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Course: Pediatric Nursing

Topic: Growth and Development of Adolescents

The Nurses International Community

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Module Goals

Learners will be able to:

Identify the normal developmental changes (e.g., physiologic, cognitive, psychosocial) that occur during adolescence.
Examine the common developmental theories (Erikson, Freud and Piaget) in relation to the growth of the adolescent.
Demonstrate knowledge of nutritional requirements during adolescence.
Identify the common developmental concerns during adolescence.
Describe the nurses’ role in adolescent growth and development.

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Growth Milestones in Adolescence

Puberty begins.
Physical maturity and a secondary sexual character appear.
Gender difference becomes apparent.
Physical growth spurts; 10-11 inches of added height and 50 to 75 pounds of increased body weight.
Average height and weight may differ by ethnicity.
Internal organs grow with the body; sexual organ maturation occurs.

Paris & et al., 2019

Lally & Valentine-French, 2019

Contact info: info@nursesinternational.org

Growth in Adolescence

Puberty is a period of rapid growth and sexual maturation. These changes begin sometime between eight and fourteen. Girls begin puberty at around ten years of age, and boys begin approximately two years later. Pubertal changes take around three to four years to complete.

Adolescents experience an overall physical growth spurt. The growth proceeds from the extremities toward the torso. This is referred to as distal proximal development. First, the hands grow, then the arms, and finally, the torso. The overall physical growth spurt results in 10-11 inches of added height and 50 to 75 pounds of increased weight. The head begins to grow sometime after the feet have gone through their period of growth. Growth of the head is preceded by growth of the ears, nose, and lips. The difference in these patterns of growth results in adolescents appearing awkward and out-of-proportion. As the torso grows, so do the internal organs. The heart and lungs experience dramatic growth during this period. During childhood, boys and girls are quite similar in height and weight. However, gender differences become apparent during adolescence. From approximately age ten to fourteen, the average girl is taller, but not heavier, than the average boy. After that, the average boy becomes both taller and heavier, although individual differences are certainly noted. As adolescents physically mature, weight differences are more noteworthy than height differences. At eighteen years of age, those that are heaviest weigh almost twice as much as the lightest, but the tallest teens are only about 10% taller than the shortest (Seifert, 2012). Both height and weight can certainly be sensitive issues for some teenagers. Most modern societies, and the teenagers in them, tend to favor relatively short women and tall men, as well as a somewhat thin body build, especially for girls and women. Yet, neither socially preferred height nor thinness is the destiny for many individuals.

Average height and weight are also related somewhat to racial and ethnic background. In general, children of Asian background tend to be slightly shorter than children of European and North American backgrounds. The latter, in turn, tend to be shorter than children from African societies (Eveleth & Tanner, 1990). Body shape differs slightly as well, though the differences are not always visible until after puberty. Asian background youth tend to have arms and legs that are a bit short relative to their torsos, and African background youth tend to have relatively long arms and legs. The differences are only averages, as there are large individual differences as well.

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Adolescence

A period that begins with puberty and ends with the transition to emerging adulthood.

Ages between 13 to 17 years.

Period of major physical, social, sexual and cognitive changes.

Paris & et al., 2019

Lally & Valentine-French, 2019

Contact info: info@nursesinternational.org

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Sexual Development:

Boys:

Testicles and scrotum grow as early as age 9. Soon, the penis begins to lengthen; reaching adult size by 18.
Pubic hair growth, as well as armpit, leg, chest, and facial hair, begin to grow.
Nocturnal emissions (wet dreams) start between ages 13 and 17.
Voice deepens.
Growth spurt peaks around age 13 and slows around age 18.

Paris & et al., 2019

Lally & Valentine-French, 2019

Contact info: info@nursesinternational.org

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Sexual Development

Girls:

Develop breast buds as early as 8 years old; develop fully between ages 12 and 18.
Pubic hair, armpit and leg hair appear.
Menarche (the beginning of menstrual periods) typically occurs about 2 years after early breast and pubic hair appear.
Growth spurt peaks around age 11.5 and slows around age 16.

Paris & et al., 2019

Lally & Valentine-French, 2019

Contact info: info@nursesinternational.org

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Secondary Sexual Characteristics

Paris & et al., 2019

Lally & Valentine-French, 2019

For Males	For Females
Shoulders broaden Voice lowers as the larynx grows Hair growth in the pubic area, under the arms and on the face Hair becomes coarser and darker Acne	Breast development at around 10, hips broaden Hair growth in the pubic area and underarms Hair becomes darker and coarser Acne

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Freud’s Psychosexual Theory of Development

Genital Stage; begins with puberty.
Experience of rising hormone levels, strong sex and hunger drive.
May engage in sexual experimentation.
Sexual instinct is directed to pleasure with others versus self.
Ego becomes fully developed, seeking independence.
Develop concrete ability to have meaningful and lasting relationships, sexual desires.

Lantz, 2021

Contact info: info@nursesinternational.org

The child's ego becomes fully developed during this stage, and they are subsequently seeking their independence. Their ability to create meaningful and lasting relationships is concrete, and their sexual desires and activity are healthy and consensual. If a child or young adult experiences dysfunction during this period, they will be unable to develop meaningful, healthy relationships. To explicate Freud's developmental theories, one must address his structural theory of mind. The latter suggests that the psyche (personality) encompasses three psychic structures: the id, ego, and superego.

