Chapter 15 The Healthy Adolescent
Adolescence is the period of transition between childhood and adulthood. Although often thought to be tumultuous, most adolescents navigate this transition with few difficulties. The physical changes that occur during this period are referred to as puberty, the psychosocial changes as adolescence. Special consideration must be given to ethical issues such as autonomy and confidentiality (see Chapter 6). Health supervision for the adolescent is discussed in Chapter 11.
What Is Puberty?
Puberty refers to the transition from sexual immaturity to potential fertility associated with the appearance of secondary sexual characteristics. There is a definite beginning and end.
Females go through puberty 2 years earlier than males on average. The first sign of puberty in females is breast development (thelarche). In approximately 15%, however, pubic hair (adrenarche) appears first. Unilateral onset of breast development is a normal variation, with the other breast starting to develop within six months. The usual progression of sexual maturation in females is breast budding, pubic hair growth, peak height velocity, and menarche. Most women undergo menarche within 6 months of peak height velocity. Growth usually stops 2 to 3 years after menarche.
Males have testicular enlargement (testicular length > 2.5 cm) as the first sign of puberty. The usual progression of sexual maturation in males is testicular enlargement, pubic hair growth, enlargement of the penis, and peak height velocity. Growth usually stops 2 to 3 years after peak height velocity.
What Is Sexual Maturity Rating?
Tanner published a sexual maturity rating (SMR) system for adolescent pubertal development in 1962; hence, sexual maturity ratings are also referred to as Tanner stages. In females, breast and pubic hair changes are staged. In males, genital and pubic hair growth are staged. SMR I is prepubertal. SMR V is considered adult.
SMR of breasts (Figure 15-1)
SMR I: The breasts are preadolescent. There is elevation of the papilla only.
SMR II: A small mound is formed by the elevation of the breast and papilla. The areolar diameter enlarges.
SMR III: There is further enlargement of the breast and areola with no separation of their contours.
SMR IV: There is projection of the areola and papilla to form a secondary mound above the level of the breast.
SMR V: The breasts resemble those of a mature female, as the areola has recessed to the general contour of the breast.
Figure 15-1 Sexual maturity rating (SMR) of breast development in females.
Used with permission of Ross Products Division, Abbott Laboratories Inc, Columbus, OH. From Johnson TR, Moore WM, Jefferies JE: Children are different: development physiology, ed 2, Columbus, OH, 1978, Ross Products Division, Abbott Laboratories Inc.
SMR of pubic hair (Figures 15-2 and 15-3)
SMR I: There is no pubic hair.
SMR II: There is sparse growth of long, slightly pigmented, downy hair, straight or only slightly curled, primarily at the base of the penis or along the labia.
SMR III: The hair is darker, coarser, and more curled. The hair spreads over the junction of the pubes.
SMR IV: The hair is adult in type but covers a smaller area than in the adult. It does not extend onto the thighs.
SMR V: The hair is adult in quantity and type. It extends onto the thighs.
Figure 15-2 Sexual maturity rating (SMR) of pubic hair development in females.
Adapted from Neinstein LS: Adolescent health care: a practical guide, ed 2, Baltimore, 1991, Urban & Fischer Verlag.
SMR of male genitalia (Figure 15-3)
SMR I: The penis, testes, and scrotum are of childhood size.
SMR II: Enlargement of scrotum and testes, but penis usually does not enlarge. Scrotal skin reddens.
SMR III: Further growth of testes and scrotum, with enlargement of penis, mainly in length.
SMR IV: Further growth of testes and scrotum with increased size of penis, especially in breadth.
When Is Puberty Too Early?
Female puberty is too early if there is breast development before 8 years of age or menarche before 10 years of age. Some girls may initiate breast development as early as age 6. This is more common in females of Latino or African American heritage. Although this may be normal, these girls should have regular follow-up.
Male puberty is too early if there is testicular enlargement (length > 2.5 cm) before 9 years of age.
When Is Puberty Too Late?
Females who have no breast development by 13 years of age or who have not had menarche by age 16 have delayed puberty.
Males whose testicular length has not exceeded 2.5 cm by age 14 have delayed puberty.
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