The Adolescent

Boys

During fetal life the placental chorionic gonadotropin stimulates Leydig cells to secrete testosterone. Thus weeks 8 to 12 of fetal life are important in the sexual development of the male (XY) child. Luteinizing hormone (LH) maintains testosterone levels. Serum levels of LH increase during sleep 1 to 2 years before puberty. The secretion of gonadotropin stimulates gonad enlargement and the secretion of sex hormones. The interaction among the hypothalamus, pituitary, and gonads supports the development of puberty.

In boys, puberty begins with hormonal changes between 10 and 13 years of age. The shoulders widen, the pectoral muscles enlarge, and the voice deepens. Hair begins to grow on the face, chest, axillae, and pubic areas (Figure 20-4 and Box 20-2). Enlargement of the testicles and of internal structures and pigmentation of the scrotum are followed by enlargement of the penis. Erections and nocturnal emissions take place. The production of sperm begins between 13 and 14 years of age. An athletic scrotal support device (jockstrap) is necessary for boys participating in sporting events or for any activity in which support and protection of the genitalia are required. Athletic supporters not only support and protect the genitalia but also prevent embarrassment from exposure. Athletic supporters are purchased by size. Good personal hygiene is necessary because heat and friction may lead to jock itch, a fungal infestation of the groin. Sharing athletic supporters is discouraged.

Some experts recommend that after puberty boys examine their testes during or after a hot bath or shower. Each testicle is examined using the index and middle fingers of both hands on the underside of the testicle and the thumbs on the top of the testicle. The testicles are gently rolled between the thumb and the fingers to feel for abnormalities. Testicular and scrotal self-examinations are performed once a month. If a lump is discovered, it should be reported immediately to a health care provider (American Cancer Society, 2010).

Girls

Pubertal changes in girls occur 6 months to 2 years before they occur in boys. Puberty is easily recognized in girls by the onset of menstruation (Figure 20-5). The first menstrual period is called the menarche. It commonly occurs about age 12 or 13 years, but this varies. It may occur as early as age 10 years or as late as age 15 years. Secondary sex characteristics become more apparent before the menarche. Fat is deposited in the hips, thighs, and breasts, causing them to enlarge (see Box 20-2).

At this time the adolescent girl may need to be fitted for a bra. Measurements must be ascertained and various styles tried on for comfort. Straps should fit so that they do not continually fall from the shoulders. Cups need to be large enough to support fullness near the underarms. The garment must fit across the back so that it is not uncomfortably tight. Adolescents generally like attractive undergarments that have some type of lace trim. Sports bras are available for girls who participate in active sports. Puberty is a good time to begin teaching breast self-examination (see Skill 11-1). Instructional materials are available through the American Cancer Society.

The external genitalia grow. Hair develops in the pubic area (see Figure 20-4 and Box 20-2) and the underarms. It is important to note that in ballet dancers, runners, gymnasts, and adolescents engaged in other athletic activities that involve a lean body and high level of physical activity, the mechanisms affecting puberty can be altered and cause a delay in the onset of menarche. Energy balance, activity, and nutrition are important factors to evaluate when menstruation is delayed. Further growth can no longer take place when the ends of the long bones knit securely to their shafts (epiphyseal closure). See Chapter 2 for a detailed discussion of the physiology of reproductive organs.

Sense of Identity

Physical growth and sexual interest correlate with sexual maturity. Cognitive growth and social changes correlate with chronological age and placement in school. Stress can increase when physical growth and cognitive growth occur at different rates in the same adolescent. Although the early-maturing male often finds positive social adjustment and acceptance, early-maturing females are often embarrassed and develop low self-esteem. The adolescent’s desire for freedom and independence is extremely important and necessary for developing individuality. To accomplish this, young persons must reject their childhood self and often the people most closely associated with it. Erikson identifies the major task of this group as identity versus role confusion. Emancipation is a critical element in the establishment of identity.

Adolescents want to be people in their own right, and they “try on” different roles. Self-concept (one’s view of oneself) fluctuates during this time and is molded by the demands of parents, peers, teachers, and others. Interaction with others helps adolescents determine who they are and in what direction they want to proceed. This process is more difficult for low-income minorities and is complicated by many factors, such as illness, broken homes, and the extent of formal education. Young persons who are unable to master confusion and establish an identity may become rigid in their actions, bewildered, or depressed, or they may cling to the conformity of peer groups long after the need should have passed. Some show an inordinate need for something “new and exciting.” They may experience low self-esteem and alienation, and they may confront many other difficulties on entering the adult world.

