Expiration Date: December 31, 2001. No CE credit will be given after this date.
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This Nursing Continuing Education Independent Study Modular Program is made possible through a grant by the Maternal and Child Health Bureau (MCHB) of the Office of Adolescent Health (OAH). Table of Contents
The deadline for completion of this module is Dec. 31, 2001. AbstractAs of 1999, despite multiple federal, state and foundation reports and books promoting over 1,000 recommendations and strategies aimed at improving the health of adolescents, no clear policy mandate exists. One new approach is to have all nurses gain a better understanding of adolescents and how to best work with them and their families to improve adolescent health. The purpose of this module is to give a general overview of adolescents, describe an assets framework for working with teens, identify the progress toward Healthy Youth 2000 objectives and describe the role of the nurse in delivering culturally competent and confidential care. ObjectivesAfter reading the article, "Working with Adolescents: A Time of Opportunity," and taking the test, you will be able to:
IntroductionBy Ann L. O'Sullivan, PhD, CRNP, FAAN
Nurses care for adolescents in multiple settings. To provide adequate care, nurses must understand normal growth and development and factors which influence that development. A great deal of progress has been made in identifying factors that influence teen development, either positively or negatively. Knowledge of these factors will help nurses to provide care to teens and their families. Traditional View of Adolescent Growth & DevelopmentAdolescence is the time of transition from childhood to adulthood. It is characterized by rapid growth, development of secondary sex characteristics and cognitive and psychosocial development. Typically, adolescence is divided into three phases based on age; early (10 - 13 years), middle (14-17 years), and late (17 - 21 years). Adolescent development is multidimensional, complex and marked by periods of rapid growth alternating with periods of remission. In the last century, the onset of physical change has occurred at increasingly younger ages, increasing the likelihood that the psychosocial and cognitive changes will lag behind (Neinstein, 1996). Timing of the physical changes of puberty varies as much as the number of adolescents going through them. Children of the same age show tremendous variation in growth and sexual development. Teens who develop earlier or later than 10-14 are faced with more questions of normalcy. Body image concerns are greatest in early adolescence. By middle adolescence, physical change is less rapid and dramatic and teens' focus shifts to concerns about improving appearance. By late adolescence many teens have dealt with these concerns and are more at ease with themselves (Krisman-Scott, 1996). Secondary Sexual DevelopmentWhat triggers puberty is still unknown; however, there are distinct changes in the hypothalamic-pituitary axis associated with the onset of puberty. These changes result in an increase in gonadotropin-releasing hormone (GnRH), which stimulates increases in leutenizing hormone (LH) and follicle stimulating hormone (FSH), hormones are responsible for the development of secondary sex characteristics. In males, LH stimulates testosterone production and FSH stimulates gametogenesis. In females, LH stimulates ovarian cells to produce androgens and progesterone and stimulates ovulation and FSH increases estrogen production (Neinstein, 1996). Development of secondary sex characteristics is measured through the use of a Sexual Maturity Rating (SMR) scale, sometimes called the Tanner scale. Because initiation and rate of growth during adolescence are so variable, age is a poor indicator and predictor of change. SMRs are essential in evaluating adolescents and provide a method to gauge developmental progress. SMRs use a five-point scale of measurement. For females, ratings measure breast development and pubic hair growth, and for males they measure genital development and pubic hair growth. As the age of onset of puberty varies, so too, does the length of time in each stage. Female pubertal development begins on average at 11.2 years of age (range 9.0 - 13.4) and lasts about 4 years. Breast budding is most frequently the first physical sign of puberty. Breast development and pubic hair development can progress at different rates and be at a different SMR level at any given time. On average, adolescent females'growth spurt starts about one year before breast development begins. Peak height velocity is reached about one year and one month after breast development begins. Menarche typically occurs one year after peak height velocity is reached, usually at SMR 3 (19%) or 4 (56%) at the average age of 12 years 4 months (range 9-17). See Table 1 for SMR parameters of female breast and pubic hair development (Tanner, 1962). Male pubertal development begins on average at 11.6 years of age (range 9.5 - 13.5). Testicular enlargement is most commonly the first physical sign of puberty in males. SMR levels for pubic hair development and genital development (testes, scrotum and penis) can differ at any given time in the same individual. See Table 1 for male SMR parameters. The average length of time for completion of puberty in males is three years. Spermarche usually occurs early in puberty during SMR 2.5 (Tanner, 1962). Table 1. Sexual Maturity Rating for Girls and Boys
