Physical development

Preadolescence refers to the beginning of the second skeletal growth spurt, when physical changes such as the development of female breasts and pubic hair also begin. These physical changes occur about 2 years earlier in girls than boys (Tortora & Derricksen 2008). The bones begin to lengthen and broaden. More in-depth descriptions of these changes are included in this chapter under the heading ‘Physical development’ in the section on adolescence below.

Cognitive development

Cognition is involved with thinking; perception, language, learning, memory and problem solving. According to the theories of the French psychologist Piaget, the preadolescent is in what is termed ‘the concrete operational stage’ of thinking (Atherton 2011). In this stage children think logically as long as they have the object of their thoughts physically present to manipulate. It is difficult for them to understand theories or abstract concepts.

Emotional development

The preadolescent is better able to describe their feelings than the younger child, especially about developmental changes they are experiencing. They become better at problem solving and achieving their goals. Some experience mood swings, which develop from the same hormones that contribute to physical changes. They may feel happy one minute and irritable or sad the next. Their feelings may be overpowering. The preadolescent may also give in to impulses, as the parts of the brain that are involved in impulse control have not yet developed fully.

Psychosocial development

In the preadolescent stage children become more social and their behavioural patterns become much less predictable. Included in this stage are experimentation with makeup by girls and the interest in music and performers that are popular with older adolescents. Typically they have same-sex friends and tend to spend more time with their friends than with their families. Preadolescents often develop friendships with adults other than their parents and use these relationships to gather information about adults. They are no longer totally egocentric and begin to see the importance of others within their social environments.

Sexual development

During this time most children experience some of the changes of puberty. As their bodies begin to change they tend to develop a natural modesty. They are frequently curious about sex and, provided that there is an environment where sex can be spoken about comfortably, they are likely to ask many questions. Sometimes when children are in hospital and curious about their bodies they ask questions of nurses they trust. This may be an indication that information relating to sexuality or sexual matters is wanted. It is advisable for the nurse to find out what knowledge the child already has to avoid giving inappropriate answers (Carpenito-Moyet 2006). (See Clinical Scenario Box 11.1.)

Physical development

The physical development and changes of early adolescence (puberty) are primarily the result of hormonal activity with the sequence of pubertal growth changes the same in most individuals (Sigelman & Rider 2011). (See Tables 11.1 and 11.2.)

Table 11.1 Usual sequence of maturational changes in adolescence

Hockenberry & Wilson 2011

Table 11.2 Growth and development during adolescence

Hockenberry & Wilson 2011

Physical changes occur rapidly in both males and females. Physical distinctions between boys and girls are determined on the basis of distinguishing characteristics: primary sex characteristics are the internal and external organs that carry out reproductive functions (ovaries, breasts, penis, uterus); secondary sex characteristics play no direct part in reproduction but are the changes that occur in the body as a result of the hormonal change (development of facial and pubic hair, changes in voice, fat deposits). Secondary sex characteristics externally differentiate males from females.

The main physical changes are:

Height and weight usually increase during the prepubertal growth spurt. The final 20% to 25% of height is achieved during puberty, with most of this growth occurring in a 24–36 month period. For girls this usually begins between 8 and 14 years of age. Weight increases by 7–25 kg and height increases by 5–20 cm. Growth in height usually stops 2–2.5 years after menarche in girls. For males this growth spurt occurs between 10 and 16 years of age. Height increases by 10–30 cm and weight increases by 7–30 kg. Growth in length of the limbs and neck precedes growth in other areas. Increases in hip and chest width take place in a few months, followed by an increase in shoulder width several months later (Crisp & Taylor 2009).

Growth in height usually stops at age 18–20 in boys. The individual often appears awkward and clumsy and the sequence of changes is responsible for the long-legged gawky appearance that is often seen. These changes require the adolescent to adjust their perception of their self in space as well as accepting a new body image. Fat becomes redistributed into adult proportions as height and mass increase, and the adolescent gradually assumes an adult appearance. Adolescents who are concerned about physical changes that make them different from their peers should be reassured by the nurse about normal growth curves and that their own growth patterns are normal.

An increase in the secretion of sebum occurs from the skin and frequently results in acne. This development can have significant effects on how the adolescent views their physical image. (See Fig 11.1.)

