What is adolescence?

Adolescence describes the developmental stage between childhood and adulthood. The World Health Organization defines the ages of an adolescent as 10–19 years, and defines youth as 15–24 years. We commonly combine these definitions (10–24 years) and use the encompassing term ‘young people’.

The onset of puberty has long been accepted as the starting point of adolescence, whereas key social and role transitions such as completion of education, financial independence, marriage and children have historically marked the end of adolescence. These endpoints formerly occurred within the few years from the late teens to the early twenties. As young people now commonly participate longer in education and are marrying and having children later, the end of adolescence has become less distinct.

The majority of adolescents rate their own health, including their mental health, as good. Many adolescents describe the period of adolescence as enjoyable and exciting, and as a time of satisfaction in achieving many milestones such as first relationships, completing school, getting a job and learning to drive. In contrast, adolescence was historically described by adults as a period of turmoil. Certainly, it is a time of increased health risk for healthy young people as well as for those with chronic illness, and there are a significant number of young people for whom adolescence is not ‘smooth sailing’. Furthermore, although many health indicators in younger children and older adults have improved (e.g. tobacco use), a wide range of public health indicators in young people has remained static or have declined (e.g. rates of obesity and sexually transmitted infections).

In many parts of the world, specialist children’s hospitals still effectively ‘end’ at 14 years of age, but adolescence is increasingly recognized as an important developmental period within the discipline of paediatrics (which is increasingly referred to as ‘child and adolescent health’). Young people up to the age of 18–19 years are now commonly managed in tertiary children’s hospitals and paediatric programmes in Australia and New Zealand. The upper age of many community-based children’s health and welfare services has also risen. Although many parts of the world also recognize the subspecialty of adolescent health, all doctors must learn the knowledge, attitudes and skills to manage young people’s health concerns, regardless of their likely future roles.

Adolescent development

Just as all paediatricians need sound knowledge of child development, they must also have a sophisticated understanding of adolescent development. The division of adolescent development into the three domains of physical, cognitive and psychosocial can be a helpful framework for monitoring development. An additional approach (if simplistic) is to divide adolescent development into early, middle and late stages. Using this approach, early adolescence corresponds to physical development, middle relates primarily to cognitive maturation, and late to psychosocial aspects.

Early adolescence (around 10–14 years old) is characterized by the physical changes of puberty that mark the acquisition of reproductive capacity. It can be a time of increased physical activity and may also be a time where mood changes are noticed by the family. The developmental tasks associated with this period are about establishing a realistic body image and also becoming aware of oneself as a sexual being with a sexual orientation. In response to these hormonal changes, the prepubertal unisex silhouette becomes characterized by a larger, muscular male physique and a more rounded female shape.

Mid-adolescence (around 15–19 years old) is characterized by increasing independence, commonly with more time spent with peers outside the home. Education is more demanding of young people’s maturing cognitive skills. The developmental tasks of this stage include a stronger sense of oneself as an individual and a greater focus on personal and social values. Neurocognitive maturation is responsible for an increased capacity for abstract thinking, the capacity to think about thoughts. Given how much of health management relates to future health outcomes, understanding young people’s cognitive maturation is an important element of the monitoring of adolescent development and of working with young people clinically. Clinical strategies that might influence self-management behaviours in adults who are motivated by future health goals will not be influential in adolescents, who are more motivated by events in the ‘here and now’. Neurocognitive maturation is now believed to continue into the early twenties.

Late adolescence (20–24 years old) is characterized by a greater focus on vocational goals, the transition between school and work, and a greater enjoyment of intimacy, including sexual intimacy. The developmental tasks are to establish adult roles and responsibilities, including longer-term relationships and less reliance on a peer group. Psychosocial development is characterized by aspects of personal individuation, such as the development of a coherent sense of self and an understanding of individual versus family responsibilities, coming to terms with one’s physical self, understanding one’s sexuality and being able to provide for oneself financially.

These stages are listed in Table 3.11.1 with an approximate age at which each stage occurs, the main feature of each stage and a key developmental question for young people at this stage.

