Health Promotion of the Adolescent and Family

BIOLOGIC DEVELOPMENT

The physical changes of puberty are primarily the result of hormonal activity under the influence of the central nervous system, although all aspects of physiologic functioning are mutually interacting. The obvious physical changes are noted in increased physical growth and in the appearance and development of secondary sex characteristics; less obvious are physiologic alterations and neurogonadal maturity, accompanied by the ability to procreate. Physical distinction between the sexes is made on the basis of distinguishing characteristics. Primary sex characteristics are the external and internal organs that carry out the reproductive functions (e.g., ovaries, uterus, breasts, penis). Secondary sex characteristics are the changes that occur throughout the body as a result of hormonal changes (e.g., voice alterations, development of facial and pubertal hair, fat deposits), but that play no direct part in reproduction.

PSYCHOSOCIAL DEVELOPMENT: DEVELOPING A SENSE OF IDENTITY (ERIKSON)

Traditional psychosocial theory holds that the developmental crisis of adolescence leads to the formation of a sense of identity. Throughout childhood, individuals have been going through the process of identification as they concentrate on various parts of the body at specific times. During infancy children identify themselves as being separate from the mother, during early childhood they establish gender-role identification with the appropriate-sex parent, and in later childhood they establish who they are in relation to others. In adolescence they come to see themselves as distinct individuals, somehow unique and separate from every other individual.

Adolescence begins with the onset of puberty and extends to relative physical and emotional stability at or near graduation from high school. During this time the adolescent is faced with the crisis of group identity vs alienation. In the period that follows, the individual strives to attain autonomy from the family and develop a sense of personal identity as opposed to role diffusion. A sense of group identity appears to be essential to the development of a personal identity. Young adolescents must resolve questions concerning relationships with a peer group before they are able to resolve questions about who they are in relation to family and society.

COGNITIVE DEVELOPMENT (PIAGET)

Cognitive thinking culminates with the capacity for abstract thinking. This stage, the period of formal operations, is Piaget’s fourth and last stage. Adolescents are no longer restricted to the real and actual, which was typical of the period of concrete thought; now they are also concerned with the possible. They think beyond the present. Without having to center attention on the immediate situation, they can imagine a sequence of events that might occur, such as college and occupational possibilities; how things might change in the future, such as relationships with parents; and the consequences of their actions, such as dropping out of school. At this time their thoughts can be influenced by logical principles rather than just their own perceptions and experiences. They become increasingly capable of scientific reasoning and formal logic.

Adolescents are capable of mentally manipulating more than two categories of variables at the same time. For example, they can consider the relationship between speed, distance, and time in planning a trip. They can detect logical consistency or inconsistency in a set of statements and evaluate a system or set of values in a more analytic manner. For instance, they question the parent who insists on honesty in the youngster but at the same time cheats on an income tax report or expense account.

In adolescence, young people begin to consider both their own thinking and the thinking of others. They wonder what opinion others have of them, and they are able to imagine the thoughts of others. With this capacity comes the ability to differentiate between others’ thoughts and their own and to interpret the thoughts of others more accurately. They are able to understand that few concepts are absolute or independent of other influencing factors. As they become aware that other cultures and communities have different norms and standards from their own, it becomes easier for them to accept members of these other cultures, and the decision to behave in their own culture in an accepted manner becomes a more conscious commitment.

MORAL DEVELOPMENT (KOHLBERG)

Although younger children merely accept the decisions or point of view of adults, adolescents, to gain autonomy from adults, must substitute their own set of morals and values. When old principles are challenged but new independent values have not yet emerged to take their place, young people search for a moral code that preserves their personal integrity and guides their behavior, especially in the face of strong pressure to violate the old beliefs. Their decisions involving moral dilemmas must be based on an internalized set of moral principles that provides them with the resources to evaluate the demands of the situation and to plan actions that are consistent with their ideals.

Late adolescence is characterized by serious questioning of existing moral values and their relevance to society and the individual. Adolescents can easily take the role of another. They understand duty and obligation based on reciprocal rights of others and the concept of justice that is founded on making amends for misdeeds and repairing or replacing what has been spoiled by wrongdoing. However, they seriously question established moral codes, often as a result of observing that adults verbally ascribe to a code but do not adhere to it.

