Pediatric Clinical Practice Guidelines for Nurses in Primary
Care
Chapter 19 - Adolescent Health
Introduction
Adolescent Development
Adolescent Health Care
Alcohol, Nicotine, Drug and Inhalant Abuse
For information about injury prevention, see "Injury
Prevention Strategies," in chapter 3, "Prevention," these
pediatric clinical guidelines.
For information about the clinical presentation and management
of STDs, see "Sexually
Transmitted Diseases," in chapter 11, "Communicable Diseases," in
the adult clinical guidelines (First Nations and Inuit Health Branch
2000). In addition, refer to and follow the Canadian STD Guidelines (Health
Canada 1998).
For information about suicide, see "Suicidal
Behavior," in chapter 15, "Mental Health," in
the adult clinical guidelines (First Nations and Inuit Health
Branch 2000).
Introduction
Adolescence is a unique time in human development, both physiologically
and psychologically. Adolescents in modern society face many health
issues, particularly in the areas of mental, emotional and social
health. Unfortunately, adolescence is also a period of life when
there is little or no contact with healthcare professionals.
Another unfortunate characteristic of adolescence is a propensity
for risk-taking behaviors, such as abuse of drugs and alcohol,
which cause premature morbidity and death within this age group.
Among adolescents, 77% of deaths are caused
by accidents, violence and suicide.
Adolescent Development
Requirements for healthy development:
- Supportive environment over the long term
- Graded steps toward autonomy
Other factors assisting in healthy development:
- Mutual positive engagement between adolescents and adults
- School and community programs
Characteristics of Developmental Stages
Early Adolescence
- Preoccupation with body changes
- High levels of physical activity and mood swings
Mid-Adolescence
- Independence
- Peer group dominates social life
- Risk behaviors more prevalent
- Sexual matters are of most interest
Late Adolescence
- Adult appearance
- More capable of orienting activities toward the future, of
mutual caring and of internal control
- Uncertainties about sexuality, future relationships and work
possibilities
Adolescent Health Care
An acute medical need is the most frequent
reason for an adolescent to seek medical care. It is important
to take this opportunity to discuss other topics important to adolescent
health. The mnemonic SAFE TIMES is one way of
remembering appropriate topics for discussion:
- S for sexuality issues
- A for affect(e.g., depression) and abuse (e.g.,
drugs)
- F for family (function and medical history)
- E for examination (sensitive and appropriate)
- T for timing of development (body image)
- I for immunizations
- M for minerals (nutritional issues)
- E for education and employment (school
and work issues)
- S for safety (e.g., vehicle)
History-Taking
Consider the following points when interviewing an adolescent:
- Ensure that the adolescent is the prime historian. It is preferable
to interview the adolescent without his or her parents or caregiver,
although it may be necessary to obtain collateral history from
parents, caregivers, teachers and others. Assure the adolescent
that all important problem will be kept strictly confidential
(there are some obvious exceptions, including suicide intention
and other high-risk, potentially destructive activity).
- Sensitively explore with the adolescent any problems with sexuality,
drugs, alcohol, school and family.
- Try to elicit information about the activities in which the
adolescent participates and what his or her peer group is doing.
Peer group activities generally reflect the individual's activities.
- If the adolescent is uncommunicative, a multiple-choice approach
can be used (e.g., "How would you compare your school performance
with that of others? Better, worse or the same?").
Functional Inquiry
A complete history of the health status of the adolescent should
be undertaken whenever an opportunity to do so presents itself.
A record of pubertal changes and, for young women, a complete menstrual
history, are essential components of this history.
Psychosocial Evaluation
Issues related to sexuality, drug or alcohol use, and family and
school problems should be systematically reviewed. Questions about
school attendance and performance and future plans for school and
employment should be part of a complete evaluation.
Comprehensive Physical Examination
Emphasis should be placed on common adolescent concerns. Height,
weight and blood pressure should be measured yearly in adolescents.
Sexual maturation (according to Tanner stages; see Table 19-1)
should be noted.
Skin
Obvious problems, particularly acne, should be noted and treated.
Eyes
Visual acuity should be screened, as myopia commonly develops
during the adolescent growth spurt.
Mouth
Dental decay and periodontal disease can be significant problems
in adolescence.
Breasts
Development and symmetry of the breasts should be assessed, and
girls should be taught how to perform breast self-examination.
Cardiovascular System
Functional murmurs are common in adolescence, but look for other
forms of cardiac pathology (e.g., mitral prolapse).
Musculoskeletal System
Sports injuries, knee problems and other problems of the musculoskeletal
system are common in adolescence. Routine screening for scoliosis
is of questionable value.
Genitalia
Assess development of pubic hair to allow Tanner staging (see Table
19-1).
Boys should be examined with respect to normal growth and development
of the external genitalia.
