INTRODUCTION
This chapter offers a practical behavioral framework to assist those who provide health care to teenagers. Stages of adolescent development along with behavioral correlates are discussed, as are suggestions for effective patient–doctor communication, interviewing, and provision of health services. From a physiologic perspective, adolescence is the interval between the onset of puberty and the cessation of body growth. In psychosocial and behavioral terms, it is the time during which adult body image and sexual identity emerge; independent moral standards, intimate interpersonal relationships, vocational goals, and health behaviors develop; and the separation from parents takes place. Although some of these tasks may begin prior to puberty and evolve into adulthood, they provide the foundation for understanding adolescent behavior.
Most teenagers are healthy. Compared with other age groups, mortality rates for teenagers are low. The majority of health problems in teenagers are behavior related and include unwanted pregnancy; sexually transmitted infections (STIs); weapon carrying; interpersonal violence; suicidal ideation; alcohol, cigarette, and illicit drug use; and dietary and exercise patterns. Nationally, accidents are the leading cause of death for most populations of teenagers, although homicide (often gang related) leads in some geographic locations. Socioeconomic status and population density, rather than ethnic or racial grouping, define the neighborhoods most at risk for gunshot deaths. Nonetheless, the most common reasons for acute office visits for teenagers are routine or sports physicals, upper respiratory infections, and acne. One of the major challenges to a provider caring for teenagers is eliciting a history that reveals health risk behaviors. Because most adolescent mortality and morbidity are preventable and because many behaviors such as sexual practices, diet, exercise, and substance use that result in adult disease begin in adolescence, ignoring this age group means missing a major public health opportunity.
In 1992, the American Medical Association published Guidelines for Adolescent Preventive Services (GAPS), the first set of developmentally and behaviorally appropriate comprehensive health care guidelines for adolescents, emphasizing anticipatory, preventive, and patient-centered services. Guidelines for Adolescent Preventive Services suggest that promotion of adolescent health and prevention of disease involve a partnership encompassing patients, parents, schools, communities, and health care providers. Although these guidelines have existed for several decades, and have been shown to be valuable as care standards and as quality measures, there is little evidence that they are being widely implemented.
Adolescent health outcomes—perhaps more than for any other population—are closely linked to cultural, educational, political, and economic policies at the local and national level. Handguns and bullying are both relevant examples. For example, the availability of handguns is not a problem that the health practitioner can resolve during an office visit, yet making them less available would substantially benefit the health of many teenagers. There would very likely be less depression and suicidal ideation if more schools instituted zero tolerance programs for bullying and developed programs that promoted diversity.
The Internet and all forms of related electronic communication including social networks, texting, and instant messaging have profoundly changed the way we all interrelate socially and how we receive and disseminate health-related and behavioral information. Adolescents and young adults are, and will likely continue to be, at the forefront of this communication transformation. It is essential that those providing care to adolescents understand how these communication developments might have beneficial and detrimental influences on this population. Electronic social networks are a good example. Such networks for adolescents with chronic diseases might serve as a positive influence to improve medication compliance and decrease the sense of isolation. Conversely, bullying through social networks has been the cause of depression and even suicide. It is especially important to understand these influences because there is compelling evidence that teens who feel connected to parents, school, and community are less likely to participate in health-compromising behavior than teens who feel isolated or disconnected. It should be expected that the evolution of new forms of electronic communication will continue to play a role in how teenagers connect to all facets of their environment including those that relate to health and well-being.
STAGES OF DEVELOPMENT
Medical services for teenagers need to be appropriate for each developmental stage. Each of the three recognized developmental stages in adolescence is distinguished by physical, cognitive, and behavioral hallmarks. Not all adolescents fit perfectly into each phase, and they often progress at different rates from one phase to the next. Moreover, rates of physical, cognitive, and behavioral development may not be congruent. For example, a 14-year-old girl who is physically mature may be emotionally and cognitively unable to decide about sexual intimacy and the potential consequences.
Rapid growth causes physical and body image changes. Many teenagers question whether their growth is “normal,” and commonly there is a good deal of somatic preoccupation and anxiety. Gynecomastia, for example (a common transient problem for boys), may cause concern, and prevent participation in physical education class. Because the topic may be too embarrassing for an already self-conscious teenager, clinician-initiated reassurance is essential when the condition is identified during a physical examination. Early or later onset of puberty has widely variable effects. Early puberty may be associated with the increased likelihood of weight concern and excessive dieting and other eating disorders in girls, but it may result in greater self-esteem and athletic prowess in boys. Because self-esteem is linked closely with physical development and peer group attractiveness, teens who develop later than their peers may have self-esteem problems. Among early adolescents, questions and concerns about menstruation, masturbation, wet dreams, and the size of their breasts (too large or too small) and genitals are common. These questions need to be anticipated and specifically and carefully addressed. Endocrine disorders related to sexual maturation are likely to emerge; early diagnosis and treatment can improve health and self-esteem.