SPIRITUAL DEVELOPMENT

As adolescents move toward independence from parents and other authorities, some begin to question the values and ideals of their families. Others cling to these values as a stable element in their lives as they struggle with the conflicts of this turbulent period. Adolescents need to work out these conflicts for themselves, but they also need support from authority figures or peers for their resolution.

Adolescents are capable of understanding abstract concepts and of interpreting analogies and symbols. They are able to empathize, philosophize, and think logically. Most teens search for ideals and speculate about illogical statements and conflicting ideologies. Their tendency toward introspection and emotional intensity often makes it difficult for others to know what they are thinking. They tend to keep their thoughts private, fearing that no one will understand these feelings that they perceive to be unique and special. However, they may reveal deep spiritual concerns. They need support and encouragement in their struggle for understanding and the freedom to question without censure.

Greater levels of religiosity and spirituality are associated with fewer high-risk behaviors and more health-promoting behaviors (Brown, 2001). Nurses play an important role for teens by providing an opportunity to discuss issues regarding spirituality.

SOCIAL DEVELOPMENT

To achieve full maturity, adolescents must free themselves from family domination and define an identity independent of parental authority. However, this process is fraught with ambivalence on the part of both teenagers and their parents. Adolescents want to grow up and to be free of parental restraints, but they are fearful as they try to comprehend the responsibilities that are linked with independence. Feelings of immortality and exemption from the consequences of risk-taking behavior, although viewed as negative, can serve an important developmental function at this time. These feelings give adolescents the courage to separate from their parents and become independent. Part of this emancipation involves developing social relationships outside the family that help teenagers identify their role in society. Adolescence is a time of intense sociability and often a time of equally intense loneliness. Acceptance by peers, a few close friends, and the secure love of a supportive family are requisites for interpersonal maturation.

ADOLESCENT SEXUALITY

Sexual activity rates have been decreasing for teens since the 1990s, including a decline in the rate among early adolescents (Santelli, Lindberg, Finer, and others, 2007). Among teenagers who have initiated sexual intercourse at an age younger than 14 years, the incidence of sexual abuse is high. In 2002 about half of all teenagers had had sexual intercourse at least once (Abma, Martinez, Mosher, and others, 2004). Teens engage in a wide range of sexual activity, including kissing and petting (fondling), oral sex, and vaginal and rectal sex. Data indicate that adolescents are engaging in sexual activity such as oral sex and delaying vaginal intercourse (Mosher, Chandra, and Jones, 2005); whether this is intended to preserve female virginity or to presumably avoid sexually transmitted disease or pregnancy is not known.

Adolescence represents a critical time in the development of sexuality. Hormonal, physical, cognitive, and social changes that occur during adolescence all have an impact on sexual development. Of all the developmental changes that affect adolescent sexuality, none is more obvious than the impact of puberty. Adolescents must come to terms with hormonal influences, physiologic manifestations such as menstruation and ejaculation, and physical changes such as breast and genital development. All these changes have a profound impact on the way teenagers perceive their bodies (i.e., body image). In addition to transitions in body image, increasing levels of pubertal hormones contribute to increased levels of sexual motivation among both boys and girls.

Changes in sexual motivations and feelings, happening at the same time as shifts in cognitive skills, contribute to painful conjectures (“Is what I’m feeling normal?”), self-conscious concern (“Am I good-looking enough?”), and hypothetical thinking (“What if she wants to have sex?”). The emergence of formal operational thinking also increases adolescents’ decision-making capabilities concerning sexual issues. As they mature, teenagers become better able to think through potential risks and benefits of sexual behaviors before they engage in any behavior. Older adolescents may also be able to conceptualize more long-term consequences of present behaviors. One of the important tasks of adolescence is to incorporate sexuality successfully into close, intimate relationships. This task is made possible by the advanced cognitive abilities that emerge over the course of adolescence.