Girls who are sexually active should undergo a pelvic examination
and Pap smear with appropriate STD screening at least once yearly.
General indications for pelvic examination would also include menstrual
irregularities, severe dysmenorrhea, vaginal discharge, unexplained
abdominal pain or dysuria.
Rectal Examination
At some point during the health maintenance program, a rectal
examination should be performed on all adolescents, but this can
be deferred to the late teens if necessary.
Puberty
Female
In the female, puberty begins between the ages of 8 and 14 years
and is usually complete within 3 years. Menarche usually occurs
2.5 years after the onset of puberty; in North America, the mean
age at menarche is 12.5 years. At menarche the adolescent female
has generally attained 95% of her adult height. The female adolescent
growth spurt usually occurs between Tanner stages II and IV (see Table
19-1), and during this period she will grow an average of 8
cm per year.
Male
Puberty usually begins 1.5-2 years later in the male than in the
female, and it takes twice as long. The male adolescent growth
spurt occurs during Tanner stage V (see Table
19-1). The average increase in height during this period is
approximately 10 cm per year.
Table 19-1: Tanner Staging of Adolescent Development*
| Stage |
Pubic Hair†:
Male |
Pubic Hair†:
Female |
Testes and Penis
in Male |
Breast Development
in Female |
| I (preadolescent) |
No pubic hair present; some fine villous hair covers the
genital area |
No pubic hair present |
Appearance of testes, scrotum and penis identical with that
of early childhood |
Juvenile breast with elevated papilla and small, flat areola |
| II |
Sparse distribution of long, slightly pigmented hair at the
base of the penis |
Sparse distribution of long, slightly pigmented, straight
hair bilaterally along medial border of labia |
Enlargement of testes and scrotum; reddish coloration and
enlargement of penis |
Breast bud forms; papilla and areola elevates to form small
mound |
| III |
Pigmentation of pubic hair increases, and hair begins to
curl and spread laterally |
Pigmentation of pubic hair increases, and hair begins to
curl and spread sparsely over mons pubis |
Continued growth of testes in scrotum and continued lengthening
of penis |
Continued enlargement of breast bud and areola; no separation
of breast contours |
| IV |
Pubic hair becomes coarser in texture and takes on adult
distribution |
Pubic hair continues to curl and becomes coarse in texture;
number of hairs continues to increase |
Testes and scrotum continue to grow; scrotal skin darkens;
penis grows in width, and glans penis develops |
Papilla and areola separate from the contour of the breast
to form a secondary mound |
| V |
Mature pubic hair chains and adult distribution, with spread
to surface of the medial thigh |
Mature pubic hair chains; adult feminine triangle pattern,
with spread to surface of medial thigh |
Mature adult size and shape of testes, scrotum and penis |
Mature areolar mound recedes into general contour of breast,
papilla continues to project |
*Adapted, with permission, from Tanner J.M., 1962. Growth at Adolescence.
2nd ed. Blackwell Scientific Ltd., Osney Mead, Oxford. © Blackwell
Scientific Publications.
†Distribution and coarseness of pubic hair may differ according
to ethnic background (e.g., an Aboriginal adolescent may not have
the same distribution of coarse hair as a Caucasian adolescent).
Sexuality
Recent estimates suggest that approximately 70% of North American
teenagers are sexually active by 17 years of age. This may occur
earlier among Aboriginal teens in some communities. Given this
prevalence of sexual activity, it is obvious that adolescence is
an important time for a person to determine his or her sexual identity
and attitudes toward sexual orientation.
In addition, the prevalences of STDs and unplanned pregnancies
are high among adolescents. These are very important public health
concerns for the community. Questions about sexual activity and
the adolescent's peer group may help to identify problems.
Homosexuality
Complex physical and social issues arise for all homosexual adolescents.
Seventeen percent of boys and 11% of girls report having had at
least one homosexual experience by the age of 19 years. It is estimated
that half of these adolescents will be homosexual in adulthood.
Teen Pregnancy: Testing and Counseling
A high index of suspicion is necessary. Consider the possibility
of pregnancy when an adolescent presents with any of the following
somatic complaints:
- Irregular menses
- Unusual vaginal bleeding
- Acute or chronic abdominal pain
- Unreliable menstrual history
- Amenorrhea
Urine Pregnancy Testing
Highly specific monoclonal antibody techniques yield positive
results in early pregnancy. A urine pregnancy test usually has
a positive result by 2 weeks after conception.
Counseling
Counseling the adolescent about her options related to pregnancy
is an important role for nurses. Options include carrying the fetus
to term and keeping the infant, carrying the fetus to term and
placing the child for adoption, or therapeutic termination of the
pregnancy. The pregnant adolescent will have to decide which option
she will pursue, and referral should be available for all options.