Sense of Intimacy

Developing intimacy is closely entwined with the resolving of a person’s sense of identity. As adolescents move toward young adulthood, they become ready to take the risks of close affiliations and friendships and to establish relationships with the opposite sex (Figure 20-6). Avoidance of building these relationships may lead to a deep sense of isolation. Adolescence is a period of trying and testing. Disagreements with parents often revolve around dating, the family car, money, chores, school grades, choice of friends, smoking, sex, and the use of illicit drugs. The young person questions parental values and morals and is particularly sensitive to hypocrisy.

Adults who associate with adolescents should try to create an atmosphere of interest and understanding. Adolescents must know that adults care. Adolescents need practice in making decisions that must be respected even if they have made a mistake. Parents should set limits and expect them to be challenged but not exceeded. Parents and nurses who see other people’s intrinsic worth, feel good about themselves, and do not see the adolescent’s behavior as a reflection on their parenting or nursing provide a more secure environment for growth. Loving detachment is not easy, but it is an effective tool in dealing with adolescents.

Cultural and Spiritual Considerations

Americans are multiethnic, multicultural, and multilingual. The value of independence as a goal of maturational and emotional development may not be adopted by all. The traditional Chinese do not recognize the period of adolescence; there is no word for it in their language. Many immigrants and Americans of Asian descent come from societies that are patriarchal and highly structured and have distinct social roles. The good of the family takes precedence over personal goals. The protection of family image and neighborhood reputation is essential.

As part of a search for their identity, adolescents focus on the values and ideals of the family and decide either to embrace them or to separate from them. Adolescents often perceive their feelings and thoughts as unique and therefore do not express their feelings freely. Adolescents can understand abstract concepts and symbols, and exposure to religion and religious practices other than those experienced within their own traditional family can help them stabilize their group identity (Figure 20-7). The nurse’s awareness of these and other cultural influences on the adolescent’s behavior will help in the effort to provide holistic care.

Body Image

In early adolescence the young person must adjust to the dramatic changes of puberty. Focusing on body development during early and middle adolescence is one factor that contributes to egocentrism, or self-centeredness. Young persons create what has been termed an “imaginary audience.” They believe everyone is looking at them. This preoccupation with self is normal and accounts for the constant hair combing and makeup repairing often observed in a group of adolescents. Young adolescents may try to hide their changing body or may advertise it. They may take pride in their abilities or feel frustrated when their actual abilities do not match their perceived abilities.

In early adolescence teens make every effort to be just like their peers. A pimple on the skin or a disability is disastrous to the young adolescent. By late adolescence, most have completed their growth, are less self-conscious, and enjoy their individual skills, abilities, and interests. Chronic illness or eating disorders (see Chapter 33) may complicate or exacerbate unresolved problems of body image.

Peer Relationships

Peer groups help adolescents to feel that they “belong” and make it possible to experiment with social behaviors (Figure 20-8). School assumes an important role in the psychological development of the adolescent by providing the focus for initiating social interaction. Small, exclusive groups called cliques form. These unisex groups are made up of adolescents with similar interests, values, and tastes. Belonging to the group is of utmost importance to the young adolescent.

Within the clique, the adolescent often develops a close personal relationship with one peer of the same sex. This best friend interaction supports social development by enabling adolescents to experiment with behaviors together and listen to and care about each other (Figure 20-9). Stable “best friend” experiences often precede successful heterosexual relationships in later life.

The peer group serves as a mirror for “normality” and helps to determine where one “fits in.” It is vitally important in helping adolescents define themselves. Acceptance by one’s friends helps to decrease the loneliness and sense of loss many adolescents experience on the road to adulthood.

The social norms and pressures exerted by the group may cause problems. The selection of friends and allegiance to them may bring about confrontations within the family. Parents need help in understanding that the adolescent’s exaggerated conformity is necessary to moving away from dependence and obtaining approval from persons outside the nuclear family. Failure to develop social competence may produce feelings of inadequacy and low self-esteem.