Part of adolescent identity formation involves the development of sexual identity. As they begin to integrate changes involved with puberty, young adolescents also develop emotional and social identities separate from their family’s. For young adolescents, the process of sexual identity development usually involves forming close friendships with same-sex peers, with whom they may experiment sexually, often to satisfy curiosity. Sexual activity among young teenagers varies by gender. Masturbation provides an opportunity for sexual self-exploration; participation in this behavior is influenced by learned cultural attitudes and sex-role expectations.

Many teenagers begin to make a shift from relationships with same-sex peers to intimate relationships with members of the opposite sex during middle adolescence (Fig. 16-6). Opposite-sex relationships typically begin with peer activities involving both boys and girls. Pairing off as couples becomes more common as middle adolescence progresses. The type and degree of seriousness of partner relationships vary. Initial relationships are usually noncommittal, extremely mobile, and seldom characterized by any deep romantic attachments. Sexual activity becomes more common during middle adolescence. The relationship between love and sexual expression is brought into focus during middle adolescence. Most young people oppose exploitation, pressure, or force in sex as well as sex solely for the sake of physical enjoyment without a personal relationship. Adolescents find it hard to believe that sex can exist without love; therefore they view each relationship as real love.

An integrated sexual identity often emerges during late adolescence as individuals incorporate sexual experiences, feelings, and knowledge. For most, this identity is consistent with their own physical and mental capacities and with societal limits and expectations. Most older adolescents identify themselves as being predominantly heterosexual or bisexual, with a smaller number self-identifying as homosexual and an even smaller group still unsure of their sexual orientation, although this varies somewhat by ethnicity (Saewyc, Bearinger, Heinz, and others, 1998; Russell, Seif, and Truong, 2001). Whatever their sexual orientation, most older teenagers possess the capacity to have intimate relationships that satisfy the emotional and sexual needs of both partners.

Sexual orientation is an important aspect of sexual identity. Sexual orientation is defined as a pattern of sexual arousal or romantic attraction toward persons of the opposite gender (heterosexual), of the same gender (homosexual, often called gay or lesbian), or of both genders (bisexual). Sexual orientation encompasses several dimensions, including attraction, fantasy, actual sexual behavior, and self-labeling or group affiliation. In individuals the direction and intensity of each dimension are not necessarily consistent with any of the others. For example, individuals may be attracted most strongly to their same gender, fantasize about both genders, have sexual activity only with the opposite gender, and identify as gay or lesbian. Other individuals may engage in same-gender sexual behavior, fantasize about both genders, but identify as heterosexual. As with all aspects of sexual identity, the dimensions of sexual orientation are influenced by cultural meaning and expectation, by gender, by peer groups, and by other environmental contexts.

Adolescence is the period during which individuals commonly begin to identify their sexual orientation as part of their developing sexual identity. However, this identification process can be profoundly influenced by cultural beliefs and values, by societal and family pressures, or by a lack of similar peers. The majority of adolescents eventually report an orientation toward exclusively heterosexual relationships. For adolescents whose orientation encompasses any same-gender dimensions, the identity process during adolescence can be complicated, especially when community norms disapprove of orientations other than heterosexual. Adolescents who have witnessed harassment or violence directed at gay, lesbian, and bisexual people, for example, may be reluctant to self-identify, even when their attractions and behaviors are exclusively same-gender or bisexual.

The development of sexual orientation as part of sexual identity includes several developmental milestones during late childhood and throughout adolescence. These milestones do not necessarily occur in the same order for everyone, nor are they completed in the same amount of time. They include (1) the realization of romantic or erotic attraction to people of one (or both) genders; (2) erotic daydreaming about one or both genders; (3) romantic partners or dates without sexual activity; (4) sexual activity with people of the preferred gender or genders (also, for some teens, sexual activity with a nonpreferred gender, out of curiosity or through social pressure); (5) self-identification of the orientation that best fits one’s current circumstances and understanding; (6) publicly self-identifying that orientation, usually to intimate friends and family first, then the wider social group; and (7) an intimate, committed sexual relationship with a person of the gender appropriate to one’s orientation.

