Developmental Management of Adolescents

Chapter 8 Developmental Management of Adolescents

Dawn Lee Garzon, Ardys M. Dunn

The changes a young person experiences during the transition from childhood to young adulthood are dramatic. The extent of physiologic growth and maturation rivals that occurring during infancy. Social and psychological changes are also extreme and can create a tenuous sense of balance during this phase of development. The common question on the minds of most adolescents is “Am I normal?” Reassurance and information about what to expect as they grow during well-child care are among the most valuable services a health care provider can offer the adolescent. This chapter focuses on the normal physical and psychosocial growth and development of adolescents and provides practitioners with a framework for structuring care of the adolescent client.

Development of Adolescents

Puberty is the term for the biologic process that ultimately leads to fertility. The hormonal regulatory systems in the hypothalamus, pituitary, gonads, and adrenal glands undergo major changes between the prepubertal and adult states. Accompanying these changes are rapid growth in height and weight, development of secondary sex characteristics, and onset of fertility (Fig. 8-1) (see Chapters 25 and 35). Normal development can be difficult to define and is, at best, an approximation rather than a precise parameter. However, even though the timing (tempo) of adolescent development is variable, the sequence of events is orderly (Fig. 8-2).

FIGURE 8-1 The endocrine system at puberty. ACTH, Adrenocorticotropic hormone; PGH, pituitary growth hormone; TSH, thyroid-stimulating hormone.

(From Valadian I, Porter D: Physical growth and development from conception to maturity, Boston, 1977, Little, Brown.)

FIGURE 8-2 Sequence of pubertal events. Breast, genital, and pubic hair development indicate Tanner stages 2 to 5.

(Adapted from Division of Adolescent Medicine, Children’s Hospital Medical Center, Cincinnati, OH, 1995.)

Adolescence refers to the psychosocial and emotional transition from childhood to adulthood. The physical changes of puberty are accompanied by significant cognitive and psychosocial development that affects how adolescents view themselves and how the world views adolescents. Successful development in adolescence culminates in achievement of goals that can provide the basis for a healthy and productive adult life (Table 8-1).

TABLE 8-1 Adolescent Development and Related Anticipatory Guidance

Area of Development	Anticipatory Guidance
Physical
Experience growth from prepubescence to sexual maturity	Teach child about body functions (e.g., menstruation, nocturnal emissions) of both genders. Teach about the timing and descriptions of primary and secondary sexual characteristics.
Reach adult parameters of height and physical growth by late adolescence	Provide prevention counseling regarding substance abuse, safety, and unintentional injuries (e.g., bicycle helmet use, seatbelts, gun storage).
Become comfortable with one’s body	Offer reassurance that physical findings are normal; explain what to expect; listen to adolescents’ concerns; encourage exercise, sports participation, and body fitness; encourage healthy nutrition.
Cognitive
Move from concrete thinking to ability to reason abstractly	Emphasize value of successful completion of school. Engage adolescent in conversation, explain procedures, and answer questions; listen.
Develop personal value system and moral integrity	Encourage discussion of what the adolescent believes is important and what the adolescent finds of value. Help the adolescent develop skills in conflict resolution and prevention. Discuss respect for rights, needs, and opinions of others.
Move from dependence on others to self for risk reduction	Provide information about how to resist peer pressure to engage in risky behavior. Discuss injury prevention strategies at home, work, and school.
Psychosocial
Establish independence from parents	Explain to parents an adolescent’s need for privacy and that not joining in all family activities is not a sign of rejection. Discuss the notion that increased independence also requires increased responsibility.
Develop sense of self-identity	Encourage adolescents to take responsibility for their own health care. Encourage adolescent to take on new challenges; discuss plans for the future (e.g., school, work, family). Help adolescents identify their own personal strengths and joys.
Create new relationships with peers and other adults	Discuss importance of activities with peers; identify healthy ways to be part of a group. Encourage the adolescent to participate in community activities. Provide information and opportunity to discuss questions regarding sexuality, how to differentiate between “love” and “infatuation,” how to be sexually responsible, and how to protect against pregnancy and sexually transmitted diseases.

Physical Development

Tanner Stages

Pubertal growth and maturation can be divided into five stages ranging from prepubertal (sexual maturity rating [SMR] 1) to adult (SMR 5). These divisions are termed Tanner stages (Tanner, 1962) (Figs. 8-3 and 8-4). Pubertal changes occur on a continuum, with individual differences in timing or tempo.

