29 Growth and Development of the Adolescent Notes

Sports

• Match sport to adolescent's ability and desire. • Sports program should have warm-up procedure and hydration policy. • Undergo sports physical before start of activity. • Coaches should be trained in CPR and first aid. • Wear appropriate protection devices for individual sport.

PHYSIOLOGIC CHANGES

Adolescence is a time of metabolic slowing and of increasing size of some organs. The basal metabolic rate (BMR) reaches the adult level during late adolescence.

ADDRESSING COMMON DEVELOPMENTAL CONCERNS

Adolescence is a time of rapid growth and development with maturation of sexuality. The adolescent period begins with a child and ends with the expectation of adulthood. There are many developmental concerns that are present during this period, including violence, suicide, homicide, and substance use. The following is an overview of some of these concerns

Other Activities

Adolescents are involved in many other activities that influence learning. Some of these activities include (1) school activities such as band, choir, or clubs requiring high achievement; (2) athletic activities in the school and community and sometimes in the state or region; (3) art, sewing, and building classes; and (4) work activities when the late adolescent has a part-time job. These activities all contribute to the growth, development, and education of the adolescent.

Growth and Development Overview

Adolescence is a time of rapid growth with dramatic changes in body size and proportions. The magnitude of these changes is second only to the growth in infancy. During this time sexual characteristics develop and reproductive maturity is achieved. The age of onset and the duration of the physiologic changes vary from individual to individual. Generally, girls enter puberty earlier (at 9 to 10 years of age) than boys (at 10 to 11 years) (see Table 29.1). Adolescents will represent varying levels of identity formation and will offer unique challenges to the nurse.

PSYCHOSOCIAL DEVELOPMENT

According to Erikson, it is during adolescence that teenagers achieve a sense of identity (Erikson, 1963). As the adolescent is trying out many different roles in regard to his or her relationships with peers, family, community, and society, he or she is developing his or her own individual sense of self. If the adolescent is not successful in forming his or her own sense of self, he or she develops a sense of role confusion or diffusion. The adolescent culture becomes very important to the teenager. It is through his or her involvement with teenage groups that the adolescent finds support and help with developing his or her own identity. Erikson (1963) believed that during the task of developing his or her own sense of identity, the adolescent revisits each of the previous stages of development. The sense of trust is encountered as the adolescent strives to find out whom and what ideals he or she can have faith in. In revisiting the stage of autonomy, the adolescent is seeking out ways to express his or her individuality in an effective manner. The adolescent would avoid behaviors that would "shame" or ridicule him or her in front of his or her peers. The sense of initiative is revisited as the adolescent develops his or her vision for what he or she might become. And the sense of industry is again encountered as the adolescent makes his or her choice to participate in different activities at school, in the community, at church, and in the workforce. The ability of the adolescent to successfully form a sense of self is dependent upon how well the adolescent successfully completed the former stages of development. Erikson (1963) believed that if the adolescent has been successful, he or she can develop resources during adolescence to overcome any gaps in previous developmental stages. If the adolescent believes that he or she cannot express himself or herself in any manner due to societal restrictions, he or she will develop role confusion. See Table 29.2 for additional information.

COGNITIVE DEVELOPMENT

According to Piaget, the adolescent progresses from a concrete framework of thinking to an abstract one (Piaget, 1969). It is the formal operational period. During this period, the adolescent develops the ability to think outside of the present; that is, he or she can incorporate into thinking concepts that do exist as well as concepts that might exist. The adolescent's thinking becomes logical, organized, and consistent. He or she is able to think about a problem from all points of view, ranking the possible solutions while solving the problem. Not all adolescents achieve formal operational reasoning at the same time. In the early stages of formal operational reasoning, the adolescent's thinking is egocentric, thinking they are at the center of everyone's attention. The adolescent is very idealistic, constantly challenging the way things are and wondering why things cannot change. These activities lead to the adolescent's feeling of being omnipotent. The adolescent must undergo this way of thinking, even though it can frustrate adults, in his or her quest to reach formal operational reasoning. As the teenager progresses toward middle adolescence, his or her thinking becomes very introspective. He or she assumes others are just as interested in what interests him or her, which leads him or her to feel unique, special, and exceptional. That feeling of "being exceptional" leads to the risk-taking behaviors of which teenagers are well known. Also, the teenager feels very committed to his or her viewpoints. He or she tries very hard to convince others of his or her viewpoints and embraces strongly those causes that support his or her opinions. This idealism can cause the adolescent to reject his or her family, culture, church, and community beliefs, which can cause conflict with his or her family, culture, church, and community. See Table 29.2 for additional information.

Sexuality

Adolescence is a critical time in the development of sexuality. Sexuality includes the thoughts, feelings, and behaviors related to the adolescent's sexual identity. Adolescence is a time when teens may begin experimentation related to their sexual identity, orientation, and behavior. This experimentation is part of the process of sorting through their sexuality and does not define their sexual identity or orientation. Sexual minoritized adolescents, which encompasses lesbian, gay, bisexual, transgender, and identities that defy discrete labels, face the same health concerns as nonsexual minoritized adolescents but additional challenges include, questioning of their sexual identity, the complexity of coming out, and possible societal discrimination (Forcier & Olson-Kennedy, 2020). The majority of sexual minoritized adolescents are healthy and well but some are at an increased risk for adverse outcomes such as depression, suicide, substance use, homelessness, sexually transmitted infections, and victimization (Forcier & Olson-Kennedy, 2020). See EBP 29.1. Personal, societal, and family acceptance are crucial and lead to decreased adverse outcomes. oncept Mastery Alert Assessment and the Adolescent When providing care to an adolescent who shares information about sexual preferences, the nurse must remember that assessment is the first step in the nursing process.

