Adolescence is a developmental period during which dependent children grow into independent adults. This period usually begins at about 10 yr and lasts until the late teens or early 20s. During adolescence, children undergo striking physical, intellectual, and emotional growth. Guiding adolescents through this period is a challenge for parents as well as clinicians. Preventive care is also important (see see Approach to the Care of Normal Infants and Children: Recommendations for Preventive Care During Adolescencea).
Fortunately, most adolescents enjoy good physical health. Psychosocial adjustment is a hallmark of this phase of development because even normal individuals struggle with issues of identity, autonomy, sexuality, and relationships. “Who am I, where am I going, and how do I relate to all of these people in my life?” are constant preoccupations for most adolescents. Psychosocial disorders are more common during adolescence than during childhood, and many unhealthy behaviors that begin during adolescence (eg, smoking, drug use, violence) can lead to acute health problems, chronic disorders, or morbidity later in life.
All organ systems and the body as a whole undergo major growth during adolescence; breasts in girls and genitals and body hair in both sexes undergo the most obvious changes. Even when this process goes normally, substantial emotional adjustments are required. If the timing is atypical, particularly in a boy whose physical development is delayed or in a girl whose development occurs early, additional emotional stress is likely. Most boys who grow slowly have a constitutional delay and catch up eventually. Evaluation to exclude pathologic causes and reassurance are needed.
Guidance concerning nutrition, fitness, and lifestyle should be given to all adolescents, with special attention paid to the role of activities such as sports, the arts, social activities, and community service in the adolescent's life. Relative requirements for protein and energy (g or kcal/kg body weight) decline progressively from the end of infancy through adolescence (see Table 4: Nutrition: General Considerations: Recommended Dietary Reference Intakes* for Some Macronutrients, Food and Nutrition Board, Institute of Medicine of the National Academies), although absolute requirements increase. Protein requirements are 0.9 g/kg/day in late adolescence; mean relative energy requirements are 40 kcal/kg.
In addition to adapting to bodily changes, the adolescent must become comfortable with the role of adult and must put sexual urges, which can be very strong and sometimes frightening, into perspective. Some adolescents struggle with the issue of sexual identity and may be afraid to reveal their sexual orientation to friends or family members. Acceptance from a clinician and, if indicated, a referral for supportive counseling, may help the adolescent adjust to life as a healthy adult.
Few elements of the human experience combine physical, intellectual, and emotional aspects as thoroughly as sexuality. Helping adolescents put sexuality into a healthy context through honest answers regarding reproduction and sexually transmitted diseases is extremely important. Adolescents and their parents should be encouraged to speak openly regarding their attitudes toward sex and sexuality; parents' opinions remain an important determinant of adolescent behavior.
As adolescents encounter schoolwork that is more complex, they begin to identify areas of interest as well as relative strengths and weaknesses. Adolescence is a period during which young people begin to consider career options, although most do not have a clearly defined goal. Parents and clinicians must be aware of the adolescent's capabilities, help the adolescent formulate realistic expectations, and be prepared to identify impediments to learning that need remediation, such as learning disabilities, attention problems, or inappropriate learning environments. Parents and clinicians should facilitate apprenticeships and experiences that expose older adolescents to potential career opportunities either during school or during school vacations. These opportunities may help adolescents focus their career choices and future studies.
The emotional aspect of growth is most trying, often taxing the patience of parents, teachers, and clinicians. Emotional lability is a direct result of neurologic development during this period, as the parts of the brain that control emotions mature. Frustration may also arise from growth in multiple domains. A major area of conflict arises from the adolescent's desire for more freedom, which clashes with the parents' strong instincts to protect their children from harm. Parents may need help in renegotiating their role and slowly allowing their adolescents more privileges as well as expecting them to accept greater responsibility for themselves and within the family. Communication within even stable families can be difficult and is worsened when families are divided or parents have emotional problems of their own. Clinicians can be of great help by offering adolescents and parents sensible, practical, concrete, supportive help while facilitating communication within the family.