FIGURE 8-3 Tanner stages: female. SMR, Sexual maturity rating.

(Adapted from Division of Adolescent Medicine, Children’s Hospital Medical Center, Cincinnati, OH, 1995.)FIGure 8-3, cont’dTanner stages: female.

FIGURE 8-4 Tanner stages: male. SMR, Sexual maturity rating.

(Adapted from Division of Adolescent Medicine, Children’s Hospital Medical Center, Cincinnati, OH, 1995.)

Female Stages

Females enter puberty earlier than males do, and their puberty usually progresses sequentially in the following pattern:

• Ovaries increase in size; no visible body changes occur.

• Breast budding (thelarche) traditionally occurs between 9 and 10 years old, with 95% of normal girls having initial breast development between 9 and 13 years old (Hagan et al, 2008). Evidence indicates that adolescent girls are entering and completing puberty younger than girls did 50 years ago (Euling et al, 2008). Most girls (85%) experience the development of breast buds approximately 6 months before the appearance of pubic hair. Girls of African descent are more likely to develop pubic hair (adrenarche) before or at the same time as breast budding, whereas Caucasian girls typically have thelarche before adrenarche (Herman-Giddens, 2006). The timing of onset of breast development in females has no relationship to breast size at the completion of puberty.

• Rapid linear growth usually begins shortly after the onset of breast budding and reaches its peak about a year later. Most girls experience peak height velocity (PHV) about 6 to 12 months before menarche, generally between 11 and 12 years old, and PHV is completed by about 13 years old. Early developers may experience a height spurt between 9 and 10 years old, whereas late developers may not experience a height spurt until between 13 and 14 years old. Final height is determined by the amount of bone growth at the epiphyses of the long bones. Growth stops when hormonal factors shut down the epiphyseal plates.

• Appearance of pubic hair (adrenarche or pubarche) commences at about 11.5 years old and is related to adrenal rather than gonadal development, not to thelarche; therefore, it is less valid than other secondary sex characteristics in assessing sexual maturation.

• The first menstrual period (menarche) occurs, on average, at 12.5 years old. More than 95% of girls experience menarche between 10.5 and 14.5 years old. The mean age of menarche is highly dependent on ethnic, socioeconomic, and nutritional factors. Menarche generally occurs 1.5 to 2.5 years after thelarche. It may be 18 to 24 months after menarche before females establish regular ovulatory cycles. To some degree, menstrual cycles can be affected by the athletic activity of the female. The American Academy of Pediatrics and the American College of Obstetrics and Gynecology recommend that health care providers recognize the menstrual cycle as a “vital sign” because of the need for education regarding normal timing and characteristics of menstruation and other pubertal signs (Hagan et al, 2008).

Changes in the body composition of females occur during puberty, and adolescent girls will benefit from the primary health care provider’s reassurance that these changes are normal. Initial breast development usually begins as a unilateral disk-like subareolar swelling, and many adolescents and parents may initially present with concerns about breast tumors. Girls often have asymmetric breasts and need assurance that breasts become more or less the same size within a few years after the onset of breast budding. The female body shape changes as girls progress through puberty, with broadening of the shoulders, hips, and thighs. Girls experience a continuous increase in proportion of fat to total body mass during puberty. They enter puberty with approximately 80% lean body weight and 20% body fat. By the time puberty ends, lean body mass drops to about 75%. Body fat is an important mediator for the onset of menstruation and regular ovulatory cycles. An average of 17% of body fat is needed for menarche, and about 22% is needed to initiate and maintain regular ovulatory cycles.

Male Stages

Physical body changes of puberty generally occur sequentially in males as follows:

• The initial sign of male puberty is testicular enlargement, on average at age 11 (Hagan et al, 2008). Growth of the testes occurs approximately 6 months before the development of pubic hair in most males. If testicular enlargement does not precede other changes, the provider should consider whether the boy is taking exogenous anabolic steroids. Once puberty begins, the left testis generally hangs lower than the right.

• Pubic hair development follows a pattern similar to that of girls (see Fig. 8-4).

• First release of spermatozoa (spermarche) generally occurs in midpuberty at a mean age of 13.5 to 14.5 years. However, it can occur at any stage of development from SMR 2 to 5.

• Elongation and widening of the penis usually begin in SMR 3 and continue through SMR 5 (see Fig. 8-4).