KEY CONCEPTS

Adolescence is a period of rapid and variable growth in the areas of physical, psychosocial, cognitive, and moral development. The adolescent is developing his or her own identity, becoming an abstract thinker, and developing his or her own set of morals and values. Inability to successfully develop an individual identity leads to poor preparation for the challenges of adulthood. Relationships with parents fluctuate widely during adolescence. The teenager eventually becomes emancipated from his or her parents. Peers become most important—guiding mainly the early and middle adolescent in his or her decisions, while the late adolescent can usually formulate his or her own decisions. Adolescence is a critical time in the development of sexuality. Sexuality includes the thoughts, feelings, and behaviors surrounding the adolescent's sexual identity. The egocentric and invincible thought processes of the adolescent can lead to injuries. Health care providers must emphasis safety regarding cars, bikes, water, firearms, and fire. Motor vehicle accidents are the number one cause of death in adolescents (Curtin et al., 2018). Nutritional habits of the adolescent lead to deficiency in vitamins and minerals needed for the rapid growth during this period. Obesity in adolescents is a growing health concern. Health care providers are facing increased numbers of adolescents with hypertension, type 2 diabetes, and hyperlipidemia. Substance abuse and experimentation is common during adolescence; it is associated with other risk-taking behaviors such as injuries and sexual activity. Health care providers must work collaboratively with the adolescent in the development of interventions to promote health.

General Hygiene Tips

Adolescents find that frequent baths and deodorant use are important due to apocrine sweat gland secretory activity. Also, to decrease oily skin due to sex steroids and hormones, teach the adolescent to wash his or her face two to three times per day with plain unscented soap. Vigorous scrubbing should be discouraged because it could irritate the skin and lead to follicular rupture. The hair should be shampooed daily or every other day to remove excess oil from the hair and scalp. Many over-the-counter medications are available for beginning acne or acne with a few lesions. These preparations may cause drying or redness. Discourage adolescents from squeezing acne lesions to prevent further irritation and permanent scarring. If the adolescent has severe acne, encourage him or her to ask a parent to make an appointment with a dermatologist.

Illicit Drugs

Adolescents may also experiment with or abuse illicit drugs. Substance abuse remains a widespread problem among American adolescents. Marijuana remains the most widely used illicit drug (Johnston et al., 2018). A national survey on drug use showed the annual prevalence rate for illicit drugs, other than marijuana, are remaining stable at the lowest levels in over 20 years, with 6.1% of 8th graders, 9.6% of 10th graders, and 12.4% of 12th graders reporting substance use (NIDA, 2018). Several illicit drugs are at historic low levels of use, including alcohol, cigarettes, heroin, prescription opioids, Ecstasy/Molly, methamphetamine, amphetamines, sedatives, and ketamine (NIDA, 2018). Factors that primarily affect drug use include the psychoactive potential and benefits reported, how risky the drug is to use, how acceptable it is to peer groups, and the accessibility and availability of the drug. The more risky or less accepted a drug is by peers, the less likely the adolescent will use it.

Promoting Appropriate Discipline

Adolescents naturally misbehave or do not follow the rules of the house, and parents must determine how to respond. Adolescents need to know the rules and expectations. After rules are established, parents must explain to the adolescent the consequences of breaking the rules. Offer guidance to parents related to disciplining teens. The parent and the teen should collaborate on what the consequences will be if the rules are broken. Parents must acknowledge and offer reinforcement and support when the teen follows the rules. Consistency and predictability are the cornerstones of discipline, and praise is the most powerful reinforcer of learning.

EMOTIONAL AND SOCIAL DEVELOPMENT

Adolescents undergo a great deal of change in the areas of emotional and social development as they grow and mature into adults. Areas that are affected include the adolescent's relationship with parents; self-concept and body image; importance of peers; and sexuality and dating.

Nursing Interventions to Decrease Substance Use Among Teens

Adolescents' brains are still developing, leaving them particularly vulnerable to the damaging effects of drugs. Substance use in adolescence is related to poorer health outcomes; therefore, it is important that nurses be aware of interventions to decrease these behaviors. Teen drug use is related to social factors, such as times of life transitions, changing schools, moving, or divorce as well as peer factors such a peer pressure (Blake & Allen, 2019b). Therefore, nurses need to target assessments and programs at these critical times. Based on reviews of programs and interventions, it has been found that certain methods work. Programs that reach children and adolescents through a variety of sources such as school, family, community, and media campaigns are more successful. Programs that are culturally competent and address all forms of drug use (alcohol, tobacco, and illicit drugs) tend to work well. Programs that focus on increasing awareness of the risks and health consequences of substance use are important. Certain factors have been found to help teens remain drug free. These include strong connections to parents, family, school, and religion; presence of parents in the home at key times of the day; and limited access to substances such as alcohol, tobacco, and marijuana (Blake & Allen, 2019b; NIH, 2017). Programs that focus on decreasing risk factors and increasing protective factors such as enhancing self-esteem, social and parental support, and stress-specific coping skills are beneficial (Blake & Allen, 2019b). Topics that should be discussed include: Short- and long-term effects of alcohol, tobacco, and drugs on health. Risk factors and implications for unintentional injuries and sexual activity. Short- and long-term effects of alcohol, tobacco, and drugs on relationships and school performance and progression. The how and why of chemical dependency. Impact of substance abuse on society. Importance of maintaining a healthy lifestyle. Importance of resisting peer pressure to use drugs and alcohol. Importance of having confidence in one's own judgment.