Nurses can assist the family by supporting and educating them in the dynamics of this age-group. Parents can be directed to groups such as peer helpers (for the adolescent) and community educational programs sponsored by various agencies. Organizations such as Parents Without Partners might be another resource.

Career Plans

Some adolescents graduate from high school with a definite idea of what they would like to do. Many, however, are unsure of what they want. To choose a career that is best suited for them, adolescents must first know themselves. What particularly interests them? What are they good at? What are their shortcomings?

By this time, adolescents have already taken some definite steps toward a goal. Choice of high school curriculum and grades determine eligibility for college or preparation for a specific vocation. Parents should observe the interests of their children and encourage them to take advantage of their talents (Figure 20-10). Whenever possible, an adolescent should investigate various fields by talking to people who are involved in them.

Valuable information can also be obtained by career exploration, which is available at most colleges, and by pamphlets from professional organizations, the government, Internet sites, and other sources. The school guidance counselor administers aptitude tests as an additional guide and can work with adolescents to expose them to as wide a selection of careers as possible. The adolescent must make the final decision. To be happy in a career, the adolescent must choose it of his or her own free will and not because parents expect him or her to follow in their footsteps.

The job market today is extremely competitive and almost nonexistent for some people without skills or higher education. Productive employment must fit young people’s life framework and offer an opportunity for personal growth. Some positive aspects of employment include helping to build self-esteem, promoting responsibility, testing new skills, constructively channeling energies, providing money for increased independence, engaging the young person in interactions with adults, and allowing the adolescent to assume an active rather than a passive role. In contrast, when adolescents are forced to take a job because of economic or personal pressures, they may need to drop out of school. With few skills and no experience, they may remain locked into low-level employment. This is often perpetuated from one generation to another.

Responsibility

Adolescents look forward to challenges. Parents must encourage their children to take on new responsibilities. The adolescent is often humiliated by being placed in a dependent role, such as when a parent or sibling drives them to school. Driving a car, riding a bicycle, or walking provides a sense of independence and responsibility. Even routine jobs can be made more inspiring if youths are taught to see them in relation to a longer-term objective.

Young adolescents must also be taught the value of money. An allowance helps them to learn financial management. If money is simply handed out as requested, it is more difficult to develop responsibility for finances. Allowances should be increased from time to time to comply with the age and needs of the adolescent.

Middle and older adolescents who have jobs can be taught to use a checkbook and a savings account. Many find satisfaction in purchasing their own clothes. An adolescent who buys an old car soon discovers that it takes money to insure, run, and repair it. Such experiences provide valuable lessons in finance. Baby-sitting is a common means of earning money among younger adolescents. Many boys and girls begin to assist with baby-sitting at about 12 or 13 years of age. Baby-sitting courses are valuable because young people need to be prepared for this important responsibility.

Daydreams

Adolescents spend a lot of time daydreaming in the solitude of their rooms or during a class lecture. Most of this behavior is normal and natural for this age-group. Daydreaming is usually considered harmless if the young person continues the usual active pursuits. It also serves several purposes. Adolescence is a lonely, in-between age; daydreaming helps to fill the void. Imaginatively acting out what will be said or done in various situations prepares adolescents to deal with others so they can better cope with real situations. Daydreams are also a valuable safety valve for the expression of strong feelings.

Sexual Behavior

Adolescents must meet and become acquainted with members of the opposite sex. This may begin with admiration from afar, which is accompanied by daydreams as the young person attempts to attract the other’s attention.

Group dates for structured school or church functions are followed by double dating and then single-couple dating. Dancing provides an opportunity for the symbolic expression of sexual urges without physical contact. Slow dancing provides a mode of close physical contact in public that is socially acceptable. Long telephone or text messaging conversations link the adolescent to peers when they are at home or feeling alone. “Crushes”—feelings of attachment to a person of the opposite sex who is popular or possesses qualities important to the adolescent—are a common occurrence. Competition and rivalry may be keen, but long-term commitment and deep romantic attachments are not often present.

Sexual experimentation often occurs as a response to peer pressure, as a means for momentary pleasure, as a learning experience to satisfy curiosity, or as a means of gaining a feeling of being loved and cared about. Sexual behavior can affect the growth and development of the adolescent. Unplanned pregnancies or sexually transmitted infections (STIs) are two major complications of adolescent sexual interaction, because few adolescents responsibly use protection (Kliegman et al., 2007).