The id is the instinctual aspect of the psyche, consisting of sexual and aggressive drives. It is essentially the biological, instinctual, unconscious drive of the individual as it is involved in gratification. A newborn's behavior is driven purely by innate instincts (id). As the child matures, the ego differentiates from the id. The ego is the decision-making aspect of personality. In contradiction to the id, which operates by way of the pleasure principle and immediate gratification, the ego operates by way of the reality principle, seeking satisfaction via practical strategies. The ego ultimately mediates the interaction between the id and the "real" world. It is rational by nature, whereas the id is irrational. The last psychic structure to develop is the superego, which incorporates the morals and values of society. This construct develops during the phallic stage and is analogous to one's moral compass. These structures can help explain pathologic behavior and sources of anxiety. Freud's developmental theories form the basis for psychoanalysis and subsequent derivatives that make up contemporary psychotherapy.

The genital stage is the last stage of Freud's psychosexual theory of personality development and begins in puberty. It is a time of adolescent sexual experimentation. Sexual instinct is directed to heterosexual pleasure rather than self-pleasure, like during the phallic stage. Fixation and conflict may prevent this with the consequence that sexual perversions may develop. For example, fixation at the oral stage may result in an individual gaining sexual pleasure primarily from kissing and oral sex rather than sexual intercourse.

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Sexual Activities

By age ten or eleven, most children experience increased sexual attraction to others that affect social life, both in school and out.

By the end of high school, more than half of boys and girls report having experienced sexual intercourse at least once.

Paris & et al., 2019

Lally & Valentine-French, 2019

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Critical Thinking Question

What kind of information should pre-teens be provided with to prepare them for the physical changes of adolescence?

What should the nurse include in an informational course for parents on these topics?

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It is helpful for pre-teens to be provided with information regarding what kind of physical changes to expect during adolescence, so they are not surprised by these changes. For boys, information could include hair growth, voice changes, changes to sexual organs, and when a growth spurt is likely to occur. For girls, information could include hair growth, development of breasts, and menstruation. Because sexual attraction and sexual experimentation frequently begin during adolescence, the nurse could play an important role in providing sex education (in a culturally appropriate way) while teaching the pre-teen about their body.
In a course for parents, the nurse should include information about providing sex education to pre-teens to reduce their risk of risky sexual behaviors. The nurse should also teach the parents to have open conversations with their pre-teens about their changing bodies, which can help the adolescent to feel less uncomfortable about their new appearance. Some other things the nurse can teach the parent include:

- Start talking about upcoming physical and biological changes around age 8-9

- Tailor these conversations to the teen’s age and keep having them, building on the previous information each time

- Listen to the teen’s concerns and don’t dismiss their feelings of being different or that “something is wrong with me.”

- Don’t make comments that will embarrass the teen about their changing body

- Don’t mistake physical maturity for overall maturity. It can take a while for the teen’s emotional maturity to catch up with their body.

(Gengler, 2018)

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Brain Development in Adolescence

Dramatic changes occur

Brain matures; more interconnected and specialized
Myelination of neurons continues
White matters increases; improves thinking and processing skills
Language area in brain undergoes myelination; improves language skills

Paris & et al., 2019

Lally & Valentine-French, 2019

Contact info: info@nursesinternational.org

The brain undergoes dramatic changes during adolescence. Although it does not get larger, it matures by becoming more interconnected and specialized (Giedd, 2015). The myelination development of connections between neurons continues. This results in an increase in the white matter of the brain and allows the adolescent to make significant improvements in their thinking and processing skills. Different brain areas become myelinated at different times. For example, the brain’s language areas undergo myelination during the first 13 years. Completed insulation of the axons consolidates these language skills but makes it more difficult to learn a second language. With greater myelination, however, comes diminished plasticity as a myelin coating inhibits the growth of new connections (Dobbs, 2012). Even as the connections between neurons are strengthened, synaptic pruning occurs more than during childhood as the brain adapts to changes in the environment. This synaptic pruning causes the gray matter of the brain, or the cortex, to become thinner but more efficient (Dobbs, 2012). The corpus callosum, which connects the two hemispheres, continues to thicken, allowing for stronger connections between brain areas. Additionally, the hippocampus becomes more strongly connected to the frontal lobes, allowing for greater integration of memory and experiences into our decision-making. The limbic system, which regulates emotion and reward, is linked to the hormonal changes that occur at puberty. The limbic system is also related to novelty seeking and a shift toward interacting with peers. In contrast, the prefrontal cortex, which is involved in the control of impulses, organization, planning, and making good decisions, does not fully develop until the mid-20s.

A significant aspect of the later developing prefrontal cortex and early development of the limbic system is the “mismatch” in timing between the two. The approximately ten years that separates the development of these two brain areas can result in risky behavior, poor decision-making, and weak emotional control for the adolescent. When puberty begins earlier, this mismatch extends even further. Teens often take more risks than adults, and according to research, it is because they weigh risks and rewards differently than adults do (Dobbs, 2012). For adolescents, the brain’s sensitivity to the neurotransmitter dopamine peaks, and dopamine is involved in reward circuits, so the possible rewards outweigh the risks.

Adolescents respond especially strongly to social rewards during activities, and they prefer the company of others their same age.

Chein et al. (2011) found that peers sensitize brain regions associated with potential rewards. For example, adolescent drivers make risky driving decisions when with friends to impress them, and teens are much more likely to commit crimes together in comparison to adults (30 and older) who commit them alone (Steinberg et al., 2017). In addition to dopamine, the adolescent brain is affected by oxytocin which facilitates bonding and makes social connections more rewarding. With both dopamine and oxytocin engaged, it is no wonder that adolescents seek peers and excitement in their lives that could end up actually harming them. Because of all the changes that occur in the adolescent brain, the chances for abnormal development can occur, including mental illness. In fact, 50% of mental illness occurs by the age of 14, and 75% occurs by age 24 (Giedd, 2015).