Substance Use

Agents commonly abused by children and adolescents include alcohol, nicotine, prescribed medications such as Ritalin and OxyContin, hallucinogens, sedatives, analgesics, anxiolytics, steroids, inhalants (inhaling fumes of common household products), stimulants, opiates, and various club drugs such as ecstasy, gamma-hydroxybutyrate (GHB), and lysergic acid diethylamide (LSD). The substance abused is related to its availability and cost. Overall the use of illicit drugs with the exception of marijuana are at their lowest level in 20 years (NIDA, 2018). Two common substances that are more accessible and have the highest incidence of use are alcohol and nicotine. A recent national survey of 8th, 10th, and 12th graders found, a significant increase in e-cigarette or vaping use making it the second most common substance used by adolescents (NIDA, 2018). Drug use often progresses from beer or wine to nicotine or hard liquor and then to marijuana, followed by illicit drugs. Some of the long-term effects and consequences of drug and alcohol use include possibility of overdose and death, unintentional injuries, irrational behaviors, inability to think clearly, unsafe driving and legal consequences, problems with relationships with family and friends, sexual activity and STIs, and health problems such as liver problems (hepatitis) and cardiac problems (sudden death with cocaine). Refer to Table 29.3 for commonly abused drugs and behaviors exhibited (see Healthy People 2030). 17.6% of 8th graders, 32.3% of 10th graders, and 37.3% of 12th graders reported vaping in the past 12 months, which is up by a one third over last year's report (NIDA, 2018). African Americans have lower rates of most licit and illicit drugs, alcohol, and cigarette use than Caucasian and Hispanic teens

Alcohol

Although alcohol remains the most widely used and abused drug for youth in the United States its use among adolescents has continued a downward trend (NIH, 2017; NIDA, 2018). A national survey on drug use found that 23.5% of 8th graders, 43% of 10th graders, and 58.5% of 12th graders reported every trying alcohol while 8.2% of 8th graders, 18.6% of 10th graders, and 30.2% of 12th graders reported drinking alcohol in the past 30 days (NIDA, 2018). The incidence of alcohol use increases throughout adolescence and adolescents who begin drinking before the age of 15 are four times more likely to develop alcohol dependence later in life (Johnston et al., 2018; NIH, 2017). Alcohol use in adolescence can lead to prevailing alcohol use in adulthood, contributes to physical health problems, school problems, legal problems, leads to increased injuries, impairs judgment, increased risk of sexual and physical assault, and interferes with brain development (NIH, 2017). It may also precede other drug abuse. Research shows teens who have parents who are actively involved in their lives are less likely to drink alcohol

CULTURAL INFLUENCES ON GROWTH AND DEVELOPMENT

Although the adolescent's culture continues to influence him or her, the desire to be in harmony with peers becomes paramount. That desire can cause conflict with the adolescent's family and culture. Today's adolescents live in a rapidly changing, increasingly culturally diverse world. They are exposed to many different cultures and ethnic groups. In 2016, over 49% of children and adolescents in the United States were minorities (Federal Interagency Forum on Child and Family Statistics, 2017). Attitudes regarding adolescence vary among different cultures. Certain cultures may have more permissive attitudes toward issues facing adolescents, while others are more conservative (e.g., toward sexuality). Experiencing a rite-of-passage ceremony to signal the adolescent's movement to adult status varies among cultures. The American culture does not universally have a rite of passage for teenagers. Some religious and social groups do have ceremonies that signal a movement toward the maturity of adulthood (e.g., the Jewish bar or bat mitzvah, the Catholic confirmation, and social debuts). In many parts of the world, separate "youth cultures" have developed in an attempt to blend traditional and modern worlds for the adolescent. It is important for the nurse to recognize the ethnic background of each adolescent. Research has shown that certain ethnic groups are at higher risk for certain diseases. For example, adolescent African Americans are at higher risk for developing hypertension (American Heart Association, 2016). But the major barrier to the adolescent's health and successful achievement of the tasks of adolescence is socioeconomic status. Adolescents at a lower socioeconomic level are at higher risk for developing physical and psychological health care problems and risk-taking behaviors; this may be in part due to their inability to access health care and to obtain needed services (American Psychological Association, 2019). In caring for adolescents, recognize the influence of their culture, ethnicity, and socioeconomic level upon them.

Dating

An interest in romantic partnerships occurs during adolescence (Fig. 29.5). Some of the reasons cited for this developing interest are physical development and body changes, peer-group pressure, and curiosity. During the past couple of decades, the percentage of 8th through 12th graders that have dated has declined (Child Trends, 2018a). It has been found that 45% of 12th graders, 55% of 10th graders, and 69% of 8th graders have never dated (Child Trends, 2018a). The percentage of teens that date frequently increases with age with 4% of 8th graders, 7% of 10th graders, and 15% of 12th graders reporting going on a date one or more times a week (Child Trends, 2018a). Teen dating can range from group dating to single dating to serious relationships. Most early adolescents spend more time in activities with mixed-sex groups, such as dances and parties, than they do dating as a couple. Popular dating activities today include going out to dinner or the movies, "hanging out" at the mall, or visiting each other's home. During early adolescence, teens tend to date for fun and recreation. Also, they may see dating as a way to upgrade social standing by being seen with a popular or attractive boy or girl, for instance. Middle and late adolescents have group and single dates. Romantic relationships are central to the social life of this age group. By age 18, 70% of adolescents report being in at least one romantic relationship in the past 18 months (Kansky & Allen, 2018). Dating or spending time with a potential romantic partner is viewed as a major developmental marker for teens and is one of the most challenging adjustments. Both positive and negative developmental outcomes can result depending on the quality of the relationship that forms. Some teens who date may report slightly higher levels of self-esteem, self-worth and social support (Kansky & Allen, 2018). However, other types of dating relationships may result in a teen having lower academic success and motivation, having higher depression rates, increased anxiety, and increased risk of substance use (Kansky & Allen, 2018). Trends in dating are changing, but dating remains a developmental milestone for the adolescent. Healthy romantic relationships in adolescence can assist the teen in developing a strong sense of self-identity and developing interpersonal skills, such as empathy, and are related to increased quality of adult relationships (Kansky & Allen, 2018). The emotional ups and downs that accompany dating can help develop emotional resilience and coping skills. Romantic relationships at this stage are a great source of emotional support. Risks of being involved in unhealthy romantic relationships include dating violence and risky sexual activity such as sexually transmitted infections (STIs) and pregnancy. Adolescents do not automatically know what makes for a healthy relationship. They need to be educated on the right and wrong behaviors of dating and what behaviors make up a healthy relationship, such as open communication, honesty, and trust. They need to know the signs of an unhealthy relationship and how to seek help if needed.