Figure 11.1 Acne on the forehead of a 15-year-old girl

(Dr P. Marazzi/Science Photo Library)

Hormonal changes of puberty

Hormonal production is controlled by the anterior pituitary gland, which is in turn stimulated by the hypothalamus. The stimulation of the anterior pituitary results in the release of the gonadotrophic hormones that stimulate the gonads. As a result of this stimulation, testicular cells produce testosterone and ovarian cells produce oestrogen. These hormones contribute to the development of secondary sex characteristics and play an essential role in reproduction. The changing concentration of these hormones is also linked to problems of adolescence, such as body odour and acne.

Sexual maturation in girls

The initial indication of puberty in most girls is the appearance of breast buds. Breasts begin to develop from about age 10 (development continues until about age 17). (See Fig 11.2.) About 2–6 months later, growth of pubic hair on the mons pubis begins. (See Fig 11.3.) The initial appearance of menstruation (menarche) occurs about 2 years after the first pubescent changes. The normal age range of menarche is 10.5–15 years, with ovulation usually beginning 6–14 months after menarche.

Figure 11.2 Development of breasts in girls. Stage 1 (prepubertal elevation of papillae only) not shown

(Adapted from Hockenberry 2005 [Modified from Marshall WA, Tanner JM: Arch Dis Child 44:291, 1969; Daniel WA, Paulshock BZ: A Physician’s guide to sexual maturity, Patient Care May 13, 122–124, 1979])

Figure 11.3 Growth of pubic hair in girls

(Adapted from Hockenberry 2005 [Modified from Marshall WA, Tanner JM: Arch Dis Child 44:291, 1969; Daniel WA, Paulshock BZ: A Physician’s guide to sexual maturity, Patient Care May 13, 122–124, 1979])

Concerns about pubertal delay in girls should be considered if breasts have not started to develop by age 13 or if menarche has not occurred within 4 years of the onset of breast development (Sigelman & Rider 2011). It is important to remember that racial origin and environmental issues can contribute to when puberty begins. Girls from some genetic backgrounds will experience earlier menarche than girls from others. Similarly, girls with nutritional problems such as anorexia or those having to keep a minimal body weight for some activities such as dancing, modelling and gymnastics may also experience delayed menarche. The body requires a set level of fat deposits before menarche can be initiated.

The commencement of menstruation is often seen as a rite of passage in many cultures and is frequently heralded with celebrations. In mainstream Australasian and North American culture this time is not celebrated overtly. However in other cultures it is celebrated by ritual bathing, specific ceremonies or the wearing of special clothing. In some Indigenous communities the practice of female circumcision is still undertaken to celebrate and mark this rite of passage.

Sexual maturation in boys

Testicular enlargement, accompanied by thinning, reddening and increased looseness of the scrotum, is the first pubescent change in boys and usually occurs between age 9.5 and 14. Penile enlargement begins, with continuing testicular enlargement and growth of pubic hair. (See Fig 11.4.) Facial hair may develop along with early voice changes. Temporary breast enlargement (gynaecomastia) and tenderness are common during mid-puberty. This breast enlargement usually disappears within 2 years. Height and weight growth occur towards the end of mid-puberty. Nocturnal emissions of seminal fluid are an indication of puberty in the male and occur spontaneously and periodically during sleep. In late puberty the testicles and penis enlarge, and the voice deepens. Axillary hair develops and facial hair extends to cover the neck. During this time the opening of the foreskin in non-circumcised boys becomes larger and enables the foreskin to be retracted to below the head of the glans.

Figure 11.4 Developmental stages of secondary sex characteristics and genital development in boys

(Adapted from Hockenberry 2005 [Modified from Marshall WA, Tanner JM: Arch Dis Child 44:291, 1969; Daniel WA, Paulshock BZ: A Physician’s guide to sexual maturity, Patient Care May 13, 122–124, 1979])

Boys may be considered to have pubertal delay if there is no enlargement of the testes or scrotal changes by age 13.5–14 or if genital growth is not complete 4 years after enlargement of the testicles.

In some cultures sexual maturation in boys is celebrated by routine circumcision or the undertaking of specific ceremonies. These ceremonies are aimed at initiating the boy into manhood. In mainstream Australasian and North American cultures no specific rite of passage is undertaken. Rites of passage for boys are more frequently celebrated at the attaining of a specific age rather than on the attaining of puberty. (See Clinical Interest Box 11.1.)