Additionally, during this period of development, the adolescent brain is especially vulnerable to damage from drug exposure. For example, repeated exposure to marijuana can affect cellular activity in the endocannabinoid system. However, researchers have also focused on the highly adaptive qualities of the adolescent brain, which allow the adolescent to move away from the family toward the outside world. Novelty-seeking and risk-taking can generate positive outcomes, including meeting new people and seeking out new situations. Separating from the family and moving into new relationships and different experiences are actually quite adaptive for society.

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Brain Development in Adolescence (Continued):

Paris & et al., 2019

Lally & Valentine-French, 2019

The corpus callosum thickens.
White matter increases.
The hippocampus becomes more strongly connected to the frontal lobe.
The limbic system regulates emotion and reward, and hormonal changes are linked to the hormonal changes that occur during puberty.
The development of the prefrontal cortex and limbic system is mismatched; leads to risky behavior, poor decision making and weak emotional control.
The brain becomes more vulnerable to damage from drug exposure.

Contact info: info@nursesinternational.org

The brain undergoes dramatic changes during adolescence. Although it does not get larger, it matures by becoming more interconnected and specialized (Giedd, 2015). The myelination development of connections between neurons continues. This results in an increase in the white matter of the brain and allows the adolescent to make significant improvements in their thinking and processing skills. Different brain areas become myelinated at different times. For example, the brain’s language areas undergo myelination during the first 13 years. Completed insulation of the axons consolidates these language skills but makes it more difficult to learn a second language. With greater myelination, however, comes diminished plasticity as a myelin coating inhibits the growth of new connections (Dobbs, 2012). Even as the connections between neurons are strengthened, synaptic pruning occurs more than during childhood as the brain adapts to changes in the environment. This synaptic pruning causes the gray matter of the brain, or the cortex, to become thinner but more efficient (Dobbs, 2012). The corpus callosum, which connects the two hemispheres, continues to thicken, allowing for stronger connections between brain areas. Additionally, the hippocampus becomes more strongly connected to the frontal lobes, allowing for greater integration of memory and experiences into our decision-making. The limbic system, which regulates emotion and reward, is linked to the hormonal changes that occur at puberty. The limbic system is also related to novelty seeking and a shift toward interacting with peers. In contrast, the prefrontal cortex, which is involved in the control of impulses, organization, planning, and making good decisions, does not fully develop until the mid-20s.

A significant aspect of the later developing prefrontal cortex and early development of the limbic system is the “mismatch” in timing between the two. The approximately ten years that separates the development of these two brain areas can result in risky behavior, poor decision-making, and weak emotional control for the adolescent. When puberty begins earlier, this mismatch extends even further. Teens often take more risks than adults, and according to research, it is because they weigh risks and rewards differently than adults do (Dobbs, 2012). For adolescents, the brain’s sensitivity to the neurotransmitter dopamine peaks, and dopamine is involved in reward circuits, so the possible rewards outweigh the risks.

Adolescents respond especially strongly to social rewards during activities, and they prefer the company of others their same age.

Chein et al. (2011) found that peers sensitize brain regions associated with potential rewards. For example, adolescent drivers make risky driving decisions when with friends to impress them, and teens are much more likely to commit crimes together in comparison to adults (30 and older) who commit them alone (Steinberg et al., 2017). In addition to dopamine, the adolescent brain is affected by oxytocin which facilitates bonding and makes social connections more rewarding. With both dopamine and oxytocin engaged, it is no wonder that adolescents seek peers and excitement in their lives that could end up actually harming them. Because of all the changes that occur in the adolescent brain, the chances for abnormal development can occur, including mental illness. In fact, 50% of mental illness occurs by the age of 14, and 75% occurs by age 24 (Giedd, 2015).

Additionally, during this period of development, the adolescent brain is especially vulnerable to damage from drug exposure. For example, repeated exposure to marijuana can affect cellular activity in the endocannabinoid system. However, researchers have also focused on the highly adaptive qualities of the adolescent brain, which allow the adolescent to move away from the family toward the outside world. Novelty-seeking and risk-taking can generate positive outcomes, including meeting new people and seeking out new situations. Separating from the family and moving into new relationships and different experiences are actually quite adaptive for society.

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Cognitive Changes

Continued development in the cortex that processes cognitive and emotional information.
Myelination and synaptic pruning; improve information processing, and neural connections between the prefrontal cortex and other regions of the brain.
Changes in dopamine and serotonin levels cause increased emotional responses to reward and stress.

Paris & et al., 2019

Lally & Valentine-French, 2019

Contact info: info@nursesinternational.org

The brain reaches 90% of its adult size by the time an individual is six or seven years of age. Thus, the brain does not grow much larger in size during adolescence. However, the creases in the brain continue to become more complex until the late teens. The biggest changes in the folds of the brain during this time occur in the parts of the cortex that process cognitive and emotional information. During adolescence, myelination and synaptic pruning in the prefrontal cortex increase, improving the efficiency of information processing, and neural connections between the prefrontal cortex and other regions of the brain are strengthened. However, this growth takes time, and the growth is uneven. Additionally, changes in both the levels of the neurotransmitters dopamine and serotonin in the limbic system make adolescents more emotional and more responsive to rewards and stress. Dopamine is a neurotransmitter in the brain that produces feelings of pleasure, while serotonin, the “calming chemical,” eases tension and stress.