The adolescent’s cultural background influences patterns of dating. Conflict often arises when the adolescent wants to be independent and quickly adopts American norms of dating while parents insist on strict traditional values. This is particularly noticeable with daughters.

Dating is one of the early social aspects of growing up. Attending the high school prom is a rite of adolescence. As such, it may become a battleground for the struggle for independence. Parents’ opposition is often based on their unspoken fears. Parents may also fear sexual experimentation, pregnancy, or acquired immunodeficiency syndrome (AIDS). They may respond by imposing strict restrictions, such as curfews, chaperones, and limitations on use of the car. When these problems are not discussed openly, the adolescent may react by rebelling sexually or by other means to test general parental control, rather than for the sake of the prohibited act itself.

Sexual curiosity and masturbation are common among adolescents. There is also a need for the intimacy of close personal friendships. Seeking one person of the opposite sex to share confidences and feelings may lead to sexual intimacies. This may produce guilt feelings and can lead to isolation from friends and family. The breaking up of such romances is often a source of great emotional pain.

Most of our knowledge about the sexual behavior of Americans comes from the pioneering efforts of Alfred Kinsey. Although his studies had flaws, they provided much in-depth information. A wide variety of sexual behavior is freely discussed and depicted in movies, in magazines, online, and on television. Music directed toward young people often centers on sexual themes. Premarital sexual activity has become much more widespread, and adolescents are initiating their sexual activity at increasingly younger ages. Thirty percent of girls and 45% of boys report having had sexual intercourse by 18 years of age (Kliegman et al., 2007).

Sex Education

Sex education for the adolescent is a challenge. Nurses must put aside their own attitudes and biases; understand society, cultural, and moral values; and incorporate a broad understanding of physical and psychological growth and development to prepare an effective school or clinic program. Television, movies, magazines, and computer chat rooms or websites provide a source of information for sex education for the adolescent that may or may not be accurate and helpful to the young adult.

The prevalence of human immunodeficiency virus (HIV) exposure, AIDS, and other STIs was a factor that resulted in the formalized incorporation of sex education in schools. This education focuses on the physiology of sex, the reproductive systems, and STIs as well as personal values concerning sexuality, facts about contraception, safe sex, and peer pressure. Formal structured comprehensive sex education programs are available from the Sexuality Information and Education Council of the United States (SIECUS) and other community agencies. These types of programs are geared to kindergarten through grade 12 and present information about all aspects of health, such as nutrition, dental care, avoidance of drugs, and STIs. These courses should be presented as age appropriate. The physiology of the reproductive systems can be taught at about grade 5. By grade 8 topics such as coping skills for dating and sexuality, pregnancy, and birth can be reviewed. Abstinence and contraception are also discussed.

Decision making is emphasized. Flowcharts should show the possible consequences of certain actions. The high school units can include how to handle adolescent pregnancy, prenatal and postnatal care, and effective parenting techniques. A unit on intimate relationships can be presented as a series of discussions and activities designed to help students think about the nature of love. It can cover ideas such as compromise, problem solving, and communication skills. It should emphasize the many reasons why adolescents should say “no” to casual sex.

Factual and sensitive information provided by concerned parents is, of course, the ideal. However, too often peers provide erroneous material or parents postpone education until a crisis arrives. Children must be told what body changes to expect and why these changes occur. Two years too soon is better than 1 day too late! Parents who have answered their children’s questions truthfully throughout childhood offer a secure and natural foundation on which to build. Studies have shown that adolescents who obtain early sex education information from caring parents or well-informed adults do not have a higher rate of sexual activity.

Concerns About Being “Different”

Adolescents have certain concerns that are specific to puberty. The girl who begins to experience physical changes at about 10 years of age may feel self-conscious because she towers over her friends or needs to wear a bra. She may be teased because she is different. The other extreme is the latecomer who feels abnormal and unattractive because her friends look more feminine.

Such problems are not limited to girls. Of particular concern is the boy on a slow schedule of development. Still short at age 15 years, he is unable to compete for placement on school teams because of his size. He sees his male friends being admired for their height and strength, and this is a threat to him. Such fears are natural and usually are alleviated by reassurances that, although boys begin to grow later than girls, their growth spurt lasts longer. During data collection, the nurse has an opportunity to support the adolescent who is concerned about normal growth and development.