Although adolescents are susceptible to the same kinds of illness that afflict younger children, generally they are a healthy group. Adolescents should continue to receive vaccinations according to the recommended schedule (see Table 13: Approach to the Care of Normal Infants and Children: Recommended Immunization Schedule for Ages 7–18 yr).
Acne is extremely common and needs to be addressed because of its impact on self-esteem.
Trauma is very common among adolescents, with sports and motor vehicle injuries most frequent. Violence, sometimes involving weapons, is an everyday threat among certain adolescent groups.
Obesity is one of the most common reasons for visits to adolescent clinics. Most cases of obesity are due to eating more than is needed, often in conjunction with a sedentary lifestyle. Genetic influences are common, and responsible genes are now being identified (see also Obesity and the Metabolic Syndrome). Determination of the body mass index (BMI) is recognized as an important aspect of physical assessment. Primary endocrine (eg, hyperadrenocorticism, hypothyroidism) or metabolic causes are uncommon. Hypothyroidism should be ruled out as a cause and should be suspected if height growth slows significantly. If the child is short and has hypertension, Cushing's syndrome should be considered. Type 2 diabetes mellitus is occurring with increasing frequency due to obesity in adolescents. Despite many therapeutic approaches, obesity is one of the most difficult and discouraging problems to treat, and long-term success rates remain low.
Infectious mononucleosis is particularly prevalent among adolescents. Sexually transmitted diseases become an important concern, and UTIs are common among girls. Some endocrine disorders, particularly thyroid disorders, are common among adolescents, as are menstrual abnormalities. Iron deficiency is relatively common among adolescent girls. Pregnancy also is not a rare occurrence and must be kept in mind when treating adolescent girls. Although not common, neoplastic diseases such as leukemia, lymphoma, bone cancers, and brain tumors also occur.
Clinicians must be aware of the high frequency of psychosocial disorders that occur during this unsettled stage of life. Depression is common and should be looked for actively (see Mental Disorders in Children and Adolescents: Depressive Disorders in Children and Adolescents). Although suicide is a rare occurrence (5/100,000), suicidal ideation is common (as many as 1 in 10 in some studies). Anxiety often manifests during adolescence (see Mental Disorders in Children and Adolescents: Anxiety Disorders in Children and Adolescents), as do bipolar disease and problems with anger management. Adolescence is also a time when some people who will develop a psychotic disorder experience their first psychotic break. Eating disorders, especially in girls, are common (see Eating Disorders). Some patients go to extraordinary lengths to hide an anorexic or bulimic state.
School problems, especially when related to learning or attention difficulties, can be dealt with by clinicians, who must work closely with school personnel and parents. Learning disorders may manifest for the first time as school becomes more demanding, particularly among bright children who previously had been able to accommodate for their areas of weakness. If a learning disorder is suspected, the clinician should recommend a complete learning evaluation followed by provision of appropriate services. Environmental changes and sometimes drug therapy can be of great help to struggling students.
A constant concern is substance use, which begins as a psychosocial problem but may develop into a physiologic disorder. Alcohol and cigarette use is extremely common, followed by marijuana and a long list of other substances available in all strata of society. Inhalant use is also a problem, particularly among young adolescents. Prescription and OTC drugs are now misused by adolescents more than any other substances other than alcohol and marijuana. All of these psychoactive substances are addictive, and delaying the onset of substance use from adolescence into adulthood both prevents the acute problems associated with substance use and decreases the lifetime risk of developing a substance use disorder. Clinicians should screen for use of alcohol and other drugs at every health maintenance visit and also should advise both adolescents and parents about safely using and monitoring OTC and prescription drugs.
The clinician who has developed an open, trusting relationship with an adolescent often can identify these problems, can supply support and practical advice, and can get the adolescent to accept a referral to specialized care if necessary.
Last full review/revision December 2007 by Sharon Levy, MD, MPH
Content last modified April 2012