developmental theories 17-20

Late (17-20 years) Able to understand implications of behavior and decisions Roles within peer groups established Feels secure with body image Has matured sexual identity Has idealistic career goals Importance of individual friendships emerges Process of emancipation from family almost complete

Piaget 17-20 years old

Late (17-20 years) Abstract thinking is established Develops critical thinking skills—tests different solutions to problems Less risky behaviors Develops realistic goals and career plans

developmental theories 14-16

Middle (14-16 years) Continues to adjust to changed body image Tries out different roles within peer groups Need for acceptance by peer group at the highest level Interested in attracting opposite gender Time of greatest conflict with parents/authority figures

Piaget 14-17

Middle (14-17 years) Increased ability to think abstractly or in more idealistic terms Able to solve verbal and mental problems using scientific methods Thinks he or she is invincible—risky behaviors increase Likes making independent decisions Becomes involved/concerned with society, politics

Personal safety

• Never go with a stranger. • Do not enter a car when the driver has been drinking. • Notify an adult where you are when out after dark. • Keep cell phone fully charged. • Never give out personal information over the internet. • Say "no" to drugs, alcohol, or smoking, or to being touched when you do not want to be touched.

PHYSICAL GROWTH

Diet, exercise, and hereditary factors influence the height, weight, and body build of the adolescent. Over the past three decades, adolescents have become taller and heavier than their ancestors and the beginning of puberty is earlier. During the early adolescent period, there is an increase in the percentage of body fat and the head, neck, and hands reach adult proportions. The rapid growth during adolescence is secondary only to that of the infant years and is a direct result of the hormonal changes of puberty. Both girls and boys experience changes in appearance and size. Height in girls increases rapidly before menarche and usually ceases 2 to 2½ years after menarche. Boys' growth spurt occurs later than girls' and usually begins between the ages of 10½ and 16 years and ends sometime between the ages of 13½ and 17½ years. Muscle mass increases in boys and fat deposits increase in girls (Fig. 29.1). During early adolescence growth is rapid, but it decreases in middle and late adolescence. Height for adolescent boys who are between the 50th and 95th percentile ranges from 132 cm (52½ in) to 176.8 cm (69½ in). Weight of boys in these percentiles ranges from 35.3 kg (77¼ lb) to 95.76 kg (211 lb). On average, boys will gain 10 to 30 cm (4 to 12 in) in height and 7 to 30 kg (15 to 65 lb) in weight. Height for girls who are between the 50th and 95th percentile ranges from 144.8 cm (57 in) to 173.6 cm (68½ in), with weight ranging from 27.24 kg (60 lb) to 82.47 kg (181 lb). On average, girls will gain 5 to 20 cm (2 to 8 in) in height and 7 to 25 kg (15 to 55 lb) in weight during adolescence. See Appendix A for growth charts for this age group. Refer to Chapter 32, Box 32.1, for instructions for calculating body mass index (BMI).

Integumentary System

During adolescence the skin becomes thick and tough. Under the influence of androgens, the sebaceous glands become more active, particularly on the face, back, and genitals. Due to the increased levels of testosterone during Tanner stages 4 and 5 in both boys and girls, both sexes may have increased sebum production, which may lead to the development of acne and oily hair. The exocrine and apocrine sweat glands function at adult levels during adolescence. The exocrine glands are all over the body and they produce sweat that helps to eliminate body heat through evaporation. The apocrine glands are found in the axillae, genital, and anal areas and around the breasts. The apocrine sweat glands produce sweat in response to hair follicles. This sweat is produced continuously and is stored and released in response to emotional stimuli.

Neurologic System

During adolescence there is continued brain growth, although the size of the brain does not increase significantly. Neurons do not increase in number, but growth of the myelin sheath enables faster neural processing.

MOTOR SKILL DEVELOPMENT

During adolescence, the teenager refines and continues to develop his or her gross and fine motor skills. Because of this period of rapid growth spurts, teenagers may experience times of decreased coordination and have a diminished ability to perform previously learned skills, which can be worrisome for the teenager.

Promoting a Healthy Sexual Identity

Encourage parents and teens to have discussions about sexuality. In addition, nurses should ensure that adolescents have the knowledge, skills, and opportunities that enable them to make responsible decisions regarding sexual behaviors and sexual orientation. Education for the adolescent should include a discussion about media influences and the use of sexuality to promote products. This discussion should make the adolescent aware of the motives of the media and the need to be an individual and not be influenced by television, magazines, and other forms of advertisement. Encourage parents to be aware of who their adolescents are dating and where they go on their dates. Refer to Teaching Guidelines 29.2 for information on counseling related to adolescent sexuality.