CLINICAL INTEREST BOX 11.1 Rites of passage

Achieving sexual maturity is often celebrated as a rite of passage in some cultures. These ritual events mark the passage from child to adult. Some of these coming of age traditions include:

• Bar Mitzvah and Bat Mitzvah—Jewish (boys and girls)

• Ritual hair cutting—Cook Islands (boys)

• Quinceañera—parts of Latin America (girls)

• Upanayana—Hindu (boys)

• Debutante balls—western culture (girls)

• Land diving—Vanuatu (boys)

• Circumcision—some African tribes (boys and girls)

The physical changes that occur during adolescence are rapid and dramatic and play a significant role in psychosocial development. By understanding these changes you are better able to plan appropriate nursing care and to reassure and educate adolescents about their body care needs. The timing of these physical changes depends on factors such as heredity and nutrition and whether the adolescent is a boy or girl. The sequence of growth changes (Tables 11.1 and 11.2) is the same in most individuals (Sigelman & Rider 2011).

Physiological needs

The strength and size of the heart and systolic blood pressure and blood volume increase during puberty. The pulse rate and basal heat production decrease. Boys have a higher blood volume than girls, which may be related to boys having a greater muscle mass. All formed elements of the body reach adult levels. Respiratory volume and vital capacity are increased, but respiratory rate and the basal metabolic rate decrease. As a result of increased strength and size of muscles and increased cardiac, respiratory and cardiac functioning, physiological responses to exercise change dramatically.

Cognitive development

Adolescents are capable of using deductive reasoning and abstract thinking and can consider the logic of a problem. According to Piaget, this stage, known as the period of formal operations, is the highest level of intellectual development. Being able to think logically about role behaviours enables adolescents to develop their own thoughts and means of expressing their identity. Intellectual development continues through formal education and the pursuit of personal interests (Atherton 2011). Without an appropriate educational environment, individuals may not reach this stage. The teenager can think abstractly and is no longer restricted to the real and actual, but can deal with the hypothetical. Adolescents are able to manipulate more than two different variables at one time. They think about what might be, whereas primary school-age children only think about what is. This allows adolescents to have more skill and insight when playing board games or video games, for example.

By mid-adolescence, cognition develops an introspective quality. At this stage adolescents wonder about what others think of them and increasingly imagine the thoughts of others. They question society and its values and, although they have the ability to think as well as an adult, they do not have the experiences that an adult has on which to build. They can think about the consequences of their actions and can detect logical consistency or inconsistency in a set of statements or actions (Crisp & Taylor 2009). For example, they will question a parent who swears but tries to persuade the adolescent not to use bad language.

Language development is relatively complete by adolescence, although vocabulary continues to expand. The main focus becomes the development of communication skills that can be employed effectively in various situations. Adolescents need to share thoughts, facts and feelings to parents, teachers, peers and others. The skills needed are varied. The adolescent must decide whom they will communicate with, the message they wish to share and the way they will transmit the message. For example, the way a teenager tells peers about a new relationship is not the same as the way they tell their parents (Mitchell & Ziegler 2007).

Psychosocial development

Adolescence is a time when the young person is seeking and learning the skills to become independent. It is often a period of emotional turmoil and insecurity, caused by the conflict between the need and desire for independence and the need to retain dependence on others. It is a time when identity is consolidated and a time when choices about vocation and lifestyle must be made. Relationships with parents undergo change and the adolescent begins to assert individuality and a desire for independence, often by resisting adult authority and advice. The adolescent usually displays mood swings, and experiences confused emotions. In later adolescence, emotions are better controlled and more mature. However, an older adolescent is still subject to heightened emotion and their expressive behaviour reflects feelings of insecurity and indecision (Crisp & Taylor 2009). As adolescents move into adulthood they normally become less reliant on positive reinforcement from others as their main source of self-esteem-enhancing experiences.

For those working with adolescents, knowledge of the theories of adolescent development is essential to obtain an understanding of the adolescent stage and the ability to recognise the tasks of adolescence. One such theory is Erikson’s theory of human development (1963) which encompasses the whole of the lifespan in eight stages, each of which involves opposing crises which must be negotiated to be able to go on to the next stage. This theory recognises the period of adolescence as a time spent searching for identity. Erikson sees identity (or role) confusion as the main danger of this stage. The adolescent’s search for identity involves the quest for individual, sex-role, moral and group identity (Mitchell & Ziegler 2007).