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Piaget’s Formal Operational Stage

Adolescents are able to understand abstract principles.
Contemplate such abstract constructs as beauty, love, freedom, and morality.
No longer limited by what can be directly seen or heard.
Demonstrate hypothetical-deductive reasoning.
Able to think about all the possibilities in a situation beforehand and then test them systematically.
Understand the concept of transitivity.

Paris & et al., 2019

Lally & Valentine-French, 2019

Contact info: info@nursesinternational.org

During the formal operational stage, adolescents are able to understand abstract principles which have no physical reference. They can now contemplate such abstract constructs as beauty, love, freedom, and morality. The adolescent is no longer limited by what can be directly seen or heard. Additionally, while younger children solve problems through trial and error, adolescents demonstrate hypothetical-deductive reasoning, which is developing hypotheses based on what might logically occur. They are able to think about all the possibilities in a situation beforehand and then test them systematically (Crain, 2005). Now they are able to engage in true scientific thinking.

Formal operational thinking also involves accepting hypothetical situations. Adolescents understand the concept of transitivity, which means that a relationship between two elements is carried over to other elements logically related to the first two, such as if A<B and B<C, then A<C (Thomas, 1979). For example, when asked: If Maria is shorter than Alicia and Alicia is shorter than Caitlyn, who is the shortest? Adolescents are able to answer the question correctly as they understand the transitivity involved.

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Critical Thinking Question

A nurse is providing education to parents about what to expect regarding brain development as their child enters adolescence. What should the nurse teach the parents about risky behavior in adolescents?

Contact info: info@nursesinternational.org

The nurse should teach the parents that the limbic system, which regulates emotion and reward, develops before the prefrontal cortex, which is involved in the control of impulses, organization, planning, and making good decisions. The outcome of this “mismatch” in development between the two systems is that adolescents frequently engage in riskier behavior and can make poor decisions because of their not yet fully developed prefrontal cortex (which does not finish developing until the mid 20s). In addition, teens often take more risks than adults because they weigh risks and rewards differently than adults do. For adolescents, the brain’s sensitivity to the neurotransmitter dopamine peaks, and dopamine is involved in reward circuits, so the possible rewards outweigh the risks. Finally, adolescents tend to engage in riskier behavior when they are with their peers in an effort to impress them. All of this information is important for parents to know so they can come up with a plan to try and keep their adolescents safe during this sensitive time.

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Social and Emotional Development in Adolescents

Raymond et al., 2021

Continues to refine their sense of self
Starts to question, “Who am I?” and “Who do I want to be?”
May adopt values and roles their parents expect of them
May develop identities that align more with the peers
Work to form their identities
Pull away from parents; peer group becomes more important
Tend to seek freedom, desires freedom and autonomy

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Social and Emotional Development in Adolescents (Continued):

Raymond et al., 2021

Power struggle or conflict in areas such as chores, homework, curfew, dating, individual appearance, and the right to privacy
Greater influence of media
Develops gender roles, sexual identity
Develops their ethnic or racial identity
May develop antisocial behaviors; e.g., bullying, bystander

Contact info: info@nursesinternational.org

Gender Roles: The term "gender role" refers to society's concept of how men and women are expected to act. As they grow, individuals learn how to behave from those around them. In this socialization process, children are introduced to certain roles that are typically linked to their biological sex. The term "gender role" refers to society's concept of how men and women are expected to act and behave. Gender roles are based on norms, or standards, created by society. In American culture, masculine roles have traditionally been associated with strength, aggression, and dominance, while feminine roles have traditionally been associated with passivity, nurturing, and subordination.

Media is another agent of socialization that influences our political views, our tastes in popular culture, views of women and men, sexual orientation and preference and many other beliefs and practices. In an ongoing controversy, the media is often blamed for youth violence and many other of society's ills. The average child sees thousands of acts of violence on television and in the movies before reaching young adulthood. Rap lyrics often seemingly extol ugly violence, including violence against women. Commercials can greatly influence our choice of soda, shoes, and countless other products. The mass media may also reinforce racial and gender stereotypes, including the belief that women are sex objects and suitable targets of male violence. In the General Social Survey (GSS), about 28% of respondents said that they watch four or more hours of television every day, while another 46% watch 2-3 hours daily (see "Average Number of Hours of Television Watched Daily"). The media certainly are an important source of socialization that was unimaginable a half-century ago.

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Erikson and Psychosocial Development Theory

Addresses self-identity vs. role confusion
Success in this stage will lead to the virtue of fidelity
Main task is developing a sense of self
Struggles with the question of “who am I?” “who do I want to be in life?”
Tries on different identities to explore what fits
Sets goals
Results in either a strong sense of identity that is true to their belief and values or developing a weak sense of self and experiencing role confusion

Paris & et al., 2019

Lally & Valentine-French, 2019

Contact info: info@nursesinternational.org

Erik Erikson – Theory of Psychosocial Development

Erikson proposed that each period of life has a unique challenge or crisis that an individual must

face. This is referred to as psychosocial development.