Physiologic Changes of Adolescence of early adolescence 14-16years

Middle adolescence (14-16 years) Pubic hair becomes coarse in texture and continues to curl; amount of hair increases Areola and papilla separate from the contour of the breast to form a secondary mound Pubic hair becomes coarser in texture and takes on adult distribution Testes and scrotum continue to grow; scrotal skin darkens; penis grows in width, and glans penis develops May experience breast enlargement Voice changes; more masculine due to rapid enlargement of the larynx and pharynx as well as lung changes

Developmental Theories 10-13 years old

Erikson (psychosocial) Identity versus role confusion or diffusion Early (10-13 years) Focuses on bodily changes Experiences frequent mood changes Importance placed on conformity to peer norms and peer acceptance Strives to master skills within peer groups Defining boundaries with parents and authority figures Early stage of emancipation—struggles to separate from parents while still desiring dependence upon them Identifies with same-sex peers Takes more responsibility for own behaviors Middle (14-16 years) Continues to adjust to changed body image Tries out different roles within peer groups Need for acceptance by peer group at the highest level Interested in attracting opposite gender Time of greatest conflict with parents/authority figures

Relationship with Parents

Families and parents of adolescents experience changes and conflict that require adjustments and the understanding of adolescent development. The adolescent is striving for self-identity and increased independence. He or she spends more time with peers and less time with family and attending family functions. Parents sense that they have less influence on the adolescent as the teen questions family values and becomes more mobile. This may lead to a family crisis, and the parents may respond by setting stricter limits or asking questions about the teen's activities and friends. Other parents may drop all rules and assume that the adolescent can manage himself or herself. Both of these responses increase tension in the family. With the adolescent attempting to establish some level of independence—and the family learning to let go while focusing on aging parents, their marriage, and other children—a state of disequilibrium occurs. The family may experience more stress than at any other time. Some families have better outcomes with their adolescents than others. Families who listen to and continue to demonstrate affection for and acceptance of their adolescents have a more positive outcome. This does not mean that the family accepts all of the teen's ideas or actions, but they are willing to listen and attempt to negotiate some limits. For tips to improve communication with teenagers, see Box 29.1. Siblings experience changes in the relationship with the adolescent brother or sister; the older sibling may attempt to parent and the younger sibling may regress in an attempt to avoid the family conflict. Understanding the status of the adolescent-family relationship is essential for the nurse.

Firearms

Firearm Safety The risk of dying from a firearm injury among 15- to 19-year-olds has been rising. Eighty-three percent of homicides and 45% of suicides in children and adolescents were caused by a firearm (Kegler et al., 2018). Provide education about gun safety. Guns in the home must be kept and locked in a safe location, with ammunition kept separately. Parents must teach adolescents about the dangers of playing with firearms. See Teaching Guidelines 29.1 for additional information on gun safety. • If guns are in household, should take firearm safety class, secure guns in safe place, use gun safety locks, and store bullets in separate place. • Never point a gun at a person.

Factors Influencing the Adolescent's Diet

• Peer pressure • Busy schedules • Concern about weight control • Convenience of fast food

THE NURSE'S ROLE IN ADOLESCENT GROWTH AND DEVELOPMENT

Growth and development in the adolescent is rapid. Nurses must be aware of the usual growth and development patterns for this age group so that they can assess the adolescent appropriately and provide guidance to the adolescent and his or her family. During adolescence, the teenager faces many challenges. His or her fluctuating relationships with parents and other adult figures may limit the teen from seeking assistance in dealing with the common issues of adolescence. In dealing with adolescents, be aware that they behave unpredictably, are inconsistent with their need for independence, have sensitive feelings, may interpret situations differently from what they are, think friends are extremely important, and have a strong desire to belong. During health care visits the adolescent or parent may have concerns that they are hesitant or uncomfortable talking about in front of each other. Try to provide an opportunity for them to have private time with a health care provider to discuss issues. The adolescent may greatly appreciate the opportunity for time to discuss concerns with a nonjudgmental informed adult. If the adolescent is hospitalized, growth and development may be altered. The adolescent is concerned about how the illness or injury will affect his or her body and body image. He or she fears pain and loss of privacy. The adolescent may experience anxiety about being separated from friends and loss of control. When caring for the hospitalized adolescent, the nurse must use knowledge of normal growth and development to recognize potential delays, promote continued appropriate growth and development, and interact successfully with the teen. Provide opportunities for them to maintain independence, participate in decisions, and encourage socialization with friends through phone, e-mail, and visits when possible.

Homicide

Homicide is the third leading cause of death in children between 10 and 24 years old, with the majority of victims being male and killed by firearms (CDC, 2016b). It is the leading cause of death in African Americans 10 to 24 years old (CDC, 2016b). Refer to Box 29.5 for factors that contribute to violence among adolescents. In a nationwide survey conducted in 2015, 16.2% of youth reported carrying a weapon (gun, club, or knife) on one or more days within the past 30 days (CDC, 2016b) (see Healthy People 2030).

MORAL AND SPIRITUAL DEVELOPMENT

It is during the adolescent years that teenagers develop their own set of values and morals. According to Kohlberg, adolescents are experiencing the postconventional stage of moral development (Kohlberg, 1984). It is only because adolescents are developing their formal operational way of thinking that they can experience the postconventional stage of moral development. At the beginning of this stage, teenagers begin to question the status quo. The majority of their choices are based on emotions while they are questioning societal standards. As they progress to developing their own set of morals, adolescents realize that moral decisions are based on rights, values, and principles that are agreeable to a given society. They also realize that those rights, values, and principles can be in conflict with the laws of the given society, but they are able to reconcile the differences. Because adolescents undergo the process of developing their own set of morals at different rates, they might find that their friends view a situation differently. This difference can lead to conflicts and the forming of different friendships. See Table 29.2 for additional information. Adolescents also may begin to question their formal religious practices or in some cases cling to them (Ford, 2007). As they progress through adolescence, teenagers become more interested in the spiritualism of their religion than in the actual practices of their religion. Adolescents are searching for ideals and may exhibit intense emotions along with introspection (Ford, 2007). Increased spirituality and religious activities are related to increased healthy behaviors and decreased high-risk behaviors