Table 3.11.1 The stages of adolescent development

While there is close association between the different domains of development, adolescent development is characterized by being uneven and complex: like earlier child development, it is influenced by the environment, is mediated by relationships and is triggered by social participation. Chronic illness and disability can affect each of these domains but the effects are inconsistent. For example, although chronic illness and disability may delay the physical changes of the adolescent growth spurt and of pubertal timing, exposure to challenging life decisions or to friends dying can result in earlier engagement with more spiritual elements of life.

The increasing cultural diversity of Australia and New Zealand results in many young people having parents who were born overseas, or who may hold different views of what adolescence is or should be about. Adolescents in these families can sometimes struggle with the discrepancy between the different expectations of their Australian peers and their family about the general aspects of role and identity, as well as specific elements of what is acceptable behaviour at given ages.

Dramatic social changes in the developed world have resulted in young people being generally healthier, wealthier and better educated than previous generations. More young people now complete 12 years of school than previously, with more continuing on with some form of post-secondary training or study. Social roles have widened for females as well as males. In Australia, the mean age of marriage is older than in previous generations, as is the age that women have their first child, which recently exceeded 30 years. In the 1950s most people had left school, got a job, got married and had children by their early twenties. Most contemporary young people achieve these milestones much later. Access to new technologies provides a much larger peer group and virtual community for young people, with uncertain consequences.

These same changes are also occurring for young people in low- and middle-income countries. In these countries, rapid urbanization, rapid social change and a loss of many of the traditional pathways to adult life contribute to many young people in these communities experiencing different pressures during adolescence than previous generations, with consequences for their health.

However, there are still many aspects of adolescence that have not changed over the centuries. Socrates is reported to have written in 450 bc that:

Burden of illness in adolescence

Adolescence has long been considered the healthiest time of life. However, dramatic improvements in infant and child mortality globally have brought greater visibility – and concern – about adolescent and young adult mortality, as this age group has experienced far less improvement in mortality than younger children. Worldwide, there are at least 2.6 million deaths in 10–24 year olds annually. There is also a marked rise in mortality from early adolescence (10–14 years) through to young adulthood (20–24 years), with the reasons varying by geographical region and sex. Mortality rates are almost 4-fold higher in low-and middle-income countries than in high-income countries. Importantly, the majority of deaths in adolescence are preventable, with prominent causes being road traffic accidents, violence, self-inflicted injury, human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) and tuberculosis. Maternal conditions are a leading cause of female death, especially in low-income countries. In 2007, the leading causes of death in 12–24-year-old Australians were injuries (65%), cancer (10%) and diseases of the nervous system, including cerebral palsy and epilepsy (5%).

The burden of illness in adolescents differs greatly from that of infants and young children, who are disproportionately affected by congenital disorders and acute infectious disease respectively, and of adults for whom ischaemic heart disease and cancer predominate. Some 60% of 12–24-year-old Australians have a long-term health condition, and 11% of young Australians have a disability that causes some form of limitation or restriction. Many other causes of ill-health are more commonly psychosocial than biological in adolescence, and tend to reflect unhealthy patterns of risk behaviours and mental disorders.

Thus, the leading causes of mortality and morbidity in the adolescent age group are from accidents and injuries (unintentional and self-inflicted), mental health problems and behavioural problems such as substance use and abuse. Other prominent health issues are unplanned pregnancy and sexually transmitted infections.

Some of the major health issues affecting young people in Australia are summarized in Table 3.11.2. The data refer to 12–24-year-old Australians unless stated otherwise.

Table 3.11.2 Some of the key health issues and selected risk factors affecting young Australians

Risk and protective factors

Learning by doing is a normal part of adolescence, but some behaviour can have harmful consequences. The onset of puberty marks a time of growing risk in relationship to certain behaviours and mental health states. Although learning about the harmful effects of alcohol by drinking some alcohol can be considered normal in Australia, binge drinking is associated with many harmful effects such as later regretted sexual activity, alcohol dependence in early adult life and death from road traffic accidents.