• Rapid growth in height occurs. The PHV for males tends to occur late in middle puberty to early in late puberty. Boys generally lag about 2 years behind girls, but the height spurt can begin as early as 10.5 years or as late as 16 years. Males typically have a higher peak growth velocity than females. One fifth of normal adolescent males do not reach their PHV until SMR 5, and there is some evidence that late maturers may achieve greater PHV (Sherar et al, 2005). Males can continue to grow, although minimally, well beyond their teenage years.

• Change in the male voice occurs; this coincides with the PHV.

• Development of axillary, facial, and body hair occurs. Axillary hair generally does not appear before SMR 4 pubic hair. Facial hair appears only after SMR 4 pubic hair and does so in an ordered sequence. It starts at the outer corners of the upper lip and moves inward, then appears on the upper parts of the cheeks and middle of the lower lip, and finally grows along the sides and lower border of the chin. The extent of body hair is determined to a large extent by genetic factors. Body hair develops gradually after facial hair. Body hair changes should not, however, be used to assess pubertal maturation related to changes in the endocrine system.

As with girls, the body composition of adolescent boys changes, sometimes causing great concern for the adolescent. The provider can be an invaluable source of information and reassurance. In contrast to females, males generally increase muscle mass and lose body fat during puberty.

Some changes associated with puberty may be unwelcome. For males, approximately half the population experiences gynecomastia, a transient enlargement of breast tissue. Gynecomastia generally lasts 12 to 18 months and resolves completely in nearly all cases by late puberty. In a small percentage of males, however, some palpable breast tissue may persist. Acne starts in early puberty, and by midpuberty many males have moderate to severe acne, which becomes somewhat worse by the end of puberty. Although generally benign, gynecomastia can occur secondary to anabolic steroid or illicit drug use. In cases of persistent gynecomastia or severe acne, the provider should ask questions about the use of alcohol, marijuana, and anabolic steroids, all of which can exacerbate these conditions.

Psychosocial, Emotional, and Cognitive Development

Principles of Adolescent Psychosocial, Emotional, and Cognitive Development

Adolescents transitioning from childhood to adulthood should achieve specific cognitive, emotional, and psychosocial developmental milestones that help them:

• Feel a sense of belonging in a valued group

• Acquire skills and master tasks that are important to the valued group

• Develop a sense of self-worth

• Develop at least one reliable relationship with another individual

• Demonstrate cognitive potential

The adolescent’s ability to achieve these goals depends in part on brain functioning. Although full sized, the adolescent brain continues to develop functional ability. In particular the prefrontal cortex, which coordinates executive functions of abstract thinking, reasoning, judgment, self-discipline, ethical behavior, personality, and emotions, experiences rapid growth. As with the infant brain, a process of pruning and reinforcement occurs, based on the stimuli, activities, and experiences of the teenager.

The brain is subject to chemical, hormonal, physical, and biologic changes. Dopaminergic and noradrenergic receptors become more active and neurotransmitter levels increase during adolescence. Neuroimaging studies indicate the midbrain, amygdala, and hippocampus change in size and are particularly affected by puberty (Joffe and Morris, 2008). The adolescent brain appears to be particularly vulnerable to schizophrenia and addiction. Schizophrenia most often appears in the second decade of life, during late adolescence or early adulthood, and is characterized by disturbances in memory and concentration, a decreased sense of connectedness, and changes in emotional responses. The individual often experiences hallucinations or hears voices. Though its cause is unknown, schizophrenia may be due to previous brain damage, and there is some indication that neurodevelopmental processes (e.g., enlarged lateral ventricles in the brain; left medial and frontal lobe gray matter deficit) may be abnormal with this disease (Janssen et al, 2008; Pagsberg et al, 2007).

Drugs, including alcohol, have a significant negative effect on the adolescent brain, damaging the neural circuitry in the “reward” or motivation pathways and shutting down the body’s ability to respond to stimuli that normally generate feelings of pleasure. In essence the drug becomes the only thing that leads to pleasurable feelings, and a craving for the drug is “etched” into the brain—the individual becomes addicted. In addition to contributing to addiction, brain changes resulting from exposure to alcohol can lead to loss of memory and cognitive function (Guerri and Pascual, 2010; Maldonado-Devincci et al, 2010). Genetic structures of individuals vary, however, and not all brains respond to drugs in this way, but the adolescent brain is highly vulnerable.