Social development

Social development involves an expansion of the network of social relationships and social activities. For many adolescents the peer group remains the most important social group, serving as a strong support providing a sense of belonging. It provides a link between independence and autonomy. Adolescents may move away from family domination and define their identity independently of parental authority. Adolescents may want to separate from parental restraints but at the same time may be fearful of the consequences associated with independence. This process of achieving independence often involves turmoil and ambiguity as both adolescent and parent learn new roles. Conflicts can arise from almost any situation or subject. Adolescents may find themselves argumentative, critical and remote with both parents as they attempt to achieve independence from parental controls. This rejection is usually not consistent and varies with mood changes. Some research shows that parents who provide a more cooperative style of parenting rather than an authorative style improve the adolescent’s ability to be independent and make appropriate decisions (Peterson 2009). Social relationships that develop outside the family help the adolescent identify their role in society.

Sexual development

Adolescence is a time of acute awareness and sensitivity to emerging sexuality and body image, when appearance, personal and sexual attractiveness and peer acceptance are of crucial importance to self-esteem and a sense of belonging (Varcarolis et al 2006; Videbeck 2007).

A positive self-concept and sense of emotional security depends significantly on the support the adolescent receives while coping with the physical and emotional changes experienced during the difficult and sometimes tumultuous transition to adulthood. Support includes allowing for privacy, the freedom to develop personal interests and new relationships and understanding the frequent changes of mood and behaviour that commonly occur.

Particular sensitivity is needed when nursing the ill or hospitalised adolescent, because changes or threats to appearance or functioning can have a profound impact, resulting in anxiety, feelings of vulnerability and a negative impact on self-image. The nurse can help the adolescent, as any other client, by demonstrating respect, which reinforces self-worth. The nurse can show this in many ways, including by being non-judgmental, reinforcing the belief that the client is doing their best to cope, to adapt or to change and by demonstrating acceptance of the adolescent client’s own perspective and feelings (Stein-Parbury 2009).

During adolescence there may be a great deal of experimentation in the expression of sexuality. Heterosexual and homosexual liaisons are common and sexual behaviour usually includes masturbation (Makadon 2007). Assurance about what is generally accepted as normal in physical and emotional development is helpful, as is open, honest and accurate information on topics such as body changes, sexual orientation, sexual practices, emotional responses within intimate relationships, sexually transmitted infections (STIs) and contraception. (Information about contraception and reproductive health is provided in Chapter 35.)

There are times when the nurse may feel it appropriate to explore sexuality issues with an adolescent, for example, when working in sexual health clinics, adolescent mental health units and in drug and alcohol clinics.

Experts generally agree that sexual orientation is probably the outcome of complex interactions between biological, cognitive and environmental factors and that it is established at an early age but commonly emerges in adolescence. It is accepted that genetic and hormonal factors play a part in shaping a person’s sexuality to the extent that the person has no conscious choice in the matter, but also that there are probably many combining reasons for a person’s sexual orientation, which may be different for different people (Makadon 2007; Rathus et al 2007). Often it is difficult for the adolescent to discuss with their family and friends their thoughts in relation to their own sexuality or sexual orientation. Always be aware that the adolescent who is developing their sexual identity may not be ready or willing to discuss this issue with health practitioners either. Huffaker and Calvert (2005) suggest that the use of social media and virtual reality may be one area in which adolescents may feel more comfortable expressing their sexual orientation and exploring their sexual identity beyond social prescriptions. This is mainly due to the anonymity that can be gained by communicating online.

Many healthcare providers including nurses feel uncomfortable and unskilled in discussing sexuality with their adolescent clients. It is essential, therefore, that you first examine your own attitudes about sexuality, particularly those that relate to adolescents, and reflect on how these attitudes affect your work with teenagers.