Generally, the earlier the onset of these ‘risk behaviours’, the greater the likelihood of poor health outcomes. For example, although 80% of adult smokers start smoking in adolescence, the onset of smoking at an early age marks a greater risk for continuing smoking as an adult. In other words, the earlier health behaviour is ‘learned’ the longer it is likely to persist. Young people with one identified health risk behaviour are more likely to have other ‘co-morbid’ behaviours.

A number of common risk factors predict earlier engagement in many different health risk behaviours and mental health and social outcomes. These include factors within the individual, family, peer and community. There are important additive or synergistic associations between such risk factors. For example, being in a peer group where most of an adolescent’s friends smoke increases their later risk of smoking; this risk is even greater if the adolescent is depressed. Lack of family connectedness or support, lack of engagement with friends, bullying at school and poor academic performance are risk factors for a wide range of poor health and social outcomes, such as substance use, poor mental health, early school-leaving and antisocial behaviours. Chronic illness and disability in adolescence is always considered a risk factor.

Identifying risk-taking behaviours and their consequences is an important part of any adolescent health assessment, but protective factors are also important to identify. These are factors that can ameliorate risk factors or increase the likelihood of positive health and social outcomes. Important protective factors are an intact and well functioning family, connectedness with school, community and peers, and participation in enjoyable extracurricular events such as sport or creative activities.

Put simply, the more protective factors in a young person’s life, the more likely they are to make healthier choices in adolescence. Although many family factors cannot be changed or ‘treated’, efforts to alter the school environment can be especially powerful.

Many adolescent health problems are a consequence of health risk behaviours (see Table 3.11.2) and developmental challenges. As a consequence, knowledge and assessment of adolescent development, including exposure to risk and protective behaviours, is the foundation of the clinical approach to working with teenagers. Health problems in adolescents don’t occur in isolation; one identified health problem raises the likelihood that there will be other health risk behaviours and various family, peer and community antecedents. Some behavioural concerns in teenagers have their onset in childhood, but others have their onset in adolescence. Once established, there is a greater risk of these behaviours continuing into adult life where they contribute to the adult burden of illness. Early identification and intervention is a desired outcome of any contact by adolescents with the health-care system.

Medicolegal context and confidentiality

Historically, children were legally viewed as property items of their parents. The law now recognizes the growing maturity of adolescents and their capacity to make independent choices and judgements on matters affecting their future, including their rights to autonomy and privacy in health care, even when they are not legally mature (i.e. under the age of 18 years in Australia). This legal view is consistent with the medical evidence. Studies demonstrate that concerns about confidentiality are a major barrier to young people accessing health services. Once young people have accessed health-care services, they are more willing to disclose honestly important information about health risk behaviours, seek health care and return for follow-up when they understand a service is confidential. Thus, attention to confidentiality should be as much a cornerstone of clinical relationships between doctors and adolescents as it is with adults. Nearly 1 in 10 adolescents report not visiting their health- care provider in the previous year – despite wanting to do so – because of the fear that their parents would find out. However, many adolescents appreciate the opportunity to share sensitive information with their parents (even when it has been obtained confidentially by the doctor), as long as this is handled sensitively, and they are actively engaged in deciding what will (or will not) be shared.

Judgement about whether to maintain confidentiality in consultations with younger adolescents is linked with assessment of maturity. In deciding whether a person is competent or mature enough to consent to medical treatment, a doctor must decide whether the young person is able to understand the nature of the problem, the nature and side-effects of any proposed treatment, and other treatment options.

The doctor can accept consent provided that the treatment is in the young person’s best interests and the treatment is not likely to have serious consequences. For more complex or contentious procedures, doctors must balance several factors in making a decision, including the age, maturity and characteristics of the adolescent, the gravity of the presenting illness and treatment, and family issues. It is important to remember that all doctors have a legal and ethical duty of confidentiality to competent young people. This duty should be breached only in serious situations such as risk of self-harm or suicide, or in cases of suspected abuse, as well as some other exceptions discussed below. Doctors should become familiar with the specific laws on this issue in the state or region where they practise. In all Australian states and territories, anyone over the age of 15 years can have their own Medicare card, and a doctor may bulk-bill a consultation without advising the parents.

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