There is no evidence that gay, lesbian, or bisexual adults are more or less likely to create long-term, stable relationships than are heterosexual couples. It should be noted that bisexual adolescents and adults do not generally engage in sexual relationships with both genders concurrently; self-identification as bisexual usually refers to the ability to be attracted to either gender but does not imply that such a person requires partners of both genders, or that one must be equally attracted to and have sexual experience with both genders in order to be bisexual.

Although the order of these milestones varies greatly among adolescents, adolescents who identify as gay, lesbian, or bisexual tend to publicly self-identify later than heterosexual peers. Without positive gay, lesbian, or bisexual role models or a supportive peer group, sexual-minority teens can feel isolated, and they may not share their orientation with anyone for fear of rejection or violence. (See Critical Thinking Exercise.) When adolescents who would otherwise identify as bisexual can only find a peer group of gay and lesbian teens, they may focus on their same-gender dimensions of orientation and adopt the label of lesbian or gay; later, they may self-label as bisexual. Likewise, some gay and lesbian adolescents may first identify as heterosexual, then bisexual, before identifying as gay or lesbian.

DEVELOPMENT OF SELF-CONCEPT AND BODY IMAGE

The sudden growth that takes place in early adolescence creates feelings of confusion for adolescents. They have lost the security of a familiar body and feel uncomfortable with their altered body. Consequently, they may try to either hide their body or advertise it, or they may alternate between the two extremes. Teenagers are acutely aware of their appearance as they begin to acquire images of themselves as adults, but they see discrepancies between their ideal and actual skills and abilities.

Adolescents are continually comparing themselves with their peers and making judgments about their own normality based on these observations. Pubertal children feel most comfortable when they are just like their friends and age-mates. Perceived defects or deviations from the group average are threatening to their idealized image. Any blemish is likely to be magnified out of proportion, and any delay of the visible evidence of maturity is cause for worry. Unfortunately, this is also the time when the hormonal effect of the sebaceous glands produces acne, which creates problems for many adolescents. To the adolescent, even the most insignificant pimple may be viewed as a gross disfigurement. The advent of chronic disease or a permanent physical disability has special significance during adolescence and creates additional stresses for both adolescents with the condition and health care providers.

Experts have determined that the body image established during adolescence is the one that individuals retain throughout life. Much of adolescents’ search for identity takes place before a mirror as they try to read from the reflected features just who they are and what they look like to other people. Adolescents practice facial expressions and postures, try out hair arrangements, worry about a pimple, and in other ways attempt to assess the best means to achieve a maximum effect—to reveal the “true self.”

The self-concept becomes more differentiated as adolescents acquire a more complex picture of themselves, one that takes situational factors into account. The self-concept gradually becomes more individualized and more distinct from the concepts of others. Although younger teenagers describe themselves in terms of similarities with peers, as adolescence advances, young people describe themselves in terms of their special characteristics.

IMMUNIZATIONS

An immunization update is an important part of adolescent preventive care. Obtaining a record of the teenager’s prior immunizations is important. Adolescents 11 to 18 years of age should receive a single tetanus-diphtheria—acellular pertussis (Tdap) vaccine if they have received the recommended childhood series of DTaP immunizations. This vaccine is now recommended because of the increased incidence of pertussis seen in adolescents and adults who were immunized with the DTaP series as young children. The adolescent who has received Td but not Tdap vaccine should also receive a single dose of the Tdap vaccine provided 5 years have elapsed between the Td and Tdap vaccination (American Academy of Pediatrics, 2006). Meningococcal vaccine (MCV4) should be given to adolescents 11 to 12 years of age or at 15 years of age if previous immunization with MPSV4 occurred in childhood and at least 3 to 5 years have passed since primary immunization. The MCV4 vaccine is now preferred over the MPSV4 vaccine (American Academy of Pediatrics, 2008).

The human papillomavirus (HPV) vaccine series is recommended only for girls based on research results at this time. Additional recommendations may be made for boys if it is determined to be safe and effective. The series may be started as early as 9 years of age, with the second and third doses at 2 months and 6 months, respectively.