Factors of Teenage Pregnancy Associated With Risks to Infant
- Poor prenatal care (reluctance to seek care)
- Poor nutrition, leading to intrauterine growth retardation
- Smoking (one-third of pregnant teens)
- Use of illicit drugs
- Associated STDs
- Poor parenting skills
Follow-Up
- Nutritional status and weight gain by the adolescent mother
constitute one of the most important features of good prenatal
care for this age group
- Because the prevalence of STDs is higher among adolescents,
the potential of passing such infections to the baby must be
stressed; initial and follow-up cultures, as indicated, should
be routine
- Assessment for immunity to rubella virus
- Long-term planning with respect to adoption placement or, more
commonly, with respect to support for the adolescent mother once
her baby is delivered
- Assessment and counseling for drug and alcohol abuse
Community Health Aims and Interventions
- Repeat pregnancy within 2 years after the first child is born
to an adolescent female is a recognized problem
- Counseling and interventions with respect to appropriate postpartum
contraception are key
- Ongoing surveillance of the adolescent's coping and parenting
skills is of prime importance
- Community education programs to prevent unplanned teenage pregnancies,
particularly those aimed at school-age children, are also important
Contraception
Hormonal Contraception
- The most effective non-surgical methods of preventing pregnancy
in adolescents are oral contraception and Depo-Provera injection
(every 3 months)
- The main problem with oral contraception as a form of birth
control is poor compliance and discontinuation of therapy (which
occurs in 25% to 50% of North American teenagers for whom this
form of contraception has been prescribed)
- Discontinuation is usually secondary to adverse effects or
to family or community pressures regarding childbearing
- Adolescent growth is not affected by the use of hormonal contraceptives
Management of Adolescent Females Requiring Contraception
- Detailed history and physical examination, including blood
pressure
- Pelvic examination and Pap smear (if the adolescent is not
yet sexually active, these tests can be deferred until she becomes
sexually active)
Contraceptives and Counseling
The nursing profession has a vital role in educating and counseling
adolescents about the risks associated with sexual activity. Use
of contraception by sexually active adolescents should be encouraged.
Appropriate counseling addresses the various methods of contraception,
presenting both their advantages and their disadvantages. The use
of condoms must be heavily emphasized. Both contraceptives and
condoms should be made readily available at the nursing station,
and condoms should be available at other strategic places in the
community.
Follow up at 1, 3 and 6 months after initiation of contraception
to ensure no significant side effects and to monitor blood pressure.
Condoms and foam should be used as back-up contraception during
the first month of oral contraceptive use. Thereafter, condom use,
to prevent STDs, should be recommended.
For detailed information about contraceptive
methods and choices for oral contraception, see "Contraception," in
chapter 13, "Women's Health and Gynecology," in
the adult clinical guidelines (First Nations and Inuit Health
Branch 2000).
Other Issues
Compliance
Compliance is a significant problem in adolescents, and lack of
compliance is a major factor in the failure of oral contraception.
The adolescent should understand that initially there is a high
likelihood of spotting or break-through bleeding and missed menses
with use of hormonal contraceptives. These side effects usually
diminish or disappear within 3-6 months.
Rubella
Adolescent females without documented evidence of rubella immunization
should undergo rubella titer testing; if negative, measles-mumps-rubella
vaccine should be given. Alternatively, those without any recorded
evidence of immunization may be immunized without first undergoing
rubella titer testing.
Pap Smear
A Pap smear should be obtained for any sexually active adolescent
female -- at annual intervals if results are normal or more frequently
as dictated by findings.
Sexually Transmitted Diseases
The occurrence of STDs in gay males is a significant public health
issue. Consideration should be given to hepatitis B vaccination
and to HIV, VDRL and STD testing for all sexually active adolescents.
See "Sexually
Transmitted Diseases," in chapter 11, "Communicable
Diseases," in the adult clinical guidelines (First
Nations and Inuit Health Branch 2000).
See "Suicidal
Behavior," in chapter 15, "Mental Health," in the adult
clinical guidelines (First Nations and Inuit Health Branch
2000).
Injury Prevention
See "Injury
Prevention Strategies," in chapter 3, "Prevention."
Alcohol, Nicotine, Drug and Inhalant Abuse
Drug abuse is widespread in North American society. The use of
so-called gateway drugs, such as alcohol, tobacco and marijuana,
usually begins in adolescence, and today's adolescents experiment
at earlier ages than adolescents of previous generations. Nicotine
is the most commonly abused drug, followed by alcohol, marijuana
and then stimulants such as amphetamines and cocaine. In Aboriginal
communities, gas and solvent sniffing also constitute a significant
hazard. Ecstasy (a drug used at raves) is a new drug of abuse.