According to Erikson, successful development involves dealing with and resolving the goals and demands of each of these crises in a positive way. These crises are usually called stages, although that is not the term Erikson used. If an individual does not resolve a crisis successfully, it may hinder their ability to deal with later crises. For example, an individual who does not develop a clear sense of purpose and identity (Erikson’s fifth crisis - Identity vs. Role Confusion) may become self-absorbed and stagnate rather than working toward the betterment of others (Erikson’s seventh crisis - Generativity vs. Stagnation). However, most individuals are able to successfully complete the

eight crises of his theory.3

Identity vs. Role Confusion

Identity vs. Role Confusion is a major stage of development where the child has to learn the roles he will occupy as an adult. In adolescence, children (ages 12–18) face the task of identity vs. role confusion. Success in this stage will lead to the virtue of fidelity. Fidelity involves being able to commit oneself to others on the basis of accepting others, even when there may be ideological differences. According to Erikson, an adolescent’s main task is developing a sense of self. Adolescents struggle with questions such as “Who am I?” and “What do I want to do with my life?” Along the way, most adolescents try on many different selves to see which ones fit; they explore various roles and ideas, set goals, and attempt to discover their “adult” selves. Adolescents who are successful at this stage have a strong sense of identity and are able to remain true to their beliefs and values in the face of problems and other people’s perspectives. When adolescents are apathetic, do not do a conscious search for identity, or pressure them to conform to their parents’ ideas for the future, they may develop a weak sense of self and

experience role confusion. They will be unsure of their identity and confused about the future. Teenagers who struggle to adopt a positive role will likely struggle to “find” themselves as adults.

Erikson saw this as a period of confusion and experimentation regarding identity and how one navigates along life’s path. During adolescence, we experience a psychological moratorium, where teens put their current identity on hold while they explore their options for identity. The culmination of this exploration is a more coherent view of oneself. Those who are unsuccessful at resolving this stage may either withdraw further into social isolation or become lost in the crowd. However, more recent research suggests that few leave this age period with identity achievement and that most identity formation occurs during young adulthood (Côtè, 2006).

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Case Study

A community health nurse is speaking with the parents of a 15-year-old who state that they are concerned that their son is spending more time with his peers and is questioning whether he will apprentice in the family’s trade, which he is expected to do in order to take over the family business. The father states, “What did we do wrong? Why is he doing this to us?” How should the nurse respond?

Contact info: info@nursesinternational.org

A major element of social and emotional development during adolescence is the refinement of a sense of self. The adolescent works to form their identity while asking themselves, “who am I?” and “what do I want to be?” They may adopt the values and roles their parents expect or may try on different identities to see what fits. During this time, they may pull away from their parents as they seek freedom and work to form themselves, and their peer group often becomes their most important social group. With all that in mind, the nurse should respond by reassuring the parents that their son’s behavior is a normal part of adolescent development. The nurse should explain that this behavior is not triggered by the parents doing something wrong and that their son is not trying to punish them but rather is working on the main task of his stage of development: developing a sense of self.

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Effects of Pubertal Age

Early puberty in girls associated with stress, obesity and endocrine-disrupting chemicals.
Mental health problems linked to children who begin puberty earlier than peers.
For girls, early puberty may be associated with depression, substance use, eating disorders, disruptive behavior disorders, and early sexual behavior.

Paris & et al., 2019

Lally & Valentine-French, 2019

Contact info: info@nursesinternational.org

Note:

Endocrine-disrupting chemicals (EDCs) are compounds that can interfere with the activity of endocrine systems. EDCs action is exerted by imitating or blocking hormone signaling through the relevant hormonal receptor. EDCs may also modulate the synthesis, metabolism, and binding of natural hormones. EDcs have been found to be used in industry as plastics (bisphenol A (BPA)), plasticizers (phthalates), solvents/lubricants (polybrominated biphenyls (PBBs), polychlorinated biphenyls (PCBs), dioxins), pesticides (chlorpyrifos, dichlorodiphenyltrichloroethane (DDT), methoxychlor), fungicides (vinclozolin) and also as flame retardant additives in manufactured materials and pharmaceutical agents, e.g., diethylstilbestrol (DES), a non-steroidal synthetic estrogen. The abundance of EDCs and their ability to interfere with the endocrine system, combined with the secular trend for earlier onset of puberty, has led many researchers to associate EDCs with early puberty, especially since some EDCs have estrogenic activity. (Papadimitriou & Papadimitriou, 2021)

Effects of Pubertal Age:

In addition to better nutrition, less positive reasons associated with early puberty for girls include increased stress, obesity, and endocrine-disrupting chemicals.

May experience negative consequences of early puberty

Research has demonstrated mental health problems linked to children who begin puberty earlier than their peers.

For girls, early puberty is associated with depression, substance use, eating disorders, disruptive behavior disorders, and early sexual behavior.

Early maturing girls demonstrate more anxiety and less confidence in their relationships with family and friends, and they compare themselves more negatively to their peers. Problems with early puberty seem to be due to the mismatch between the child’s appearance and the way they act and think.

Adults, especially, may assume the child is more capable than they actually are, and parents might grant more freedom than the child’s age would indicate. For girls, the emphasis on physical attractiveness and sexuality is emphasized at puberty, and they may lack effective coping strategies to deal with the attention they may receive.

Additionally, mental health problems are more likely to occur when the child is among the first in his or her peer group to develop. Because the preadolescent time is one of not wanting to appear different, early developing children stand out among their peer group and gravitate toward those who are older. For girls, this results in them interacting with older peers who engage in risky behaviors such as substance use and early sexual behavior.

Boys also see changes in their emotional functioning at puberty.

Most boys experienced a decrease in depressive symptoms during puberty. Boys who began puberty earlier and exhibited a rapid tempo, or a fast rate of change, actually increased depressive symptoms.

Early maturing boys and rapidly maturing boys displayed decrements in the quality of their peer relationships as they moved into early adolescence, whereas boys with more typical timing and tempo development actually experienced improvements in peer relationships.

Consequences for boys attaining early puberty were increased odds of cigarette, alcohol, or other drug use (Dudovitz, et al., 2015).