The Adolescent Growth SpurtDuring adolescence, children experience a rapid increase in height and weight. This growth spurt is highly variable, generally lasting 24-36 months. Females typically experience this growth spurt one-and-one-half to two years earlier than males and on average grow 23-28cm. Male average growth is 26-28cm. The growth spurt ends with epiphyseal closure, which is under the influence of the sex steroids. Males experience a 2-year delay in bone closure as compared to females, and this accounts in part for their greater growth in height. In addition to increases in height, teens experience increases in weight. About 50% of adult ideal body weight is gained during puberty. Adolescent male weight gain primarily reflects an increase in lean body mass. In contrast, adolescent females experience an increase in percentage of body fat and a decrease in percentage of lean body mass. Body structures also have dissimilar growth rates. The first structures to reach their adult size are hands, feet and head. Leg length reaches its peak before body breadth. This sequence of growth can give teenagers a long-legged appearance and lead to clumsiness and tripping (Tanner, 1972). Cognitive DevelopmentAdolescence is also marked by major changes in cognitive thinking. During adolescence, teens move from concrete thinking to what psychologist Jean Piaget (1969) calls the period of formal operations. When functioning at the concrete operational level, teens cannot transcend the immediate and are unable to deal with remote, future or hypothetical problems. In contrast, formal operations functioning allows the individual to "think about their own thinking," transfer information from one situation to another, deal efficiently with the complex problems involved in reasoning, plan realistically for the future and conceptualize abstract ideas. Not all teens or adults attain full formal operational thought. In fact, more than one-third of college students and middle-aged adults do not use formal operations when faced with the need to solve an unfamiliar problem (Keating & Clark, 1980). As the young adolescent moves toward abstract reasoning, a new type of introspection occurs. Daydreaming, increased self-interest and fantasy are common. This is frequently manifested in young teens by spending hours examining every aspect of their appearance in front of a mirror. Adolescents assume that others are as interested in their thoughts and actions as they are. They view the world as a stage on which they are the principal actors and the entire world their audience. They see themselves as unique and destined for unusual fame and fortune. Psychologist David Elkind (1968) refers to this form of egocentrism as the "personal fable." By age 15 or 16 this type of egocentrism decreases. Young adolescents, at the beginning of this cognitive shift, have unrealistic career plans with visions of an idealized future, i.e., as a rock star or pro basketball player. By middle adolescence, they begin to have more realistic career goals and begin to realize their limitations. For teens in disadvantaged situations, this may lead to the beginning of feelings of hopelessness. Ideally, the late adolescent will have realistic career goals, a sense of perspective, be able to problem solve, consider all aspects of a situation, and delay gratification. Moral Development and Psychosocial DevelopmentKohlberg (1984) has described three levels of moral thought; the preconventional, conventional and postconventional. Adolescence marks the movement from the conventional level of moral judgement to postconventional. At the conventional level, people are motivated by external factors such as others' opinions and existing law. These individuals hold simplistic conceptions of what is right. Postconventional orientation embraces more universal and abstract principles of justice. The focus moves from acts to motivations, consequences and relationships. Postconventional morality is not achieved by all. It cannot be attained unless the structure of an individual's thought process develops and the ability to reason abstractly is attained. According to psychoanalyst Erik Erickson (1963), the central developmental task of adolescence is to develop a sense of identity. A sense of identity allows one to answer the questions: Who am I? Who am I to become? Identities are shaped and reshaped over a lifetime. Adolescence represents a significant turning point as the individual lets go of childhood beliefs and fantasies and confronts the imminent tasks and decisions of adulthood. Adolescence provide teens an opportunity to "try on" different roles, beliefs and commitments. This "trying on" of a variety of roles can result in role confusion. Erickson believes this role confusion leads many to over commit themselves to social causes, cliques and loves (Erickson, 1968). The development of a sense of identity requires individuation or separation from family. Separation from family does not indicate a lack of connectedness with family, but rather indicates the adolescent's need to have an identity separate from the family. Family connectedness can be promoted in a number of ways such as, parents' taking an interest in a teen's activities, spending time together or having family meals. Family connectedness has been shown to be the most important factor in positive outcomes for teens (Blum & Reinhardt, 1997). Early adolescence marks