Traditional gender stereotypes define being “male” by activity and achievement and being “female” by sensitivity and interpersonal competence. Society’s current trends toward equality of the sexes may affect these roles. Nevertheless, few adolescents escape the social pressures that dictate acceptable sexual attitudes and behavior for each sex.

Homosexuality

When a person has an attraction for a person of their own sex, that person is referred to as homosexual. A lesbian is a female who prefers other females as sexual partners. A male is called gay when he prefers another male as his sexual partner. Homosexual behavior in adolescence is not uncommon. This experimentation is not a positive predictor of adult sexual preference; it may merely indicate a desire to explore alternative lifestyles. Homosexuality occurs in about 5% of men and women (Kliegman et al., 2007) but is no longer listed as a mental disorder by the American Psychiatric Association (2000). It is thought that a combination of cultural, biological, and psychological factors contribute to sexual orientation and development. The nursing role is not to change homosexual behaviors but to help the child understand how to cope with the reaction of others.

Nurses must be sensitive to these issues when obtaining histories and working with young adolescents. They must also be aware of their personal biases to determine their potential effectiveness with this population. Support groups for parents and friends of gays and lesbians are available. Those who question their sexual orientation are referred to counselors and health agencies that can respond to their needs. Table 20-2 provides an example of the use of the nursing process in planning sex education for the adolescent.

Vegetarian Diets

Foods and eating fads are often the main conflict between adolescents and their parents. However, adolescents are now a growing segment of the vegetarian population. Ninety percent of adolescent vegetarian diets include eggs and milk. Iron-rich foods include fortified grain products. However, a high intake of whole grains, bran, and foods rich in oxalic acid (e.g., spinach) can impair the absorption of iron. Tofu, nuts, wheat germ, and legumes can provide the zinc necessary for cognitive development. If animal products are totally excluded in the diet, a vitamin B₁₂ supplement may be necessary. The nursing role is to understand the eating pattern, identify fad diets, and understand the reason the diet was selected, and then evaluate and discuss any deficiencies or needs within that diet. Developing a partnership with the adolescent in meeting growth needs and allowing the adolescent to take responsibility for meeting his or her own health needs are the cornerstones for success in nutritional education.

Vegetarians who eat no animal protein, eggs, or dairy products (vegans) are at particular risk of developing deficiencies in protein, vitamin B_¹², calcium, iron, iodine, and possibly zinc. A total vegetarian diet is adequate only if it is carefully planned.

Sports and Nutrition

The best training diet is one that contains foods from each of the basic food groups in sufficient quantities to meet energy demands and nutrient requirements. What to eat and when to eat it in relation to muscle exercise are vital to successful athletic performance. Athletes exhaust reserves of muscle glycogen. Carbohydrates that can be rapidly converted to blood glucose and transported to muscles will provide the rapid recovery of muscle glycogen necessary for maintaining prolonged intense muscle activity. Eating a slowly absorbed glucose source will prevent the development of chronically low muscle energy stores. To hasten muscle energy recovery, the young athlete should consume at least 50 g of a rapidly used carbohydrate within 4 hours after exercise. Foods high in fat and protein will prolong carbohydrate metabolism.

Carbohydrates that provide both energy and other nutrients are best for athletes. Therefore fruits and fruit juices are a better choice than sugar-rich soft drinks and candy. The fat content in candy will slow carbohydrate absorption. Some foods that provide a rapid supply of carbohydrates to muscles include corn flakes, bagels, raisins, maple syrup, potatoes, and rice. Some foods that supply a slow release of carbohydrates to muscles include apples, pears, green peas, chickpeas, skim milk, and plain yogurt.

Fluids lost by sweat must be replaced by drinking small amounts of fluid during a workout. Thirst is one guide for intake. Caffeine and alcohol deplete body water and are to be avoided.

Anabolic steroids, used by some athletes to gain weight and increase strength, are detrimental to bone growth. Iron is particularly necessary for female athletes, who may be borderline or deficient in their intake of this mineral.