Suicide and homicide are also risks for adolescents. Although motor vehicle accidents and unintentional injuries are the major causes of adolescent mortality, 14.5% of teens in grades 9 to 12 across the country have seriously considered suicide, and 12% of deaths in the ninth- to twelfth-grade age group are due to suicide. Data from the Youth Risk Behavior Survey indicate that in 2009 13.8% of these teens had seriously considered suicide; 10.9% made a plan, and 6.3% attempted suicide (Eaton et al, 2010). Particularly vulnerable are younger (ninth grade), white and Hispanic girls. Depression is a contributing factor to suicide and is discussed in Chapter 19. Homicide represents 16% of all teenage deaths (Eaton et al, 2010).

A wide variety of normal behavior characterizes the process of psychosocial, emotional, and cognitive development in adolescents. Three general principles may be used to understand the changes seen:

• Transition is continual and generally smooth.

• Disruptive family conflict is not the norm.

• The quality of thinking changes from concrete to formal operational thinking.

Smooth Transition

The first principle of adolescent psychosocial development is that the transition from adolescence to adulthood is continuous and generally smooth. A commonly held myth is that adolescence is a period of “storm and stress.” This view was originally described by G. Stanley Hall in 1904 (Hall, 1904). Although his argument was not based on research, this myth continues to be widely believed. It is important to remember that adolescence is only one of many transitional phases in life and, for many people, it may not be particularly difficult.

Family Relationships Change

The second principle of adolescent psychosocial development is that the biologic, cognitive, and emotional changes experienced by adolescents require a reworking of family relationships. Some degree of adolescent-parent conflict is to be expected because of this reworking of relationships, but disruptive family conflict is not the norm. Mundane, everyday issues such as which clothes to wear, hairstyles, household chores, curfew, and friends continue to be the usual sources of parent-adolescent conflict, and negotiation between parent and child is essential. Inexperienced in negotiation, adolescents will often argue a point to excess. It may help to remind parents that this verbal debate, or “arguing,” is a normal behavior of teens that reflects their use of more abstract thinking skills. It is a way of practicing abstract thinking and engaging parents. However, the parent should not become too deeply engaged because the adolescent rarely is, and the “arguments” tend to blow over fairly quickly (Box 8-1).

BOX 8-1 Tips for Parents: Adolescent Survival Guide

• Start with clear rules and expectations before children are teenagers. Work on developing good communication with children early and continue through adolescence. State expectations and future consequences before trouble has occurred (e.g., before the dance, not when the teen comes home late).

• Be firm and follow through.

• Try to be flexible and allow teenagers to negotiate. Discussing principles and negotiating solutions are valuable life skills for the future. Do not negotiate rules that are nonnegotiable.

• Fighting and arguing are typical, often used by teens as they practice their developing reasoning skills. Often teens are engaged more recreationally than emotionally. Therefore, when the parent is tired, disengage and walk away. Try not to take what they say personally.

• Teenagers want parents to be involved, concerned, and ask questions. They just may not know it or know how to express their desire.

• Know who their friends are and call those parents from time to time. Compare household rules if possible.

• Be involved at their school if possible. Try to meet their teachers and stay in contact with them.

• Continue to involve teenagers in family activities, even when they no longer want to. Bringing friends along will help.

• Keep promises made to teens. This builds trust and respect and makes you a role model.

• Model good behavior. Adolescents recognize the hypocrisy of saying one thing and doing another.

• Don’t forget that teenagers still need adult supervision at times.

• Keep communication lines open and don’t be afraid to start conversations. Adolescents sometimes want to talk to adults but are nervous about speaking first.

Families should not be experiencing one crisis after another. If family crises are the norm, one should be concerned. When true turmoil exists, it usually represents psychopathology and will not be simply “outgrown.” Careful assessment and treatment are required. Behavior that results in negative consequences is cause for concern (e.g., red hair dye grows out, but being expelled from school has long-term consequences).

Cognitive Changes

The third principle of adolescent psychosocial development is about change in cognitive abilities. Adolescents develop what Piaget referred to as formal operational thinking, characterized by the use of propositional thinking and abstract reasoning. The principal difference between concrete and formal operational thinking is the ability to reason using verbal manipulation rather than in terms of concrete objects. In early adolescence, thinking tends to be very concrete. The classic example is an adolescent who when asked, “Are you sexually active?” responds, “No, I just lie there” or when asked, “What brought you here to see me today?” answers, “The bus.” Most teenagers acquire increasing sophistication in abstract thought after age 14 years. They learn to conceptualize about past and future events and to relate actions to consequences. During this process, adolescents begin to:

• Consider values. The ones they challenge most are those with which they are most familiar, ones they have grown up with.