Social media

The adolescent of today has always had exposure to electronic media. The computer, the internet and mobile phones have been part of their lives since early childhood. Their use as a tool for communication is an important aspect of the adolescent’s life. There is significant discussion about the effects of the use of social media, with some researchers suggesting that heavy use can have negative effects, and others observing the positive influences that social media can have on adolescent development (Valkenburg & Peter 2007). Networking sites like Twitter and Facebook are often used by the adolescent to keep in touch with their friends and can be seen as positive tools in maintaining relationships. However, heavy usage of these sites may have risks for susceptible persons. Cyber bullying, stalking and predatory behaviour are just a few of the issues that can affect the adolescent user. Unfortunately the cyber bully can remain anonymous to the victim, making it difficult to track and/or halt the behaviour. It is suggested that the cyber bully can be motivated to use not only SMS phone text messages but to also use chat rooms and emails as tools of bullying. While research in this area is still fairly limited, it has been suggested that such bullying is widespread. The management of cyber bullying can be difficult due to its covert nature and the difficulty of tracing the offender (Cross et al 2009).

Body image

How the adolescent responds to the physical changes of puberty depends on their stage of development. In early adolescence some adolescents are preoccupied with the changes in their body and body image. Girls find body changes difficult to adjust to and are often concerned with weight increase and associated fat deposits. This may lead them to think they are obese and lead to fad dieting. Frequently they will compare their body with images in the media and their peers. With the increased use of ‘photoshopping’ of photographs of celebrities to remove evidence of imperfections and fat deposits, and the increasingly slimmer bodies of those portrayed in the media, the adolescent is often using an invalid measure to compare their bodies with. As the average model is 23% thinner than the average person and with the media praising and celebrating this fact, it can be very difficult for the adolescent to be satisfied with their body shape (Derenne & Beresin 2006). The nurse must be extremely cautious when working with the adolescent with body image distortions. Always refer to the care plan or seek advice from the RN when you are unsure how to approach an adolescent in your care who has body image issues.

Overeating or undereating during adolescence is of concern particularly for girls who, when they experience the normal increase in fat deposition and weight associated with the growth spurt, are more likely to resort to dieting.

Anorexia nervosa is a clinical syndrome with physical and psychosocial components. People with anorexia nervosa have an intense fear of gaining weight and refuse to maintain their weight at the normal minimal weight for their age and height. Bulimia nervosa involves binge eating followed by behaviours such as induced vomiting, use of laxatives and excessive exercise to prevent weight gain. It is important to take a thorough dietary history when working with these adolescents. Good and appropriate nursing care can make a significant difference in the recovery process of clients with anorexia nervosa (Ommen et al 2009). (See Nursing Care Plan 11.1 for a sample care plan for an eating disorder.)

Obesity is becoming more prevalent in adolescence. American studies refer to ‘the childhood obesity crisis’ with research identifying that almost one-third of children in the US over the age of 2 are already overweight or obese (Wojcicki & Heyman 2010). Australian research also identifies similar findings, with up to 25% of all children between the ages of 5 and 17 identified as being either overweight or obese. In 2006–07 the prevalence of obesity in the 15–24 year age group in New Zealand was 14.2% (Ministry of Health 2009). There are now more severely obese children than ever. Poor nutrition and decreased physical activity have been identified as two major risk factors for individuals who are overweight and obese. In the adolescent the most immediate consequence of obesity is social discrimination associated with poor self-esteem and depression. They are also more likely to develop other comorbidities such as diabetes than children within normal weight ranges (Queensland Health 2008). This problem has serious ongoing affects across the health continuum.

Indigenous adolescents

Australian and New Zealand Indigenous adolescents have not only the concerns of all adolescents, but also their own specific set of problems. They may feel alienated from both their traditional cultures and mainstream society. Without a thorough understanding of both the contemporary and the historical issues surrounding these two groups no appropriate understanding of the health and developmental issues of these adolescents can be gained. Readers are advised to research texts and articles specifically written for these groups to obtain further information.

As a nurse you are also urged to discover more about social determinants and their effects on the Australian and New Zealand Indigenous adolescent before attempting to make assumptions on the health status of the adolescents you are caring for. When developing health promotion and other tools to address these issues, care must be taken to ensure that the literature is culturally sensitive and in the appropriate language. It is essential to adopt a culturally appropriate approach to provide effective client education. Chapter 9 of this text provides you with a greater insight into Indigenous health.