With the exception of pregnant teenagers, all adolescents should receive a second measles-mumps-rubella (MMR) vaccine unless they have documentation of two MMR vaccinations during childhood.

All adolescents who have not previously received three doses of hepatitis B vaccine should be vaccinated against hepatitis B virus. The hepatitis A vaccine should be given to all adolescents as part of the routine immunization schedule; the two-dose series may be completed in childhood, and a catch-up schedule for those who have not been previously immunized is recommended. Annual influenza vaccination with either the live attenuated influenza vaccine or trivalent influenza vaccine is now encouraged for all children and adolescents. All adolescents should also be assessed for previous history of varicella infection or vaccination. Vaccination with the varicella vaccine is recommended for those with no previous history; for those with no previous infection or history, the varicella vaccine may be given in two doses 4 or more weeks apart to adolescents 13 years or older (American Academy of Pediatrics, 2008). (See also Immunizations, Chapter 10.)

NUTRITION

The rapid and extensive increase in height, weight, muscle mass, and sexual maturity of adolescence is accompanied by increased nutritional requirements. Because nutritional needs are closely related to the increase in body mass, the peak requirements occur in the years of maximum growth, during which the body mass almost doubles. The caloric and protein requirements during this time are higher than at almost any other time of life. As a result of this increased anabolic need, the adolescent is highly sensitive to caloric restrictions.

Current guidelines for caloric intake are provided by a number of sources. The Dietary Reference Intakes (DRIs) provide age-specific guidelines for nutrients (see Chapter 6). Another guideline, which was recently developed by the American Heart Association (2005), aims at promoting balanced nutrient intake in children and adolescents with an overall decrease in fat intake and discretionary calories or snacks that increase the propensity for obesity and cardiovascular disease. Caloric intake can be tailored to meet the adolescent’s increased growth needs as well as activity level such as involvement in sports. The guidelines also encourage limiting sweetened beverage consumption and moderating caloric intake to activity levels.

Adolescents usually have sufficient intake of protein to meet their needs, except for those who limit their food intake because of economic problems or in an attempt to lose weight. There is a substantial increase in the need for the minerals calcium, iron, and zinc during periods of rapid growth: calcium for skeletal growth, iron for expansion of muscle mass and blood volume, and zinc for the generation of both skeletal and bone tissue. Girls with heavy or frequent menses may be especially susceptible to iron deficiency resulting from blood loss. Calcium intake from food sources is essential during adolescence to assist in the prevention of osteoporosis. Eventual bone mass is a balance between the amount of bone laid down during adolescence and the amount later lost with aging. Overall, osteoporosis is a result of polygenic and multiple environmental factors such as nutrition, economics, and exercise (Ongphiphadhanakul, 2007). Dietary intervention should promote the regular consumption of breakfast and a balanced intake of a variety of foods.

SLEEP AND REST

Teenagers vary in their need for sleep and rest. Rapid physical growth, the tendency toward overexertion, and the overall increased activity of this age contribute to fatigue in adolescents. During growth spurts the need for sleep is increased. Their propensity for staying up late makes it difficult to arise in the morning, and they may sleep late at every opportunity. Adequate sleep and rest at this time are important to a total health regimen.

EXERCISE AND ACTIVITY

Although today’s youth are less fit than children 20 years ago, adolescents probably spend more time and energy practicing and participating in sports activities than members of any other age-group. Many adolescents participate in sports within school settings (Fig. 16-8). School-based, health-oriented physical education may provide both immediate effects of the activity and sustained effects through encouragement of lifelong activity patterns. High schools continue to cut physical education classes, with only half of high school students attending physical education classes in 2005. Less than half of students attended these classes daily, and the majority of classes included only 20 minutes of exercise (Centers for Disease Control and Prevention, 2006a). To improve health outcomes, school-age children and adolescents should engage in 60 minutes or more of moderate to vigorous physical activity daily (Strong, Malina, Blimkie, and others, 2005).