Caring for Body Piercings and Tattoos

It is not uncommon for a teen to experiment with body piercing on areas such as the tongue, lip, eyebrow, navel, and nipple (Fig. 29.10). Other sites such as the genitals, chin cleft, knuckles, and even the uvula have been used. Generally, body piercing is harmless, but nurses should caution teens about performing these procedures under nonsterile conditions and should educate them about complications. Qualified personnel using sterile needles should perform the procedure. Teach the adolescent to cleanse the pierced area twice a day and more often at some sites. The complications of body piercing vary by site. Infections from body piercing usually result from unclean tools of the trade. Some of the infections that may occur as a result of unclean tools include hepatitis, tetanus, tuberculosis, and HIV. Also, keloid formation and allergies to metal may occur. The navel is an area prone to infection because it is a moist area that endures friction from clothing. After a navel infection occurs, it may take up to a year to heal. Pierced ear cartilage also heals slowly and is prone to infection. Tongue piercings heal very quickly, usually within 4 weeks, probably due to the antiseptic effects of saliva. Other concerns with tongue piercing include tooth damage from biting on the jewelry or partial paralysis if the jewelry pierces a nerve. Tattoos are continuing to grow in popularity among adolescents and are more commonplace among both adolescents and adults (Breuner et al., 2017). Tattoos serve to define one's identity and are a form of self-expression (Fig. 29.10). Because of the invasiveness of the tattooing procedure, it should be considered a health-risk situation. Like piercings, tattoos are open wounds predisposing to infection. Having multiple piercings and tattoos can lead to certain health risks. Nurses should educate adolescents about the risk of tattooing including blood-borne infections, such as hepatitis B and C, HIV, skin infections, scarring, bleeding, and allergic reactions to dyes used in the tattoo process (Breuner et al., 2017). They need to encourage the teen to go to a licensed facility with licensed tattoo artists and to double check that all equipment used is disposable and/or sterilized (Breuner et al., 2017). Teach teens to cleanse tattoos with an antibacterial soap and water several times a day and to keep the area moist with an ointment to prevent scab formation. Refer to Box 29.4 for additional information about tattoos.

Gross Motor Skills

It is usually during early adolescence that teenagers begin to develop endurance. Their concentration has increased so they can follow complicated instructions. Coordination can be a problem because of the uneven growth spurts. During middle adolescence, speed and accuracy increase while coordination also improves. Teenagers become more competitive with each other (Fig. 29.2). During late adolescence, the teenager usually narrows his or her areas of interest and concentrates on the needed relevant skills. Adolescents become involved in competitive sports, which draw upon their gross motor skills. Adolescents become involved in competitive sports, which draw upon their gross motor skills.

PROMOTING HEALTHY GROWTH AND DEVELOPMENT

It takes multiple groups who address multiple issues to promote healthy growth and development in the adolescent. Some of these groups include sports teams in the school or the community, peers, teachers, band and choir members, and so forth. Also, the family's support and love will influence growth and development.

Kohlberg

Kohlberg Postconventional level III Morals based on peer, family, church, and societal morals Early (10-13 years) Asks broad, usually unanswerable questions about life Middle (14-17 years) Developing own set of morals—evaluates individual morals in relation to peer, family, and societal morals Late (17-20 years) Internalizes own morals and values Continues to compare own morals and values to those of society Evaluates morals of others

COMMUNICATION AND LANGUAGE DEVELOPMENT

Language skills continue to develop and be refined during adolescence. Adolescents have improved communication skills, using correct grammar and parts of speech. Vocabulary and communication skills continue to develop during middle adolescence. However, the usage of colloquial speech (slang) increases, causing communication with people other than peers to be difficult at times. By late adolescence, language skills are comparable to those of adults.

Physiologic Changes of Adolescence of early adolescence 17-20 years

Late adolescence (17-20 years) Mature pubic hair distribution and coarseness Mature pubic hair distribution and coarseness Breast enlargement disappears Adult size and shape of testes, scrotum, and penis; scrotal skin darkening. The first sign of pubertal changes in boys is testicular enlargement in response to testosterone secretion, usually occurring in Tanner stage 2. As testosterone levels increase, the penis and scrotum enlarge, hair distribution increases, and scrotal skin texture changes. During late puberty, boys will typically experience their first ejaculation, which may occur while they are sleeping (nocturnal emissions). Nurses should provide anticipatory guidance to adolescent males regarding involuntary nocturnal emissions (wet dreams) to assure them that this is a normal occurrence. Tanner stages 3 to 5 usually occur during adolescence. Refer to Figures 32.28, 32.36, and 32.34 for an illustration of the increase in breast tissue and pubic hair distribution in girls, and scrotal and penile changes as well as hair distribution changes in boys. The nurse should provide guidance to adolescents about the normalcy of the sexual feelings and evolving body changes that occur during puberty.

Promoting Growth and Development Through Sports and Physical Fitness

Many adolescents are involved in team sports that provide avenues for exercise. High levels of physical activity may reduce cardiovascular disease risk factors and provide disease prevention against cancer, obesity, osteoporosis, diabetes, and depression (Centers for Disease Control and Prevention [CDC], 2018a). Adolescents probably spend more time and energy participating in sports than any other age group. Participation in sports contributes to the adolescent's development, educational process, and better health. Sports and games provide an opportunity to interact with peers while enjoying socially accepted stimulation and conflict. Competition in sports activities helps the teenager in processing self-appraisal and in developing self-respect and concern for others. Every sport has some potential for injury. Rapidly growing bones, muscles, joints, and tendons are more vulnerable to unusual strains and fractures. Incidence of concussions (which is considered a mild traumatic brain injury) is a growing concern in all teen athletes. To help prevent injury, parents and coaches need to be aware of early warning signs of fatigue, dehydration, and injury. See Chapter 44 for a discussion of sports injuries. In relation to youth sports, the role of the nurse is to educate to prevent injuries (Fig. 29.6). This education should include discouraging participation when the teen is tired or has an existing injury, encourage the use of proper well-fitting protective gear, and ensure the adolescent learns how to play a sport before participating in it. Stretching before exercise is an important part of exercise. In addition, adolescence is a good time to develop an exercise program. The U.S. Department of Health and Human Services (HHS) recommends that adolescents participate in 60 minutes of moderate to vigorous physical activity each day (CDC, 2018a). Nurses should encourage all adolescents to be physically active daily.