Risk taking

Adolescents are risk takers. While there are a number of theories which attempt to determine why the adolescent engages in risk-taking behaviours, it is often seen as a normal part of the adolescent process. Teenagers are good at weighing up the pros and cons of their decisions but take risks because they enjoy the thrill of a risky situation more than other age groups, especially when they have a ‘lucky escape’. Teenagers take risks, not because they do not foresee the consequences, but because they choose to take those risks (Burnett et al 2010). Research with adolescents has revealed that risk-taking behaviour is more prevalent among males, early school leavers, as well as youths with less parental supervision, peers who also actively engage in risk-taking behaviour, negative attitudes to authority and high alcohol use. Unfortunately, a tendency for risk-taking behaviour together with feelings of indestructibility makes adolescents particularly prone to accidents, especially those involving motor vehicles and sports. Risk behaviours in adolescents are reported to be the primary source of death in adolescents (Fredrickson & Levin 2007). (See Clinical Scenario Box 11.2.)

Suicide

Suicide accounted for 20% of deaths among older teenagers and young adults (aged 15–24 years) in Australia in 2004–06, making it the second most common cause of death in that age group (Australian Bureau of Statistics 2008). This compares to 1% of deaths among people aged 25 years and over. Every year approximately 100 young New Zealanders (aged 15–24 years) die by suicide. This accounts for about one-fifth of the total number of suicides each year. Suicide continues to be a significant cause of death accounting for approximately 25% of all deaths in this age group (Ministry of Health 2008).

In New Zealand men and Māori youth are particularly affected by suicide. Based on 2006 figures, young men have a rate of 31 per 100 000 population, which is significantly higher than the total population rate of 12 deaths per 100 000. The Māori youth rate is 33 per 100 000 population, compared with the non-Māori youth rate of 15 per 100 000 (The Social Report 2010).

Suicide usually results from a combination of factors and between 23.5% and 49% of teenagers have thoughts of suicide at some time (RCMH 2010). In adolescence it is often used to escape from a situation that they do not feel they can manage and it can be associated with depression. The following warning signs may occur for at least a month before a suicide attempt:

Prevention of suicide always involves education. This can be done in major health promotional campaigns such as the Queensland Government Suicide Prevention Strategy 2003–2008 Queensland, (Queensland Health nd), the New Zealand Suicide Prevention Strategy 2006–2016 (Ministry of Health 2006) or in smaller campaigns run by school and community nurses or even one-on-one sessions with susceptible individuals. As a nurse, you need to be able to identify precipitating events and adolescent suicide risk factors. If assessment suggests that the adolescent is at risk of suicide you need to facilitate referral to mental health professionals while helping the adolescent to focus on the positive aspects of life and develop coping skills such as problem solving, anger management, conflict resolution and assertive communication.

Substance abuse

Substance abuse involves the use of mood-altering substances in an attempt to create a sense of wellbeing or improve levels of performance. The adolescent’s peer group can have a significant affect upon the individual’s use of illicit or other substances. All adolescents are at risk of substance abuse and have a higher risk of becoming addicted than an adult if abuse continues. The adolescent will use illegal/recreational substances for a number of reasons; these include perceived risk, social approval and availability (Crisp & Taylor 2009). Drug-related health problems vary according to the type of drug, how much is used and the duration of use.

Alcohol is one of the main substances that the adolescent is liable to abuse and although only a small percentage (2.6%) of all adolescents claim to have undertaken risky drinking, the percentage is increasing. Not only is alcohol use by the young person proven to be linked to dependence later in life, it also can have a detrimental effect on the maturing brain (AIHW 2009).

It is important to note that if the adolescent has a substance abuse problem it is not just an individual problem. Their network of family and friends will also be affected in some way.

Sexual experimentation

Sexual experimentation during adolescence is often seen as behaviour to confirm sexual orientation. The two main consequences of sexual activity during adolescence are sexually transmitted infections (STIs) and unplanned pregnancy. At least 1 in 4 sexually active teenage American girls has a sexually transmitted disease (Centers for Disease Control and Prevention 2008). While these are American statistics it is reasonable to assume that the figures would be similar in Australasia.

A thorough sexual history should be included in any screening of adolescent health. The nurse can use the interview process to identify risk factors. Education about the ways STIs are transmitted is recommended, as most adolescents believe they are not at risk. The rate of adolescent pregnancy has fallen in Australia. This is a result of education and the availability of contraception and, in most states and territories, access to abortion. (See Clinical Interest Box 11.2.)