The practice of sports, games, and even dancing contributes significantly to growth and development, the education process, and better health. These activities provide exercise for growing muscles, interactions with peers, and a socially acceptable means of enjoying stimulation and conflict. In addition, competitive activities help the teenager in the process of self-appraisal and the development of self-respect and concern for others. Because physical fitness appears to be a major influence on one’s lifelong health status, children should be encouraged to participate in activities that contribute to lifelong physical fitness. Nurses can encourage participation as a way to promote health and build self-esteem. However, adolescents should not be encouraged to engage in physical activities that are beyond their physical or emotional capacity (see Health Problems Related to Sports Participation, Chapter 17).

DENTAL HEALTH

Dental health should not be neglected during adolescence, although the rate of caries formation is not as great as in childhood. Dental care is an aspect of preventive care that is not received by substantial proportions of children in the United States. Pit and fissure sealants are a safe and effective technique for dental caries prevention. Early adolescence is usually when corrective orthodontic appliances are worn, and these are frequently a source of embarrassment and concern to the youngster. Reassurance regarding the temporary nature of the annoyance and anticipation of an improved appearance help adolescents tolerate the inconvenience. It is also important to reinforce the orthodontist’s directions regarding use and care of the appliances and to emphasize careful attention to toothbrushing during this time (see also Chapters 12 and 15).

PERSONAL CARE

The body-conscious teenager is highly amenable to discussion and counseling about personal care and hygiene. Body changes associated with puberty bring special needs for cleanliness. The hyperactive sebaceous glands and newly functioning apocrine glands make frequent bathing or showering a necessity, and underarm deodorants assume an important place in personal care. The adolescent discovers that hair requires more frequent shampooing, and girls often have questions about hair removal, use of cosmetics, and menstrual hygiene. Peer group discussions center on the advantages of particular products or methods. Adolescents are continually bombarded with messages from the media regarding the best way to enhance their popularity and attractiveness. Nurses are in a position to help them evaluate the relative merits of commercial products.

STRESS REDUCTION

The multiple changes occurring in adolescence can result in great stress (Fig. 16-9 and Box 16-2). Adolescents are faced with pressures from peers that often involve taking serious health risks, including pressures for sexual experimentation; use of drugs, alcohol, and cigarettes; and potentially dangerous physical activities.

Early-maturing girls and late-maturing children are especially sensitive to the stresses of being different from their peers. Many feel intense anxiety over their identity. Both early- and late-maturing children feel out of place among their classmates, but slow-maturing children appear to suffer the most pronounced inner turmoil and may be hesitant to voice their concerns. Slow-maturing adolescents need support and reassurance that they are not abnormal and need only be patient until the time comes when they, too, will mature physically.

SEXUALITY EDUCATION AND GUIDANCE

Contemporary adolescents are constantly exposed to sexual symbolism and erotic stimulation from the mass media. At the same time, the development of primary and secondary sex characteristics and the increased sensitivity of the genitalia produce thoughts and fantasies about sexual relationships. Sexual aspects of interpersonal relationships become particularly important. Societal expectations push adolescents toward dating, and their own inner sex drive urges them toward exploration.

Our society continues to do a poor job of educating adolescents about pubertal growth and development. Omar, McElderry, and Zakharia (2003) found that 36% of boys and 2% of girls had never been spoken to about pubertal development or sexuality issues. Girls received education at a mean age of 13 years and boys at an average age of 15 years. A large portion of their knowledge relating to sex is acquired from peers, television, movies, and magazines. In addition, some information obtained from their parents may be inaccurate. As a result, the information they accumulate may be incomplete, inaccurate, riddled with cultural and moral judgments, and not very helpful.

The responsibility for providing sexuality education has been assumed by parents, schools, churches, community agencies such as Planned Parenthood Federation of America, Inc.,^* and health professionals, especially nurses. Many adolescents perceive nurses, especially school nurses, as individuals who possess important information and who are willing to discuss sex with them. To be able to discuss the topic adequately, nurses must have not only an understanding of the physiologic aspects of sexuality and a knowledge of cultural and societal values, but also an awareness of their own attitudes, feelings, and biases about sexuality.