the beginning of developing a separate identity from the family. Close relationships with peers develop. These peer relationships are primarily same sex with strong solitary friendships developing. These young teens are preoccupied with their appearance and have numerous questions about normalcy and tend to look to peers for answers. Middle adolescents are less preoccupied with questions of normalcy. These teens are concerned with making themselves as attractive as possible and have concerns about clothing and makeup. Involvement in peer groups increases, and further separation from family occurs. Dating relationships and experimentation with sex occur during this period. Feelings of omnipotence and immortality are at a peak in this group, leading to risk-taking behaviors. As teens enter late adolescence, if all has progressed satisfactorily, they are well on the way to separating from family and establishing identity. It's getting there that can be difficult! This is especially true for teens who are defined by some segments of the larger society or their peers as "being different" ( i.e., gay, bisexual, or questioning youth; youth with special needs; youth who have recently immigrated; disenfranchised youth -- homeless, abused, or neglected youth; etc.). These youth not only have to grapple with the "normal" pressures of adolescence, they have the extra burden of establishing a sense of self in the midst of these additional pressures. In other words, while they are expected to develop a positive sense of self and pride in who they are, they are also expected to fit certain "so-called norms" -- even though those "norms" may be in direct contradiction to who they are. These conflicting messages prove to be too much for some adolescents. They may react by completely disassociating from their peers, family, and/or the larger community; developing a facade to make themselves more acceptable to others; or participating in self depreciating or "acting out" behaviors which lead to further ostracization. Others, however, are able to put these conflicting messages into perspective, and somehow develop a positive sense of self. The question becomes: What makes some adolescents more resilient than others? A relatively new model for looking at adolescent development, The Developmental Assets Model, may provide some clues. This model provides a new framework for guiding care provided to adolescents. It, however, does not provide all the answers, and should be used in conjunction with other, perhaps more familiar frameworks, i.e., Bright Futures (1994) and the American Medical Association's (AMA) Guidelines for Adolescent Preventive Services (GAPS) (1995). Each has its own unique value. Developmental Assets FrameworkNavigating through the multiple changes of adolescence is challenging. While most adolescents do so successfully, there are still too many others that do not. What makes some adolescents more adept at making it through this transition relatively unscathed, while others get caught in a quagmire of potentially devastating risk-taking behaviors? This is a fundamental question underlying the work of the Search Institute, an institute dedicated to studying healthy youth development. In 1990, Peter Benson and colleagues of the Search Institute introduced a new way of looking at adolescent development — through a developmental assets framework, rather than the more typical, problem-focused approach. Initially, this framework identified 30 (later expanded to 40) assets that facilitated successful transition from adolescence to adulthood. These 40 assets are divided into two groups and eight categories (Fig. 1). Benson's work shows that adolescents with more assets report fewer high-risk behaviors. It appears that assets retard health compromising behavior. As assets increase, so do school grades, educational aspiration and prosocial behavior. This asset model provides benchmarks by which to measure positive development. Fig. 1. External Assets
Benson further refined this model by surveying 99,000 6th-12th grade students in public and alternative schools in 23 states during the 1996-97 school year. Regretfully, students surveyed, on average, had only 18 of the 40 assets, with boys having three less than girls. According to Benson, youth face two major types of challenges to their positive development – high-risk behaviors (i.e., substance abuse, sexual intercourse, violence and attempted suicide) and developmental deficits. High-risk behaviors limit a young person's health and well-being psychologically, physically and economically. According to Benson and Scales (1998), one in five students engage in high risk behavior. Of these, violence and alcohol use were reported most frequently. The five developmental deficits identified included:
These developmental challenges, however, are offset by what Benson and Scales identified as thriving indicators, such as succeeding in school, helping others, valuing diversity, maintaining good health, exhibiting leadership, resisting danger, delaying gratification and overcoming adversity. These indicators show concern for one's own health and well being. Young people cannot build and maintain assets by themselves. As Benson (1998) states, "The foundation for healthy development depends on the support of all youth workers, neighbors, community leaders, parents, and educators within a young person's community. No single influence in a community can provide all of what adolescents need. We must work together." Accordingly, much of the Search Institute's work is directed at assisting communities to promote developmental assets. Nurses' Need for Cultural CompetencyA favorite motto of ours is, "Know thyself, know thy client, know how hard it is to change." A resourceful nurse working with adolescents will certainly know the traditional information regarding adolescent growth and development and may well have his/her own framework for working with teens. These factors alone, however, do not assure positive working relationships with adolescent patients. Beliefs and values of health care providers can also significantly influence the course of provider/patient relationships. Ideally, these beliefs and values do not get in the way of providing quality care. To ensure that they do not, nurses must be willing to partake in self assessment — "know thyself" — to acknowledge the existence of their beliefs, identify the source of these beliefs and understand how these beliefs influence interactions with patients. While multiple variables impact the development of personal beliefs, one of the primary influences is that of culture. Culture affects how individuals think, act, and communicate with others. It influences daily interactions, decisions and judgements about what is appropriate or valuable. Because of the implicit process by which culture guides people's thoughts and actions, it is assumed that "everybody" thinks, feels and acts the same way. The frailty of this assumption, however, becomes obvious when a conflict is encountered between cultures. For example, some adults have a very negative reaction to adolescent body piercing or tattooing, viewing adolescents who participate in these practices as deviant or defiant. If they let these negative perceptions pervade their interactions with these adolescents, establishing a positive working relationship will be difficult. In this situation, the nurse can demonstrate cultural competence by:
In addition to becoming aware of their cultural biases regarding adolescents as a group, nurses also need to be aware of larger cultural differences, i.e., racial/ethnic, socioeconomic, educational, etc. This is particularly important given that by the year 2000, it is estimated that 33% of individuals under 19 years of age will belong to various racial and ethnic minority groups (Davis & Voegtle, 1994). To establish positive working relationships with adolescents and their families it is crucial for nurses, then, to understand and accommodate cultural differences, especially those surrounding communication. This will require nurses to do some background research — "know thy client" — about the different racial/ethnic and cultural groups with whom they work. They can do this by reading about various cultural groups and/or by talking to people from these groups who are willing to serve as a resource (AMA, 1994). Information gathered, however, should only serve as a guide. Not all members of a particular cultural group will act in the same way. Nurses must determine from their patients how they view their culture and whether they adhere to traditional cultural communication customs. Caring for adolescents, in many cases, also involves working with their parents who may be more grounded in traditional cultural beliefs and values. As a result, nurses also need to assess parental cultural communication patterns. If, for example, an adolescent or family member appears distant, the nurse needs to evaluate whether cultural differences may be influencing their interaction. She/he needs to seek the adolescent's and parents' input on ways of facilitating communication and find acceptable solutions to bridging communication barriers. If a situation is unclear or complex, the nurse may want to seek an additional person to mediate or act as a "culture broker." When a cultural misunderstanding does occur, it should be acknowledged directly and with respect. In addition to effectively communicating with clients from various cultural/ethnic groups, nurses need to understand that culture affects overall health care practices. Factors such as family structure and dynamics, health beliefs and level of ethnic identification will either facilitate or deter adherence to desired health care behaviors. Although not discussed here, the role of socioeconomic factors in affecting health care also needs to be explored. It is only by examining at the total cultural context of the adolescent patient that nurses can begin to develop a plan of care for the adolescent that can facilitate behavior change. Remember, "change is hard," and the best way to make it a little easier is to understand what makes the adolescent "tick." By doing so, you can begin to identify and capitalize on the assets the adolescent patient brings to the relationship. Confidentiality and AdolescentsDelivering confidential health service to teens is complicated by payment issues, transportation problems and differences in legislation from state to state. Teens who have health insurance are typically covered under their parents' health plans and bills reflecting services provided are sent to parents. Many teens do not have access to a car and must depend on parents to transport them for health services making it difficult for them to obtain services without parental involvement. In addition, legislation concerning teens right to privacy in health care vary from state to state. Results of a recent survey (Klein, 1998) of 14-19 years old adolescents indicated that only 8.4% had used confidential services. More than half of the adolescents interviewed did not know where they could go to receive confidential health services. Nurses know that "confidentiality refers to the privileged and private nature of information provided during the health care transaction" (AMA, 1993). There is strong national consensus endorsing confidential health services for adolescents. Most membership organizations have a policy that directly supports adolescents' need for confidential health services (Gans, 1993). Over the past ten years, these policies have been supported by important national reports including; "Adolescent Health" (1991) by the U.S. Congress, Office of Technology Assessment; "Code Blue: Uniting for Healthier Youth" (1989) by the National Commission on the Role of the School and the Comnmunity in promoting Adolescent Health; and "Turning Points" (1989) by the Carnegie Council on Adolescent Development, which also advocate for confidential health services for adolescents. Likewise, adolescents report that confidentiality is important in the delivery of health care (Resnick, 1980). Their reasons included the need to prevent rumors, to avoid punishment from punitive parents, and to promote better problem-solving skills. Confidentiality is considered crucial to adolescents' willingness to provide accurate information about sensitive health issues. Recent research documents that counseling of adolescents about risk-taking behaviors by nurses was enhanced by their use of a confidential computerized health assessment tool (Papenny, 1999). Adolescents participating in this study were told that the information they provided was confidential and, as a result, it is believed, answered questions about risk-taking behaviors more honestly. Subsequently, counseling messages could be tailored to specific risk-taking behaviors and were more likely to be relevant to the adolescents' needs. Not only did this tool provide essential information, it, or similar type tools, could also be used to alleviate provider time constraints. On average, each adolescent client reports participating in 10 risk behaviors, only 7 of which were discussed by providers during a preventive service visit (Epner, 1998). Similarly, if a teen reports 3 or more risk behaviors, or a relatively severe health problem, even fewer risk behaviors are discussed. Since confidentiality laws vary from state to state, it is imperative that nurse providers explain their policies regarding confidentiality during an initial clinic interview. These policies need to be explained to both the adolescent patient and parent(s). Providing this explanation in the beginning will help to allay future misunderstandings. When working with a family over time, nurses have an opportunity to prepare parents for their child's growing need for privacy as part of normal adolescent development. By beginning early, parents may come to accept confidential visits by their teenagers as part of healthy maturation during adolescence. Given the array of laws pertaining to informed consent and confidentiality that currently exist, it is no wonder that adolescents and perhaps even nurses are confused about how these laws pertain to them. Congress has the ability to intervene to reduce these uncertainties by moving federal and state laws in the direction of greater uniformity. Until this occurs, it may be easier for nurses to encourage their localities and schools to integrate information about legal aspects of adolescent access to health services into health education courses. Health Status of Youth in the U.S. and ConclusionHealthy Youth 2000 is a document which outlines the adolescent component of the Healthy People 2000 objectives. These objectives allow us to measure the state of health of adolescents in the United States. An interim report, "Healthy Youth 2000 — a Mid-Decade Review" (Fleming, 1996), looked at our progress in meeting thirty-five of the adolescent health objectives. Specifically, objectives related to physical activity and fitness, nutrition, tobacco, alcohol and other drugs, family planning, mental health and mental disorders, violent and abusive behavior, unintentional injuries, sexually transmitted diseases and clinical preventive services were reviewed. Overall the report found that progress was mixed, with a few successes and a number of challenges. Figure 2 provides a brief overview of some of the findings. Figure 2. Summary of Findings from Healthy Youth 2000
The findings of this review are clear — we have much yet to accomplish in the area of adolescent health. While many challenges remain, so too do the opportunities to intervene on adolescents' behalf. Most of the outcomes reviewed above are related to behavior choices. Nurses, who traditionally have focused on patient education and health promotion, are key to the improvement of adolescent health behaviors. Nurses can empower adolescents to make healthier decisions by becoming familiar with adolescent development; providing culturally competent and confidential care to teen clients; working with families to increase their knowledge of the importance of family connectedness in the health of their teens; and assisting families and communities in cultivating developmental assets. ReferencesAmerican Medical Association Council on Scientific Affairs (1993). Confidential health services for adolescents. JAMA, 269, 1420-1424.
