart almost doubles in weight and increases in size by about one half during adolescence (Malina & Bouchard, 1991). Although the heart continues to enlarge until age 17 or 18, the rate of growth is slower in comparison with other body systems and the pumping mechanism is somewhat inefficient. This may be one cause of fatigue and symptoms of inadequate oxygenation that some adolescents complain about (Murray & Zentner, 2001). Systolic blood pressure accelerates during puberty, before achieving adult values by the end of adolescence. Average blood pressure is 100-120/50-70 mm Hg. The pulse drops from childhood rates to average 60-70 beats per minute. Females have a slightly lower systolic blood pressure and a slightly higher pulse and body temperature than males (French, Perry, Leon, & Fulkerson, 1994; Katchadourian, 1977). Red blood cell mass and hemoglobin concentrations increase and the white blood cell count is decreased in both genders during adolescence. Platelet count and sedimentation rates are increased in females, whereas hematocrit levels and blood volume are in reased in males (Katchadourian, 1977).
The lungs increase in length and diameter during adolescence, and the respiratory rate averages 16-20 breaths per minute. Males have greater vital capacity, volume, and rate because of their greater shoulder width and chest size. Their lung capacity, however, matures later than in females, probably due to their general later maturation. The slowness of respiratory system growth relative to the growth of other body systems may be another cause of the inadequate oxygenation and fatigue sometimes experienced by adolescents.
Neurological System
Brain growth continues during adolescence. The cells that support and nourish the neurons proliferate, even though the number of neurons does not increase. Continued growth of the myelin sheath allows faster neural processing (Graber & Peterson, 1991), and is reflected in the adolescent’s increasing ability to think abstractly and to hypothesize.
Gastrointestinal System
Rapid maturation of the gastrointestinal system occurs during adolescence, and by the 21st birthday, all 32 teeth have erupted. Gastric acidity and capacity increase (up to 1,500 mL) to accommodate and facilitate digestion of the increased food intake that occurs in response to rapid growth. Adult size, function, and location of the liver is attained, as are adult elimination patterns (Katchadourian, 1977).
PSYCHOSEXUAL DEVELOPMENT
The basic assertion of Freud’s psychosexual theory is that we are motivated by two competing forces; one compels us to appease our inherent biologic drives while the other fosters the desire to live in a social community. Freud contended that virtually all psychological development is an adaptive response to the upsurge in our
Physiologically based “drives” and our attempts to satisfy these drives while coexisting with others. While these instinctive drives are motivated by several biologic needs (hunger, fatigue, etc.), the sexual instinct, or id, is the most important in establishing individuals’ psychological makeup or personality. For Freud, the physical changes of puberty reawaken the sexual and aggressive energies felt toward parents during early childhood, but that were repressed during latency or late childhood. To effectively cope, adolescents need to redirect these newly reemerging energies from parental relationships to nonfamilial relationships (friendships, love interests) and career endeavors. For this to occur, a separation or detachment from parents is necessary, sometimes resulting in conflict between adolescents and their parents. As adolescents struggle with the inner tension brought on by pubertal change, Freud believed anxiety, heightened distress over how to act out their inner conflict, and a likely demonstration of psychologically regressive or immature behavior occurred.
Thus, Freud argued, many psychological issues adolescents face are attributable to physiological changes. Most researchers now contend the implications of these physiological changes are much more complex than Freud or the psychosexual perspective originally indicated, and in fact, are more a result of how the individual and others respond to the adolescent’s physiological changes than to the changes themselves.
Body Image
A primary example of interaction between the psychological and physiological attributes of adolescents is evident in their evolving sense of body image or mental conception of their physical appearance. Body image encompasses positive or negative feelings, and the self-perception of physical attractiveness. Implicit in the definition is the assumption that one’s body image varies with maturation, and changes across time, situations, and experiences one has with others. Constant changes in appearance—including increases in weight and height, appearance of body hair, oversized hands and feet, developing sex organs, and facial blemishes—present the adolescent with new challenges, both real and imagined, that affect their body image.
This is particularly significant during adolescence because the adjustment required by rapid physiological changes affect self-esteem; few adolescents are satisfied with their physical appearance (Guinn, Semper, Jorgensen, & Skaggs, 1997). Adolescent females tend to be more dissatisfied with their appearance and more likely to be concerned about particular parts of their bodies than their male counterparts (Berger, 1994; Blyth, Simmons, & Zakin, 1985; Rozin & Gross, 1987). Often, they perceive themselves as weighing more than they actually do (Feldman, Feldman, & Goodman, 1988). In fact, in a 1999 survey of American high school students (CDC, 2000), 30% of students nationwide believed they were overweight, and 42.7% reported they were trying to lose weight. This distortion of body image is not only a potentially significant emotional problem for adolescents, but also may motivate the adolescent female to engage in potentially dangerous and life-threatening weightreducing behaviors such as anorexia, bulimia, vigorous aerobic exercise, or special diets (Whitaker, Davies, Shaffer, Abrams, Walsh, & Kalikow, 1989). In fact, 7.6% of high school students report trying to lose weight by taking diet pills, and 4.8% of high school students had vomited or taken laxatives to lose or avoid gaining weight (CDC, 2000).