Generally, adolescent boys abuse all forms of drugs and alcohol
to a greater extent than do adolescent girls.
Factors Associated with Higher-Risk Behaviors
- Drug and alcohol use
- Sexual activity
- Poor school performance
- Peer pressure
- Poor diet and limited physical activity
- Low socioeconomic status
- Poor relationship with parents or caregiver
Risk for Substance and Alcohol Abuse
- Family history of alcohol or substance abuse on either side
of the family
- Use of alcohol, marijuana or cocaine in early adolescence
- Use of cross-dependent drugs, such as marijuana, sedatives,
tranquilizers
- Drug use within peer group
- Adolescents with attention deficit hyperactivity disorder,
learning disability or depression
- Adolescents who are suicidal
- Family dysfunction: divorce, alcohol or drug abuse, child abuse,
inconsistent or impulsive stealing
- Adolescents with school problems (e.g., absenteeism) or problems
with the law
Alcohol
Genetic Risk Factors
One-third of surveyed alcoholics reported that at least one parent
was alcoholic. Biological studies support this familial trend.
Preventive Measures
- Incorporate questions about alcohol, drug and cigarette use
during routine questioning of adolescents, beginning at an early
age. Look for a profile consistent with drug abuse (e.g., the
T-ACE questionnaire).
- Any adolescent with school or family problems, depressive symptoms,
antisocial behavior, a peer group that uses drugs heavily, or
a family history of drug or alcohol-related problems should be
assessed for drug or alcohol abuse. Adolescents with a history
of repeated accidents, drunk driving offenses, and other similar
problems should be considered to have a drug or alcohol problem
until proven otherwise.
- Adolescents with antisocial behavior in combination with significant
drug or alcohol dependency usually require a long-term treatment
program designed for their age group. Finding appropriate treatment
programs is difficult, especially in remote areas, and reference
to a social worker or a National Native Alcohol and Drug Abuse
Program (NNADAP) worker with knowledge of appropriate referral
agencies is generally required.
Nicotine
Nicotine is one of the most addictive (and lethal) drugs known.
It is estimated that 85% of adolescents who learn to smoke cigarettes
will become addicted.
Nursing Intervention
- Educate children early (when they are of school age) about
the risks of tobacco use
- Counsel about the short-term effects: bad breath, staining
of the teeth and fingers, foul-smelling clothes, decreased athletic
fitness and high financial cost
- Provide those addicted to tobacco with smoking cessation counseling
and support
Source: "Tobacco Use among Aboriginal Children and Youth," (CPS,
Indian and Inuit Health Committee 1999)
Marijuana
This is the illicit drug most commonly used by adolescents and
young adults. It is associated with an increase in the risk of
respiratory cancer, as well as acute panic attacks, confessional
states and acute psychotic reactions (especially in those with
a genetic risk for mental illness).
Abuse of marijuana may be associated with chronic depressive illness
or abuse of alcohol or other drugs.
Inhalants
Dozens of inhalants are available in stores. Commonly used products
are liquids (such as model glue), contact cement, lacquers and
aerosols (such as gasoline, cooking sprays and toiletries [hair
spray, cologne]). Inhalants are most often used by younger adolescents.
Acute depression of the CNS can result, and there is a strong
potential for accidents, such as burns or drowning. Sudden sniffing
death is rare and is probably the result of rapid nasal or pulmonary
absorption of the inhalant, which sensitizes the heart to arrhythmias
(generally fatal ventricular arrhythmias).
Long-term neurologic deficit secondary to the inhalation of volatile
hydrocarbons such as toluene has been documented, although much
research is still needed in this category of drug abuse. Hearing
loss and other cranial nerve deficits have been suggested, as well
as long-term encephalopathy.
Interventions in Substance Abuse
Prevention
Healthcare professionals need to promote awareness about the health
hazards of substance abuse to children, adolescents, parents and
caregivers, teachers, vendors of volatile substances and community
leaders.
Education is considered the most effective prevention strategy,
particularly if it is initiated before the usual age of experimentation.
A progressive school-based curriculum with developmentally appropriate
modules, offered throughout elementary school, is seen as the most
efficient strategy and should be implemented, particularly in areas
where inhalant abuse is prevalent.
Providing alternative activities, such as recreational facilities,
and promoting cultural values encourage positive lifestyles and
may diminish the risk of inhalant abuse and other destructive behaviors.
Treatment
Adolescents with significant alcohol, solvent or other drug problems
should be referred to the most appropriate social services (e.g.,
NNADAP). Provincial alcoholism foundations also sponsor treatment
programs specifically aimed at teenagers. In remote areas, consultation
with a mental health worker or a physician may be indicated to
establish the most effective and practical treatment program.
Source: "Inhalant Abuse," (CPS, Indian and Inuit Health
Committee 1999)
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