• Understand concepts of good and evil and understand human nature (e.g., not all authority figures are good people).

• Be aware of contradictions between what is said and what is done (e.g., adolescents are acutely aware when parents tell their children not to smoke or drink even though they do, or when they tell them to wear their seat belts although the parent does not).

• Understand the significance of their place within the construct of time (past, present, future) and begin thinking about what they will be doing in the future (e.g., college, technical school, job, marriage, and family).

Although most teenagers develop the ability to translate experiences into abstract ideas and think about the consequences of actions, approximately one third do not achieve more fully sophisticated thinking abilities, even as adults. Children who have demonstrated intellectual skill continue to be more successful in academic or intelligence testing as adolescents and adults (Shaw et al, 2006). Neurologic changes underlying the development of executive function, memory, social inhibition, intelligence, and cognition in adolescence are being investigated; additional research is needed to clarify relationships among environment (e.g., drugs, alcohol, noise, etc.), innate traits, and cognitive ability (Blakemore and Choudhury, 2006; Crone, 2009; Luna et al, 2010).

Emotional Changes of Adolescence

Hormones present during puberty cause emotional and physical changes. As with physical growth and development, emotional changes appear differently in males than in females. Some males may experience an association between an increase in testosterone and sad or anxious feelings, acting out, aggressive behavior, or sexual activity.

Some emotional changes that occur are not directly associated with hormonal changes. Research shows that boys with adult-like physiques are given more leadership roles, are more proficient in sports, are perceived as more attractive and smarter than their peers, and are more popular than others in their age group. In general, they demonstrate higher self-esteem in early adolescence. Late-maturing boys who are short and child-like in appearance until 15 years or older tend to show more personal and social maladjustment over the entire course of adolescence. They can be insecure, suggestible, vulnerable to peer pressure, and subjects of bullying or seen as weak, immature, and less competent than average. Males, as they progress through puberty, typically develop a more positive self-image and mood, whereas females may feel a diminished sense of attractiveness as their bodies mature. Boys tend to be more satisfied with their body image and, depending on their current size, may want to either gain or lose weight, whereas girls are more likely to express a desire to lose weight (Al Sabbah et al, 2009). This dissatisfaction with body image can appear before adolescence (in one study of third graders, 17% of boys and 24% of girls had dieted or were dieting to lose weight [Robinson et al, 2001]), may be related to weight changes in early childhood (Angle et al, 2005), and can continue into the teen years (Al Sabbah et al, 2009).

The emotional affect and behavior of pubescent females differ in other ways from those of boys. Both early-maturing boys and girls demonstrate more risky behaviors than do adolescents who are late maturing, but girls are at greater risk as a result of romantic liaisons. Often these early bloomers get “bumped up” to an older group of peers and become the objects of sexual attention from older males. The developing body of early-maturing females may not match their chronologic age or emotional maturity. This difference can influence their behavior and place them at risk for early sexual involvement, smoking, and drinking (Halpern et al, 2007).

Egocentrism of Adolescents

Changes in the quality of adolescent thinking coupled with physical and emotional changes give rise to a form of egocentrism. This change may result in a rather self-centered, but not necessarily selfish, view of the world. Although there are recommendations that this prototype requires more research for validation and evidence that adolescent egocentrism continues into late adolescence (Schwartz et al, 2008) and adulthood, four major types of egocentrism in the adolescent are generally recognized (Elkind, 1984):

• Imaginary audience: Everyone is thinking about them.

• Personal fable: They are special.

• Overthinking: They make things more complicated than they are.

• Apparent hypocrisy: Rules apply differently to them than to others.

Imaginary Audience

Abstract thinking allows teenagers to wonder what others are thinking about. At the same time, adolescents are obsessed by the physical changes brought about by puberty. These changes and their new thinking abilities create the notion that everyone is thinking about the same thing that they are (i.e., them). Teenagers may believe that one can read minds and know what others are thinking. For example, a boy who goes to the pharmacy to purchase a condom may feel that he is “on stage,” the object of everyone’s scrutiny. An adolescent wearing orthopedic braces may think that everyone is staring at him. A young girl who has a pimple on her nose may feel that it is the first thing others see when they look at her.