While developing a sense of body image, most adolescents look to the cultural ideal valued by their society. In Western culture, this traditionally has been the shapely, thin woman and the muscular, tall man. However, few adolescents, or any individual for that matter, can successfully measure up to these standards. More than vanity, the adolescents preoccupation with appearance is a recognition of the role physical attractiveness plays in gaining the attention and admiration of the opposite sex. The fact that physique is valued by both genders is understandable. There is a strong relationship between how adolescents feel about themselves and how they feel about their bodies. Looking “awful” or believing others view them as looking “awful” is the same as being “awful.” These feelings may be reinforced by the fact that physically unattractive teens tend to have fewer friends than attractive teens (Berger, 1994; Sprinthall & Collins, 1995).
Many factors influence body image, including present and past experiences, level of cognitive development, and identity formation. Other factors are one’s degree of attractiveness, size and physique appropriate to gender (including weight and body type), name/nickname, cultural ideals and values, degree of identification with same-sexed parent, peer and sibling relationships, level of aspiration, and ability to reach societal or individual ideals (Berger, 1994; Duke- Duncan, 1991; Murray & Zentner, 2001; Sprinthall & Collins, 1995; Wright & Whitehead, 1987). The rate and timing of maturation can also be an important factor in an adolescent’s self-image.
The young people who have the most difficult time adjusting to their physical development and body image are those whose body is on a different schedule from their peers. For example, late Maturing adolescents may feel a sense of failure about their body if they are not as fully developed as their friends, which affects self-esteem and causes them to feel uncomfortable and insecure. Since, on average, early maturing males and females are shorter than their later maturing counterparts, they too may have difficulties with body image as their later maturing peers catch up and overtake them in height.
Social experiences are different for early and late maturing males and females. For boys, early maturation (appearance of secondary sexual characteristics during early adolescence) is associated with favorable social adjustment, whereas for females the picture is more complex. Some findings suggest that early maturation is associated with high social status and prestige in the peer group, whereas other findings indicate greater vulnerability to social pressures, leading to problems in social adjustment (Magnussen, Stattin, & Allen, 1988). For example, some studies indicate that about 20% of early maturing males are more attractive to peers and adults, given responsibility earlier, often excel in athletics, commonly receive honors, hold offices in student government, and have a positive self-image. They also are more poised and confident in social settings and report more frequent feelings of positive affect, attention, strength, and being in love (Steinberg, 1999). Finally, since for boys, physical ability is most valued, those who develop early have the edge in all realms.
Early maturing females on the other hand, may be socially disadvantaged because they are out of step with their peer group. They may become lonely and experience pressure to become involved in sexual relationships beyond the level of their maturity and coping ability (Simmons & Blyth, 1987). This can result in damaged self-esteem or unwanted sexual activities. Often, those who are taller and more developed early on than their classmates discover there are few peers who share common interests or problems. They may be teased about their developing body; called “boy crazy” by peers; scrutinized by parents; criticized by girlfriends for not spending time with them; be more introspective, unsure, submissive, and withdrawn; and be less poised and expressive. Early maturing females are also less satisfied with their weight and less positive about their bodies than late maturers (Koff & Rierdan, 1991). Often, they violate norms more frequently than their late maturing peers (Magnussen, Stattin, & Allen, 1988; Silbereisen & Kracke, 1993). They are also at heightened risk for engaging in delinquent behavior (Caspi & Moffitt, 1991; Simmons & Blyth, 1987) and are more vulnerable to eating disorders, depression, and deviant peer pressures (Brooks-Gunn & Paikoff, 1993; Ge, Conger, & Elder, 1996; Stattin & Magnussen, 1990) as compared with their late maturing or on-time peers. About 20% of late maturing adolescents feel a sense of failure about their body because their development lags behind that of their friends. This also influences self-esteem and causes them to feel shy, uncomfortable, and insecure. Later maturing males tend to be less relaxed, poised, and popular with peers; feel more restless and talkative and feel socially inadequate and inferior. As adults they tend to hold fewer leadership positions in their jobs or organizations, and are less responsible, dominant, and controlling. They also have lower educational aspirations; often express a need for sympathy, encouragement, and understanding; and may feel rejected or inferior (Berger, 1994; Steinberg, 1999). Later maturing females on the other hand, are higher on scales of activity, sociability, leadership, prestige, popularity, and expressivity during their early adolescence (Sprinthall & Collins, 1995). They also are twice as likely as early maturing girls to continue their education beyond the compulsory number of years of high school (Steinberg, 2001).