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Effects of Pubertal Age (Continued)

May assume the child may be more capable than they actually are.
May emphasize physical attractiveness and sexuality.
May lack coping strategies with the attention they receive.
Boys may exhibit rapid tempo, risk-taking behavior, increase in depressive symptoms.
May result in increased substance use.

Paris & et al., 2019

Lally & Valentine-French, 2019

Contact info: info@nursesinternational.org

Effects of Pubertal Age:

In addition to better nutrition, less positive reasons associated with early puberty for girls include increased stress, obesity, and endocrine-disrupting chemicals.

May experience negative consequences of early puberty

Research has demonstrated mental health problems linked to children who begin puberty earlier than their peers.

For girls, early puberty is associated with depression, substance use, eating disorders, disruptive behavior disorders, and early sexual behavior.

Early maturing girls demonstrate more anxiety and less confidence in their relationships with family and friends, and they compare themselves more negatively to their peers. Problems with early puberty seem to be due to the mismatch between the child’s appearance and the way they act and think.

Adults especially may assume the child is more capable than they actually are, and parents might grant more freedom than the child’s age would indicate. For girls, the emphasis on physical attractiveness and sexuality is emphasized at puberty, and they may lack effective coping strategies to deal with the attention they may receive.

Additionally, mental health problems are more likely to occur when the child is among the first in his or her peer group to develop. Because the preadolescent time is one of not wanting to appear different, early developing children stand out among their peer group and gravitate toward those who are older. For girls, this results in them interacting with older peers who engage in risky behaviors such as substance use and early sexual behavior.

Boys also see changes in their emotional functioning at puberty.

Most boys experienced a decrease in depressive symptoms during puberty. Boys who began puberty earlier and exhibited a rapid tempo, or a fast rate of change, actually increased depressive symptoms.

Early maturing boys and rapidly maturing boys displayed decrements in the quality of their peer relationships as they moved into early adolescence, whereas boys with more typical timing and tempo development actually experienced improvements in peer relationships.

Consequences for boys attaining early puberty were increased odds of cigarette, alcohol, or other drug use (Dudovitz, et al., 2015).

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Eating Habits in Adolescents

Soft drinks with added sugar becomes popular with increased age.
Healthy eating behaviors become less common.
Frequency of breakfast consumption, eating fruit and having evening meals with the family decreases between ages 11 and 15.
Prioritizes body image; Some tend to eat more/less.
Eating disorder is more common in teen years.

World Health Organization, 2006

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Nutritional Requirements for Adolescents

World Health Organization, 2006

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Nutritional Requirements (Continued):

American Heart Association, 2018

Calories/ foods	Age: 13 to 18
Calories kilocalories/ day (kcal/d)	Male = 2200; Female = 1800
Fat	25% to 35%
Milk / Dairy	3 cups
Lean Meat and Beans	Female=5 ounces; Male= 6 Ounces
Fruits	Male= 2 cups : Female= 1.5 Ounces
Vegetables	Male: 3 Cups; Female= 2.5 Cups
Grains	Male= 6 Ounces; Female= 7 Ounces

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Critical Thinking Question

Take a dietary inventory of an adolescent and compare the results to the recommendations.

How do you think a nurse would advise the adolescent about his nutritional intake?

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Common Developmental Concerns In Adolescents

Eating disorders

Extreme diets: Obesity and starvation

Weight management
Adolescent pregnancy
Sexually transmitted infections
Sleep health
Drug and substance experimentation
Emotional regulation
Disorders and syndrome
Education interrupted
Self-harm and injury

Paris & et al., 2019

Lally & Valentine-French, 2019

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Eating Disorders: Although eating disorders can occur in children and adults, they frequently appear during the teen years or young adulthood (National Institute of Mental Health (NIMH), 2016). Eating disorders affect both genders, although rates among women are 2 1⁄2 times greater than among men. Similar to women who have eating disorders, men also have a distorted sense of body image, including body dysmorphia or an extreme concern with becoming more muscular. Researchers are finding that eating disorders are caused by a complex interaction of genetic, biological, behavioral, psychological, and social factors (NIMH, 2016). Eating disorders appear to run in families, and researchers are working to identify DNA variations that are linked to the increased risk of developing eating disorders. Most common eating disorders:

Anorexia nervosa: Restriction of energy intake leading to significantly low body weight, Intense fear of gaining weight, Disturbance in one’s self-evaluation regarding body weight.

Bulimia nervosa: Recurrent episodes of binge eating, Recurrent inappropriate compensatory behaviors to prevent weight gain, including purging, laxatives, fasting or excessive exercise, Self-evaluation is unduly affected by body shape and weight.

Binge-eating disorder: Recurrent episodes of binge eating, marked distress regarding binge eating; binge eating is not associated with the recurrent use of inappropriate compensatory behavior.

Obesity: Children need adequate caloric intake for growth, and it is important not to impose highly

restrictive diets. However, exceeding caloric requirements on a regular basis can lead to childhood obesity, which has become a major problem in North America. Nearly one of three US children and adolescents is overweight or obese. Obesity has a profound effect on self-esteem, energy, and activity level. Even more importantly, it is a major risk factor for a number of diseases later in life, including cardiovascular disease,

Type 2 diabetes, stroke, hypertension, and certain cancers.