Benson, P., & Scales, P.C. (1998). A Fragile Foundation: The State of Developmental Assets Among American Youth. Minneapolis, MN: The Search Institute.
Benson, P., & Scales, P.C. (1990). A Portrait of 6th-12th Grade Youth. Minneapolis, MN: The Search Institute.
Blum, R.W., & Rinehart, P.M. (1997). Reducing the risk: Connections that make a difference in the lives of youth. Minneapolis, MN: University of Minnesota.
Carnegie Council on Adolescent Development. (1989). Turning points: Preparing American youth for the 21st century. New York: Carnegie Foundation.
David, B., & Voegtle, K. (1994). Culturally competent health care for adolescents. Chicago, IL: American Medical Association Department of Adolescent Health.
Elkind, D. (1968). Cognitive development in adolescence. In J.F. Adams (Ed.), Understanding adolescence. Boston: Alleyn & Bacon.
Erickson, E.H. (1963). Childhood and society. New York: Norton.
Epner, J.E.G., Levenberg, P.B., & Schoeny, M.E. (1998). Primary care providers' responsiveness to health risk behaviors reported by adolescent patients. Archives of Pediatric and Adolescent Medicine, 152, 774-780.
Fleming, M. (1996). Healthy youth 2000 — A mid-decade review. Chicago, IL: American Medical Association.
Gans, J.E. (1993). Policy compendium on confidential health services for adolescents. Chicago, IL: American Medical Association.
Green, M. (Ed). (1994). Bright futures: Guidelines for health supervision of infants, children and adolescents. Arlington, VA. National Center for Education in Maternal and Child Health.
Hill, P. (1993). Recent advances in selected aspects of adolescent devilment. J Child Psychol Psychiatry 33:69.
Keating, D.P. & Clark, L.V. (1980). Development of physical and social reasoning in adolescence. Developmental Psychology, 16, 23-30.
Klein, J.D., McNulty, M., & Flataw, C.N. (1998). Teenagers' self-reported use of services and perceived access to confidential care. Archives of Pediatric and Adolescent Medicine, 152, 676-682.
Kohlberg, L. (1984). Psychology of moral development: The nature and validity of moral stages. San Francisco: Harper and Row.
Krisman-Scott, M.A. (1996). Reducing the risks: Adolescents and sexually transmitted diseases. Nurse Practitioner Forum, 7(1), 23-29.
Levenberg, P.B., & Elster, A.B. (1995). Guidelines for adolescent preventive services. Chicago, IL: American Medical Association.
Liff, I.F. (1991). The interaction of pubertal and psychosocial development during adolescence. Pediatric Review 12:249.
The National Commission on the Role of the School and the Community in Improving Adolescent Health (1989). Code blue: Uniting for healthier youth. Chicago, IL: American Medical Association.
Neinstein, L.W. (1996). Adolescent health care. 3rd Ed. Baltimore: William and Wilkins.
Paperny, D.M.N., & Hedberg, V.A. (1999). Computer-assisted health counselor visits. Archives of pediatric and Adolescent Medicine, 153, 63-67.
Piaget, J. (1969) The intellectual development of the adolescent, in Caplan, G., Lebovici, S. Eds. Adolescence; Psychological perspectives. New York: Basic Books.
Remschmidt, H. (1994). Psychosocial milestones in normal puberty and adolescence. Horm Res 41 (suppl 2); 19.
Resnick, M.D., Blum, R.W., & Hedin, D. (1980). The appropriateness of health services for adolescents: Youths' opinions and attitudes. Journal of Adolescent Health Care, 1, 137-141.
Tanner, J.M. (1962). Growth at adolescence. 2nd Ed. Springfield, Illinois: Charles C. Thomas.
U.S. Congress, Office of Technology Assessment (June, 1991). Adolescent health — Volume III: Crosscutting issues in the delivery of health and related services (OTA-H-467). Washington, DC: U.S. Government Printing Office. |
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