Personal Fable

The second type of egocentrism is the personal fable. If everyone is watching you and thinking about you (thanks to the imaginary audience), you must be someone special. The personal fable is the concept that the laws of nature do not apply to oneself and that one’s thoughts and feelings are totally unique. The personal fable has a very positive aspect in that it provides adolescents with a sense of importance, purpose, and hope; it helps them to imagine possibilities and opportunities in their lives and futures. Personal fables can also have a negative effect (e.g., when adolescents believe that they will never grow old, cannot get pregnant [especially the first time], cannot get a sexually transmitted infection despite engaging in unprotected intercourse, or will not suffer long-term consequences from substance use).

Overthinking

Overthinking involves making things more complicated than they need to be. An example is an adolescent who attributes complicated motives to simple oversights (e.g., an adolescent boy who thinks that his parents would not have divorced if only he had helped more with the chores around the house or an adolescent girl who breaks up with her boyfriend because she assumes that he does not like her because he did not compliment her on her new red dress).

Apparent Hypocrisy

Apparent hypocrisy is the notion that rules apply differently to adolescents than they do to others. For example, an adolescent girl may believe that she should have free access to her parent’s clothes and electronic equipment (such as the MP3 player or home computer), whereas her parents entering her room to borrow a disk constitutes an invasion of privacy.

Developmental Screening and Assessment

Approaches to Assessment of Adolescents

Throughout infancy and the preschool and school years, the focus of the health care visit is the parent or caregiver and the child as a unit. This dyad changes with adolescence. Teenagers must be evaluated independently of their parents, and developmental issues must be discussed privately with the adolescents themselves. Nonetheless, parents remain concerned, and it is ideal that they be involved in their child’s health care. Adolescents continue to be part of the family system, and providers should work with adolescents to maximize communication with parents around health issues. Some providers believe that involving parents or other significant adults in the adolescent’s care is essential. However, that decision is not always the provider’s to make, and it may not always be in the best interest of the adolescent. Adolescents must be actively included in decisions about sharing information with others. For many sensitive health issues, providers will need to help the teenager understand and evaluate the risks and benefits of involving family members. They must also provide guidance and support on how to best inform the family, if that is the final choice. This approach can help protect a teen from the parent who may be abusive or unsafe. It can also reduce the problem of parents who are upset if they feel they are denied information about the child they love and for whom they feel responsible.

Effective interviews with adolescent clients are based on the use of good general interviewing techniques: demonstrating respect for the client; establishing parameters of what can be accomplished during the visit; using appropriate body language, active listening, and communication techniques; and working with the client to develop a realistic, individualized treatment plan. The provider gives the message that the teenager and his or her concerns are important, that no judgments will be made, and that the provider and teenager are a team, working together to achieve the healthiest outcome possible.

Preserving confidentiality with the teenager is essential. Adolescents should be reassured that the provider will not share information with the child’s parent or caregiver (general confidentiality) unless the adolescent agrees, or unless the health of the child or others may be compromised (e.g., threat of potential suicide, violence, evidence of an eating disorder). Providers must inform the teenager that there are limits to confidentiality (limited confidentiality). As “mandatory reporters,” primary health care providers are required by law to report information that puts the child or others in danger (e.g., physical or sexual abuse; some states require reporting teen sexual activity, even if consensual, if an age difference of 3 or more years exists between the couple). If adolescents perceive that their provider will maintain confidentiality, they are more likely to disclose more sensitive, relevant information (Berlan and Bravender, 2009), and it has been found that even when providers tell adolescents there are limits to their confidentiality, teens continue to disclose.

The American Medical Association (AMA) has developed a thorough interview format for teens in their published AMA Guidelines for Adolescent Preventive Services (GAPS) program (Elster and Kuznets, 1994), and basic health assessment of adolescents is discussed in Chapter 2. The HEEADSSS technique can be used to assess risk behaviors of adolescents and includes items that reflect the health issues that cause the greatest morbidity and mortality in adolescence (see discussion later in this chapter).

For teenagers who are hesitant to discuss sensitive issues, a questionnaire or checklist may be an effective way to collect information. Questionnaires used to identify adolescent strengths have also been created by the Search Institute and have been used by communities to enhance adolescent self-concept (see Chapter 16).

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Jul 24, 2016 | Posted by admin in PEDIATRICS | Comments Off

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