COGNITIVE DEVELOPMENT
Although the physiological changes associated with puberty are the most apparent indicators of development, equally important to young people’s movement toward adulthood are the cognitive changes that occur during this time. As young people’s thought processes become more sophisticated, their ability to think about themselves and the world around them changes radically. Piaget, Vygotsky, Selman, and Elkind describe the cognitive changes occurring during adolescence from a variety of perspectives. By far, the majority of research about the changes in young people’s thought processes is the result of Jean Piaget’s (1972) theoretical ideas (see Chapter 6). During adolescence (Piaget’s stage of formal operations), the most distinct feature of young people’s thinking is that they caow consider what is possible rather than just what is real. Thinking is no longer constrained by the concrete, physical world of their existence; rather, they are now capable of considering abstract possibilities. No longer are potential solutions based only on previous experiences; young people are able to consider all possible solutions to a problem, both real and abstract, and they can assess options and determine the best solution. Young people caow consider their own thoughts as real objects to be studied and analyzed—they can think about their own thoughts.
One outcome of adolescents’ ability to consider abstract possibilities is that they begin to recognize the distinction between how things are and how things could be (the difference between the “real” and the “ideal”). During earlier stages of development, the “real” and the “ideal” are largely the same. However, as adolescents’ thinking ability moves beyond the limitations of reality, they begin to conceive of the possible. Out of this ability comes a new sense of idealism and a new set of standards with which they begin comparing themselves to the world around them. Adolescents’ critical assessment of their world is most likely to be seen in their interactions with their parents and in the emergence of their social, political, and religious identities.
Another significant cognitive change is language development. Adolescents generally become more sophisticated in their ability to understand words and their related abstract concepts (Figure 12-8). Because of this increased sophistication, adolescents experience a whole new world regarding the meaning of words, including metaphors and satire. Children can generally identify the obvious story that exists in a book or movie, but it is ofteot until adolescence that they begin to understand more abstract metaphorical meanings.
During adolescence, young people also begin to find great joy in the double meaning of puns, satire, and parodies. An example of this new-found appreciation can be seen in the popularity among adolescents of MAD magazine, which pokes fun at all aspects of our culture. The shift to formal operational thought occurs gradually and aries individually. Formal operational thought consists of two subperiods: early and late (Broughton, 1983). When adolescents first acquire the abilities associated with formal operational thought, their new-found skill to think in hypothetical ways produces unconstrained thoughts with unlimited possibilities. This early stage of thinking results in an inordinate attempt to fit newly available abstract information into their existing immature understanding of how the world works, resulting in a subjective and idealist perception of the world (Santrock, 2001), which can be observed in the almost zealous, simplistic way they frequently embrace political or social causes. As adolescents become more cognitively mature, they are better able to adjust their thinking strategies to fit the new informatioow available to them. However, although researchers have suggested that a link exists between the timing of pubertal and cognitive development (Newcombe & Dubas, 1987), there are still no conclusive data (Linn & Petersen, 1985).
Cognitive Socialization
Lev Vygotsky, a Soviet cognitive theorist who did not base his work on Piaget’s, considered the differences among adolescents’ cognitive abilities to be a function of identifiable features of their cognitive environment (Santrock, 2001), and emphasized the way society promotes cognitive growth. For example, Vygotsky believed cognitive development was the result of social relationships with important others (e.g., parents, teachers and peers), rich in cognitively challenging interactions (Figure 12-9). One of Vygotsky’s most important concepts is the zone of proximal development (ZPD) — tasks that are too difficult for individuals to master alone but that can be mastered with the guidance and assistance of adults or more skilled adolescents (Santrock, 2001). The lower limit of this zone is the level of problem solving reached by the adolescent working independently; the upper limit is the level of additional responsibility the adolescent can accept with the assistance of an able instructor. According to Vygotsky, the greatest growth occurs when adolescents are stretched to perform at the upper limit of their ZPD. Cognitive development, therefore, is a function of the social relationships adolescents experience and the extent to which they are challenged within these relationships to think at a level beyond their independent capability. For example, most seventh-grade students would be overwhelmed if they were placed in a college-level calculus course. However, these same students are capable of understanding far more complex ideas (i.e., math operations) if they are coached by an adult or peer who is sensitive to their potential upper limit of understanding and can push them to think at that higher level. Once introduced to new skills, young people then internalize and make use of them on their own (SprinthaU & Collins, 1995).
Social Perspective Taking
Another important aspect of adolescents’ cognitive development is their broadening ability to assume another persons perspective. Based on Piaget’s work and the symbolic interaction theory of George Herbert Mead, Selman (1980) proposed that an individual’s interactions are in large part due to their social perspective taking ability. For Selman, an adolescent interacts or communicates with others according to the social-cognitive understanding they have about who they are in relation to those around them. Maturation and social experience changes this over time.
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