Teen Pregnancy

Although adolescent pregnancy rates have declined since 1991, teenage birth rates in the United States are higher than in most industrialized countries. In 2014, females aged 15–19 years experienced a birth rate of 24.2 per 1,000 women. This is a drop of 9% from 2013. Birth rates fell 11% for those aged 15–17 years and 7% for 18–19 year-olds. It appears that adolescents seem to be less sexually active than in previous years, and those who are sexually active seem to be using birth control. Residing in disorganized/dangerous neighborhoods, living in a lower SES family, living with a single parent, having older sexually active siblings or pregnant/parenting teenage sisters, early puberty, and being a victim of sexual abuse place adolescents at an increased risk of adolescent pregnancy. After a child is born, life can be difficult for a teenage mother. Only 40% of teenagers who have children before age 18 graduate from high school. Without a high school degree, her job prospects are limited and economic independence is difficult. Teen mothers are more likely to live in poverty, and more than 75% of all unmarried teen mothers receive public assistance within five years of the birth of their first child.

Sexually transmitted infections (STIs), also referred to as sexually transmitted diseases (STDs)

or venereal diseases (VDs), are illnesses that have a significant probability of transmission by

means of sexual behavior, including vaginal intercourse, anal sex, and oral sex. It’s important to

mention that some STIs can also be contracted by sharing intravenous drug needles with an

infected individual, through childbirth or breastfeeding. Common STIs include: chlamydia, herpes (HSV-1 and HSV-2), human papillomavirus (HPV), gonorrhea, syphilis, trichomoniasis, HIV (human immunodeficiency virus) and AIDS (acquired immunodeficiency syndrome). Those most affected by STDS include

younger, gay/bisexual males, and females.

Sleep Health: According to the National Sleep Foundation (2016), adolescents need about 8 to 10 hours of sleep each night to function best. The most recent Sleep in America poll in 2006 indicated that adolescents between sixth and twelfth grade were not getting the recommended amount of sleep. For older adolescents, only about one in ten (9%) get an optimal amount of sleep, and they are more likely to experience negative consequences the following day. These include feeling too tired or sleepy, being cranky or irritable, falling asleep in school, having a depressed mood, and drinking caffeinated beverages (NSF, 2016). Additionally, they are at risk for substance abuse, car crashes, poor academic performance, obesity, and a weakened immune system. Troxel et al. (2019) found that insufficient sleep in adolescents is a predictor of risky sexual behaviors. Reasons given for this include that those adolescents who stay out late, typically without parental supervision, are more likely to engage in a variety of risky behaviors, including risky sex, such as not using birth control or using substances before/during sex.

An alternative explanation for risky sexual behavior is that the lack of sleep negatively affects impulsivity and decision-making processes.

Drug and substance experimentation: People have used, and often abused, psychoactive drugs for thousands of years. Perhaps this should not be surprising because many people find using drugs to be enjoyable. Even when we know the potential costs of using drugs, we may engage in them anyway because the pleasures of using the drugs are occurring right now. Some common drugs being used or experimented with are cigarettes, marijuana, alcohol, barbiturates, cocaine, opioids, inhalants, and morphine. The use of such substances can easily cause addiction and negative consequences on our physical and mental health. Unlike adults, the teen brain is actively developing and often will not be fully developed until the mid-20s. Adolescents are curious and love adventures and experimenting with such substances and drugs. Drug use is, in part, the result of socialization. Adolescents may try drugs when their friends

convince them to, and these decisions are based on social norms about the risks and benefits of

various drugs.

Emotional regulation is the ability to successfully control our emotions, which takes effort, but the ability to do so can have important positive health outcomes. Adolescents may suffer to control emotions. Emotional responses such as the stress reaction are useful in warning us about potential danger and in mobilizing our response to it, so it is a good thing that we have them. However, we also need to learn how to control and regulate our emotions to prevent them from letting our behavior get out of control.

Some common mental health problems and disorders: Anxiety Disorders, Dissociative Disorders, Mood Disorders, Schizophrenia, Personality Disorders, Somatization Disorders, Factitious Disorders, Sexual Disorders, Paraphilia, and Depression.

Consequences of Mental Illness: The consequences of mental illness in children and adolescents can be substantial. Many mental health professionals speak of accrued deficits that occur when mental illness in children is not treated. To begin with, mental illness can impair a student’s ability to learn. Adolescents

whose mental illness is not treated rapidly and aggressively tend to fall further and further behind in school. They are more likely to drop out of school and are less likely to be fully functional members of society when they reach adulthood. We also now know that depressive disorders in young people confer a higher risk for illness and interpersonal and psychosocial difficulties that persist after the depressive episode is over. Furthermore, many adults who suffer from mental disorders have problems that originated in childhood. Depression in youth may predict more severe illness in adult life. Attention deficit hyperactivity disorder, once thought to affect children and adolescents only, may persist into adulthood and may be associated with social, legal, and occupational problems. Mental illness impairs a student’s ability to learn. Self-injury is a sign that someone is struggling. People who are anxious, depressed, or have an eating disorder are also more likely to turn to self-injuring behaviors. Adolescents who feel like there is no possible resolution to their mental health struggles may consider, attempt, or commit suicide. Suicidal behavior causes immeasurable pain, suffering, and loss to individuals, families, and communities nationwide.

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Nurses’ Role in Adolescent Growth and Development

Be knowledgeable and assess for age-appropriate growth and development
Understand adolescent health and development within the context of families, communities and the healthcare system
Consider creative health strategies and recommend interventions to enhance health and wellbeing
Acknowledge and respect individuality and differences
Empower adolescents
Consider adolescents and families as partners in healthcare

World Health organization, 2004

Contact info: info@nursesinternational.org

A careful analysis of the community structures is essential to understand the context of health choices.
Creative health strategies and demonstrated interventions can prevent disease and enhance the potential for lifelong behavior that will contribute to the health of the world’s people. Addressing the parts — whether it be sexual behavior, substance use, or schooling — somehow would take care of the whole individual.
Parenting of adolescent programs: As children mature into adolescence, the parenting relationship evolves, and parents require new developmentally-appropriate skills and strategies to meet their children’s needs. Building on parents’ existing strengths and equipping them to provide support to their adolescent children through parenting programming has the potential to have a profound positive influence on adolescent development, consolidating and magnifying benefits from earlier investments.