Nutrition and School Examinations

The role of diet in the management of illness has become traditional practice. The role of diet in maintaining health is becoming prominent in health education today. Nutritional practices are the focus of weight control programs, and special nutritional supplements are available for athletes, pregnant women, and older adults. Studies have shown that foods can affect behavior, moods, and alertness.

For the adolescent who is scheduled to take an important school examination, the nurse can offer nutritional guidance as part of the examination preparation. Carbohydrates such as pancakes and syrup, breakfast pastries, or a muffin and jelly increase serotonin in the brain, resulting in a soothing, sleepy response. Bacon and eggs are high in fat and cholesterol and are therefore slow to digest, diverting blood from the brain during the digestion process and causing decreased alertness. Drinking more than 4 cups of a caffeine-containing beverage such as coffee can cause overstimulation and nervousness. However, protein-rich meals increase amino acids and tyrosine, which will break down into norepinephrine in the brain and result in increased alertness. Fish, soy, peanuts, and rice increase choline and acetylcholine in the brain, which result in increased memory. Therefore a “proper” meal before a big school test may help the adolescent’s achievement as well as his or her health.

Hygiene

The adolescent needs personal hygiene information because body changes require more frequent bathing and the use of deodorants. The nurse can help the young person sort out the various claims of reliability for hair removal, menstrual hygiene, and cosmetic products and procedures. Body piercing, a popular adolescent fad, should be performed only by an experienced person using sterile instruments. The skin around the point of insertion of the body ring should be regularly inspected for signs of infection. Swapping of body rings is discouraged. Adolescents are warned not to use another’s razor or toothbrush, particularly in light of the risk of HIV infection.

Dental Health

The prevalence of tooth decay has substantially decreased. This is believed to result from the widespread use of fluorides, including community fluoridation, dental sealants, and dental products containing fluorides. Adolescents are nonetheless at risk for dental caries because of inadequate dental maintenance and frequent snacking on sucrose-containing candies and beverages. When dental hygiene is neglected, the period of greatest tooth decay in the permanent teeth is from ages 12 to 18 years. Lack of oral hygiene (inadequate brushing, flossing, and rinsing, particularly after meals) fosters the accumulation of plaque and food debris. Missing, aching, or decayed teeth contribute to poor nutrition. Young people with unattractive teeth may suffer from low self-esteem. Corrective orthodontic appliances are often worn during adolescence, and meticulous oral hygiene is essential to prevent discoloration of tooth enamel and other complications.

According to media hype, healthy, white teeth are synonymous with popularity and sex appeal. Regular dental visits during adolescence must be maintained as a priority in the health care teaching of adolescents and their families. See Chapter 15 for a detailed discussion of dental health.

Sunbathing

Adolescents respond to movie and magazine pictures of the ideal “healthy suntanned body” as an attractive aspect of a body image. The young adult looks forward to sunbathing on the beach or at the pool during summer vacations and often prepares his or her body by trying to obtain a tanned appearance using artificial means. The nurse plays a vital role in educating the adolescent concerning the danger of the sun’s rays and the need for skin protection with a sun protective factor (SPF) of at least 15. Protection of the eyes from the sun is also essential. Excessive sunlight and the use of artificial tanning machines can cause serious long-term reactions such as early aging of the skin or skin cancer (see Chapter 30).

Sports Injuries

Sports involving body contact can be hazardous to the adolescent. Sports teams separated by age only are a special problem, because adolescents of one specific age-group can vary in size, weight, and muscle strength. Protective gear should be worn by all team players in any contact sport. The feeling of strength and the need to show off can motivate the adolescent to participate in risky behavior. Assessment of the female athlete in training should include identification of the “female athlete triad,” which includes an eating disorder, amenorrhea, and osteoporosis. Coaches, parents, and health care providers must be vigilant for this condition, which has serious long-term complications (Loman, 2009).

All student athletes should have comprehensive cardiovascular screening before participating in competitive sports activities. Each year, many high school athletes die in a nontraumatic sports-related death. Most deaths result from cardiac problems that are not obvious. The American Academy of Pediatrics Committee on Sports Medicine has established guidelines for medical clearance for sports activities (Saglimbeni, 2010). There may be a future role for genetic testing for cardiac disease in athletes with a family history of cardiac problems. The school nurse can play a key role in safety education by working closely with school coaches and parents.

Key Points