In adolescence, peer group involvement increases and family involvement decreases. Friendships are idealized and are mostly same gender. Close peer relationships coupled with curiosity about body development may result in homosexual and other sexual experimentation, anxiety, and fear. Although some heterosexual relationships are initiated, contact with the opposite sex frequently occurs in groups. Often by this age adolescents have access to the Internet, participate in online social networks, and use cell phones. How they are used and potentially monitored will often become an important issue of family discussion.
The transition from concrete to abstract thinking begins. Because experience and emotion play important roles in decision making, improved cognition alone is not enough to prevent many teenagers from making impulsive decisions with little regard for consequences. Increased cognitive ability linked with the search for identity often leads teenagers to test limits both at home and at school. Daydreaming is common.
The issues of early adolescence may continue, although most physical development is complete by the end of this phase.
Independence, identity, and autonomy struggles intensify. Peer groups may become more important than family to some teenagers and result in increasing teen–parent conflict. Experimentation with alcohol, drugs, and sex is common. A sense of invincibility coupled with impulsiveness leads to relatively high rates of automobile accidents and interpersonal violence. Suicide, impulsively linked to failed love relationships, or poor self-esteem because of difficulty finding peer group acceptance may also occur during this phase. Despite adhering to peer group norms regarding music, dress, and appearance (including body piercing, tattoos, clothes, hair color, and makeup), the expression of individuality is common. Many teenagers find identity and support in school, sports, community, or church activities. For teenagers whose support systems or community resources are inadequate, gangs may supplement personal strength and provide a sense of identity. Teenagers from alienated and disenfranchised ethnic groups are at particular risk for gang activity. In spite of slowly improving cultural acceptance, gay, lesbian, and transgendered teenagers may feel increased isolation, alienation, and bullying (see Chapter 17). This may lead to depression, sexual promiscuity, or suicide. The Internet leads to easy linkage to social networks for minority youth, such as those with chronic diseases, who in the past might have felt isolated and now can gain access to social and psychological support. Those same networks, however, also make it much easier for sexual encounters and resulting exposure to STIs or unintended pregnancy.
Improved reasoning and abstraction allow for closer interpersonal relationships and empathy in this group. Evaluation of future academic and vocational plans becomes important. Poor school performance may heighten anxiety and concern about vocational choices and lead to “escape” in drugs and alcohol. Practical guidance that identifies strengths and builds self-esteem can help avoid frustration and failure.
Body growth is usually no longer a concern. The quest to become comfortable with one’s physical appearance often continues throughout adulthood.
If the adolescent’s development has occurred within the context of a supportive family, community, school, and peer environment, individual identity formation and separation will be complete. In reality, however, at least some developmental issues usually remain unresolved into adulthood. Late adolescents typically spend more time developing monogamous interpersonal relationships and less time seeking peer group support. Ideally, decision making, based on an individualized value system, is modulated by limit setting and compromise.
Vocational goals should now be set in practical terms, and there should be realistic expectations about education and work.
ADOLESCENTS & THE MEDICAL INTERVIEW
A general health assessment should include a review of systems and an evaluation of health-related behavior. This should include risk factors for accidents, STIs, including human immunodeficiency virus (HIV), pregnancy, interpersonal violence (including past physical or sexual abuse), nutrition, substance use, exercise, sleep, learning, and mental health problems. Guidance about promoting healthful behaviors and preventing disease should be integrated into the discussion. Inclusion of these factors is considered community standard of care for adolescents. Documentation of health encounters ideally should be done electronically; it is therefore recommended that a standard written protocol be developed so that all elements described above can be documented and searched for quality assessment. From the patient’s perspective, the clinician’s inquiries and assessment of some behaviors may be viewed as embarrassing, intrusive, or trivial. It is therefore helpful to explain, prior to questioning, that (1) the same questions are asked of all patients and that (2) the encounter goal is patient self-awareness and health education. During the interview it is important to reinforce and praise healthy decisions, such as sexual abstinence.
Certain ground rules are important. Ensure the adolescent that, unless homicide or suicide is threatened or ongoing abuse is reported, all conversations are confidential, and the information will not be shared with parents, teachers, or other authorities without permission. Discussions about sex and drugs should always occur in private unless otherwise requested by the patient. If the patient is accompanied by a parent, solicit parental concerns, and then ask the adult to leave the room and conduct the interview in private. It is also helpful to let the parent know (if present) about the confidential nature of the patient–clinician conversation.
Although most teenagers want to receive health information and discuss personal behavior, these discussions must generally be initiated by the physician. Many teenagers are not accustomed to interacting in such participatory, nonjudgmental conversations with adults. The willingness of a teenager to share personal or intimate information depends on the perceived receptiveness of the provider. Teenagers need to feel that they have permission to share personal, behavior-related information. For example, it is usually not difficult for patients and clinicians to discuss routine chronic medical conditions such as diabetes or asthma. Control of these conditions in some teenagers, however, may be related more to dietary indiscretions and cigarette use, than to insulin or inhaler use. Such health-compromising behaviors must be identified before they can be dealt with; comments, facial expressions, or body language indicating disapproval can undermine the patient’s willingness to disclose confidential behavior (Table 13-1).
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