Understand adolescent health and development within the context of families, communities and health care systems.
Consider health and development questions, including those concerning adolescents, requires a comprehensive approach that includes health services delivery, health policy, research, and community participation.
Acknowledge the gap in adolescent health research related to “how race, ethnicity, gender and socioeconomic status influence, individually and interactively, the development of health values, perceived health options and health behaviors
Adolescents must have a greater voice in explaining their health choices in an atmosphere that encourages dialogue.
Consider adolescents as partners in health care with their families when determining a plan of health.

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Nurses’ Role in Adolescent Growth and Development

Education

Overall hygiene, menstrual hygiene for girls
Dental hygiene: brushing twice daily, morning and evening, preferably after meals
Healthy diet, physical activities

Assess and address the child’s physical, emotional, and social concerns
Guidance, tools, activities and supplies aim to promote positive outcomes for adolescents’ psychological well-being
Advocate for creating

Physical, sexual education and sports in schools
Nutritional programs in schools/community

Paris et al., 2019

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Nurses’ Role in Adolescent Growth and Development

Educate adolescents and their families:

Growth and development process (physical, cognitive, psychosocial)
Nutritional requirements

Be knowledgeable about local foods containing essential nutrients

Personal hygiene
Safety issues: Safe driving, sexual activity; substance use

Paris et al., 2019

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Red Flags

Research has demonstrated mental health problems linked to children who begin puberty earlier than their peers.
For girls, early puberty is associated with depression, substance use, eating disorders, disruptive behavior disorders, and early sexual behavior
Suicidal Ideation
Substance use
Eating disorders
Signs and symptoms of physical, sexual and/or emotional abuse

Lally & Valentine-French, 2019

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Cultural Considerations

Religion, culture, beliefs, and ethnic customs can influence how families understand and use health concepts:

Health beliefs: In some cultures, talking about a possible poor health outcome will cause that outcome to occur.
Health customs: In some cultures, family members play a large role in health care decision-making.
Ethnic customs: Differing gender roles may determine who makes decisions about accepting and following treatment recommendations.

AHRQ, 2020

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Cultural Considerations (Continued)

Religion, culture, beliefs, and ethnic customs can influence how families understand and use health concepts:

Religious beliefs: Faith and spiritual beliefs may affect health-seeking behavior and willingness to accept treatment.
Dietary customs: Dietary advice may be difficult to follow if it does not fit the foods or cooking methods of the family.
Interpersonal customs: Eye contact or physical touch may be accepted in some cultures but inappropriate or offensive in others.

AHRQ, 2020

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Cultural Considerations: Examples with Assessment

Average height and weight vary somewhat due to racial and ethnic background. In general, children of Asian background tend to be slightly shorter than children of European and North American backgrounds.
African-American girls are typically the first to develop. They are less likely to experience negative consequences of early puberty when compared to European-American girls.
Hispanic girls start puberty the second earliest, while European-American girls rank third in their age of starting puberty.

Lally & Valentine-French, 2019

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References

American Heart Association ( 2018, April 16). Dietary Recommendations for Healthy Children. https://www.heart.org/en/healthy-living/healthy-eating/eat-smart/nutrition-basics/dietary-recommendations-for-healthy-children

Andrews, M.M., Boyle, J.S. & Collings, J. W. (2020). Transcultural Concepts in Nursing Care (8th Ed.). Wolters Kluwer, Philadelphia, PA.

Gengler, C. (2018). Biological and physical changes in teens. University of Minnesota Extension. https://extension.umn.edu/teen-development/biological-and-physical-changes-teens

Lally, M., Valentine-French, S. (2019). Lifespan Development: A Psychological Perspective (2 Eds.). College of Lake County Foundation, licensed under a Creative Commons Attribution 4.0 International License.http://dept.clcillinois.edu/psy/LifespanDevelopment.pdf

Lantz, S. E., Ray, S. (2021, December 11). Freud Developmental Theory. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK557526/

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References:

Papadimitriou, A., & Papadimitriou, D. T. (2021). Endocrine-Disrupting Chemicals and Early Puberty in Girls. Children (Basel, Switzerland), 8(6), 492. https://doi.org/10.3390/children8060492

Paris, J., Richardo, A., & Rymond, D. (2019). Child growth and development: ECE 101 (A. Johnson, Ed.). College of the Canyons, licensed under a Creative Commons Attribution 4.0 International License. https://open.umn.edu/opentextbooks/textbooks/750

Raymond, P., Ricardo, & Johnson. (2021, January 4). Adolescence - Social Emotional Development. College of the Canyons. https://socialsci.libretexts.org/@go/page/24693

World Health Organization. (2006). Adolescent Nutrition: A Review of the Situation in Selected South-East Asian Countries. https://apps.who.int/iris/bitstream/handle/10665/204764/B0239.pdf%3Bjsessionid%3D8105F6F7E5A54939A9E8AB5CAB1BA128?sequence=1

World Health organization. (2004). Adolescent Health and Development in Nursing and Midwifery Education. https://apps.who.int/iris/bitstream/handle/10665/69039/WHO_EIP_HRH_NUR_2004.1.pdf

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