Comprehensive information about sexuality education is offered by the Sexuality Information and Education Council of the United States (SIECUS)^† and the Sex Information and Education Council of Canada.^‡ SIECUS maintains that every sexuality education program should present the topic from six aspects: biologic, social, health, personal adjustments and attitudes, interpersonal associations, and the establishment of values.

Whether nurses counsel young people on an individual basis, in mixed groups, or in groups segregated by gender makes little difference. Ideally, boys and girls should be able to discuss sexuality objectively with one another and in groups, but this is not always possible. The differences in the rate of maturation between boys and girls and between different members of the same sex often make it desirable to discuss certain aspects of sexuality in segregated groups. As a rule, the need for separate discussion groups diminishes as young people mature.

Sexuality education should consist of instruction concerning normal body functions and should be presented in a straightforward manner using correct terminology. When discussing sex and sexual activities, nurses should use simple but correct language, not street language, highly scientific terminology, or evasive jargon. Once they understand the meaning of biologic terms such as uterus, testicles, and vagina, most teenagers prefer to use them in their discussions.

Many girls arrive at menarche with ambivalent attitudes, myths, and illogical beliefs. Even girls adequately prepared for menstruation do not always understand its relationship to the total process of reproduction. Many are under the incorrect impression that the “safe” time for sexual intercourse is midway between menstrual periods.

Teenagers’ curiosity and desire for information extend beyond the need for anatomic and physiologic knowledge. They need to know more than the mechanics of conception, pregnancy, and birth. Adolescents, girls in particular, want answers to questions such as “What is it like?” “Does it hurt?” “What happens when … ?” and “Is it all right if you … ?” Boys are often concerned about the fallacy that a relationship exists between penis size and sexual function. They need reassurance that masturbation is a normal and common practice, that some degree of homosexuality in early adolescence is not unusual, and that oral-genital relations can be normal substitutes for intercourse.

Teenagers need to discuss intercourse, alternative methods of sexual satisfaction, and how to resist peer pressure. With the increased incidence of sexually transmitted diseases, especially HIV infection, the topic of “safe sex,” especially abstinence or the use of condoms, is essential. Role-playing can help teenagers learn effective approaches to dealing with difficult situations. Sex and sexuality cannot be taught without discussions of mature decision making, sexual responsibility, and values clarification. Adolescents may receive inaccurate and ambiguous messages regarding sexual behavior; for example, an adolescent may be told that abstinence from vaginal intercourse will prevent transmission of a sexually transmitted disease. Accurate and unbiased information regarding sexual practices should be provided in a setting wherein the adolescent feels comfortable asking questions without being degraded or made to feel uncomfortable for seeking information.

Adolescents need role models and life experiences with delayed gratification. Most important, they need problem-solving experience and decision-making skills so that they can anticipate the positive and negative outcomes of a decision. With this type of assistance, teenagers can become sexually responsible young adults.

INJURY PREVENTION

Physical injuries are the greatest single cause of death in the adolescent age-group and claim more lives than all other causes combined. The most vulnerable ages are the years 15 to 24, when accidental injuries account for about 60% of deaths in boys and 40% of deaths in girls. These figures remain fairly constant from year to year and are significant because almost all fatal injuries are preventable.

During adolescence, peak physical, sensory, and psychomotor function gives teenagers a feeling of strength and confidence that they have never experienced before, and the physiologic changes of puberty give impetus to many basic instinctual forces. One manifestation of this is an increase in energy that simply must be discharged through action, often at the expense of logical thinking and other control mechanisms. Their propensity for risk-taking behavior plus feelings of indestructibility makes adolescents especially prone to injuries. Some of the developmental characteristics of teenagers and injury prevention suggestions are outlined in Box 16-3.

ANTICIPATORY GUIDANCE—CARE OF FAMILIES

Both adolescents and their parents are often confused and perplexed about the changes and behavior of this stage of development. Parents need support and guidance to help them through this trying time. They need to understand the changes taking place and to accept the expected behaviors that accompany the process of detachment. Parents may need help to “let go” and to promote the changed relationship from one of dependence to one of mutuality (see Family-Centered Care and Family Focus boxes).

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