Promoting Healthy Teeth and Gums

Most permanent teeth have erupted with the possible exception of the third molars (wisdom teeth). These molars may become impacted and require surgical removal. The rate of cavities decreases but the need for routine dental visits every 6 months and brushing two to three times per day is very important. Some of the conditions that occur during adolescence include malocclusion, gingivitis, and tooth avulsion. Malocclusion (a poor bite) occurs from facial and mandibular bone growth that results in misalignment of the top teeth with the bottom teeth. It is the most common reason for referral to an orthodontist. The treatment includes braces and other dental devices. Teach the adolescent to brush the teeth more frequently if he or she has braces or other dental devices. Gingivitis is inflammation of the gums and breakdown of gingival epithelium due to diet and hormonal changes. The use of dental devices/braces makes cleaning more difficult and contributes to gingivitis. Tooth avulsion (knocked-out teeth) may occur during sports and other activities such as falls. The avulsed tooth should be reimplanted as soon as possible. The nurse may see the teen first so it is important that nurses know the proper procedure, which is to reinsert the tooth into its socket if possible or to store it in cool milk or normal saline for transport to the dentist.

Safety Issue Motor vehicle

Motor vehicle • Wear seat belt at all times. • Do not drive or drive with someone who is impaired. • Take driver-education course. • Establish driving rules between parent and adolescent prior to getting license. • Have all passengers wear seat belts. • Do not use cell phone or text while driving, drink and drive, or drive when tired. • Maintain car in good condition. • Drive with adult supervision for a period of time after receiving license. • Encourage limit on teenage passengers.

Gangs

Much of youth violence is a result of the behavior of adolescent gangs. Gangs tend to consist of adolescents and young adults but recent trends indicated that younger youth are being recruited (American Academy of Child and Adolescent Psychiatry, 2016). The risk factors for gang involvement are similar to those for aggressive or delinquent behavior. See Box 29.7 for risk factors for adolescent gang involvement. Gang membership occurs in cities and in suburban areas, but may differ in composition. All socioeconomic groups are represented in gang membership. Gang membership may aid in the formation of identity by providing status and a sense of belonging. However, adolescents who are gang members are more likely to commit serious and violent crimes. Identifying those at risk and providing early intervention is important. Research has shown that increasing parental monitoring, increasing involvement in extracurricular activities, improving coping skills to deal with conflict, and educating about the negative consequences of gang membership may be beneficial in preventing gang membership

Nursing Interventions to Decrease Youth Violence

Nurses working with adolescents should include violence prevention in anticipatory guidance. Violence is a learned behavior. It is often reinforced by the media, television, music, and personal example. Explain to parents, teachers, and peers the importance of being good role models. Parents should monitor video games, music, television, and other media to decrease exposure to violence. Parents need to know who their adolescent's friends are and monitor for negative behaviors and actions. Pediatric nurses play a key role in identifying at-risk youth and developing, planning, implementing, and evaluating interventions to prevent youth violence.

Promoting Nutrition

Nutritional needs are increased during adolescence due to accelerated growth and sexual maturation. Adolescents may appear to be hungry constantly and need regular meals and snacks with adequate nutrients to meet the body's needs. Multiple factors influence the adolescent's diet and eating habits (Box 29.2). According to CDC data, over the past 30 years, the obesity rate in adolescents has more than tripled (CDC, 2018d). Poor diet and physical inactivity have led to the mounting problem of obesity in this age group. Obesity in adolescence is associated with obesity in adulthood along with numerous adverse health conditions such as diabetes, heart disease, certain types of cancer, osteoarthritis, and overall poorer health (CDC, 2018d).

Importance of Peers

Peer groups play an essential role in the identity of the adolescent (Holland-Hall & Burstein, 2016). Adolescent peer relationships are very important in providing opportunities to learn about negotiating differences; for recreation, companionship, and someone to share problems with; for learning peer loyalty; and for creating stability during transitions or times of stress. Learning to work out differences with peers is a skill that is important throughout life. Peers serve as someone safe to discuss family issues with, as the teen emotionally moves away from the family while trying to find his or her identity. Due to changes that have taken place within family systems in society, peer groups play a significant role in the socialization of adolescents (Fig. 29.4). Peers serve as credible sources of information, role model social behaviors, and act as sources of social reinforcement. Friends provide an opportunity for fun and excitement. Peers impact teens' appearance, dress, social behavior, and language. Peers can also have positive influences on each other, such as promoting college attendance, or negative influences, such as involvement with alcohol, drugs, or gangs. Early and middle adolescence are periods when teens are prone to join gangs. Peer role modeling and peer acceptance may lead to the formation of a gang that provides a collective identity and gives a sense of belonging. Peer pressure, companionship, and protection are the most frequent reasons given for joining gangs, particularly those associated with criminal activity. Parents must know their teen's friends and continue to be aware of potential problems while allowing the teen the independence to become his or her own person. Nurses must remind parents of the importance of peers and the impact they have on the teen's decisions and life choices. The transition to greater peer involvement requires guidance and support. Adolescents who do not have parental or adult supervision and opportunities for conversation with adults may be more susceptible to peer influences and at higher risk for poor peer selections.

piaget 10-13 years old

Piaget (cognitive) Formal operations Early (10-13 years) Limited abstract thought process Egocentrical thinking Eager to apply limited abstract process to different situations and to peer groups

Promoting Personal Care

Promotion of personal care during adolescence is an important topic to cover with the adolescent and his or her parents. Topics to discuss include general hygiene tips, caring for body piercings and tattoos, preventing suntanning, and promoting a healthy sexual identity.

School

School plays an essential part in preparing adolescents for the future. Completing school prepares the adolescent for college or employment to make an adequate income. Schools in the United States may not meet the developmental needs of all adolescents. Minority students may not be at the appropriate grade level and the dropout rate may be higher than in nonminority students. Dropout rates have declined since the 1970s but still remain a concern (Child Trends, 2018b). Dropout rates are highest among Hispanic students (Child Trends, 2018b). Those who drop out of school may lack skills needed to function in today's society. They are more likely to be unemployed, they have higher rates of incarceration, and have lower income levels and occupational status than those with a high school diploma (America's Promise Alliance, 2018; Child Trends, 2018b) (see Healthy People 2030). There is evidence that the transition from elementary school to middle school at age 12 or 13, and then the transition to high school, both of which occur at the time of physical changes, may have a negative effect on teens. It is important to observe for transition problems into middle or high school, which may be exhibited by failing grades or behavior problems. Also, students who experience difficulties in school, resulting in negative evaluations and failing grades, may feel alienated from school. Students with poor grades and low academic achievement exhibit more emotional behavior such as violence and are more likely to engage in risky behaviors such as early sexual initiation (CDC, 2018b). Schools that support peer-group relationships, promote health and fitness, encourage parental involvement, and strengthen community relationships have better student outcomes. Parents, teachers, and health care providers should provide guidance and support.

Promoting Learning

School, teachers, family, and peers influence education and learning for the adolescent. Also, activities such as athletics and club membership enhance learning through interactions with peers, coaches, club leaders, and others.

Self-Concept and Body Image

Self-concept and self-esteem are often tied to body image. Adolescents who perceive their body as being different than peers or as less than ideal may view themselves negatively. Adolescent girls often are influenced by peers and the media and want to weigh less and have smaller hips, waist, or thighs. Boys tend to view themselves as being too thin or not muscular enough. Sexual characteristics are important to the adolescent's self-concept and body image. Boys are concerned about the size of their penis and facial hair while girls are concerned about breast size and the onset of menstruation. Larger breasts are considered more feminine and menstruation is considered the right of passage into adulthood. All of these body changes are important to the adolescent's self-concept.

Tobacco/Nicotine

Smoking remains the leading preventable cause of death in the United States (CDC, 2018i). Long-term consequences of youth smoking are reinforced by the fact that most young people who smoke regularly continue to smoke throughout adulthood. Each day in the United States, approximately 2,000 children younger than 18 years old try their first cigarette, with 300 becoming regular smokers; nine out of 10 adult smokers started smoking before age 18 (CDC, 2019). One of 13 Americans will die early from the effects of smoking (CDC, 2019). The overall rate of smoking has been declining, with the latest estimates at 2.1% of middle schoolers and 7.6% of high schoolers reporting they smoked cigarettes in the past 30 days (CDC, 2019). There are many forms of tobacco use, such as flavored cigars, smokeless tobacco, hookahs, pipes, and bidis. A recent trend of Electronic Nicotine Delivery Systems (ENDS), such as vaporizers, vapes, and e-cigarettes, may look like conventional cigarettes or resemble things such as pens and USB flash drives. ENDS use has increased by 78% among high schoolers and 48% among middle schoolers from 2017 to 2018 (Cullen et al., 2018; U.S. Food & Drug Administration, 2019). Teens need to be aware that e-cigarettes are not a safe alternative to smoking. Nicotine, which is highly addictive, and other harmful chemicals are absorbed through the lungs and into the body with the use of e-cigarettes. Nicotine is harmful to the developing brain and can have lasting effects. Teens who smoke are more likely than nonsmokers to use alcohol and illegal drugs (American Cancer Society, 2018). Smoking is associated with other risky behaviors, including fighting, carrying weapons, mental health problems such as depression, attempting suicide, and engaging in unprotected sex (American Cancer Society, 2018). Studies have found the use of e-cigarettes (or vaping) in youth is strongly linked to the use of regular cigarettes and other tobacco products in adulthood. The short-term health effects of smoking include damage to the respiratory system, addiction to nicotine, and the associated risk of other drug use. Smoking negatively impacts physical fitness and lung growth and increases the potential for addiction in adolescents. Smokeless tobacco may also cause many problems. It can lead to bleeding gums and sores in the mouth that never heal. Smokeless tobacco use leads to discoloration of the teeth and eventually may lead to cancer. In 2016, the FDA extended their regulation on all tobacco and nicotine products and has a comprehensive plan to help better protect our youth and decrease the number of teens using ENDS. Most states have enacted minimum legal age for sales of ENDS ranging from 18 to 21 years old.

Physiologic Changes of Adolescence of early adolescence 10-13years

Stage of AdolescenceChanges in FemalesChanges in Males Early adolescence (10-13 years) Pubic hair begins to curl and spread over mons pubis; genitalia pigmentation increases Breast bud and areola continue to enlarge; no separation of breasts First menstrual period (average 12 years, normal range 9-16 years) Pubic hair spreads laterally, begins to curl; pigmentation increases Growth and enlargement of testes in scrotum (scrotum reddish in color) and continued lengthening of penis Leggy look due to extremities growing faster than the trunk

Suicide

Suicide is the second leading cause of death in youths 10 to 24 years old (Heron, 2018). In a nationwide CDC study, 17% of adolescents surveyed reported that they had seriously considered suicide within the past 12 months, with 13% creating a plan and 7% attempting to take their own life (CDC, 2017b). Certain factors can put youth at risk for suicide, but having these risk factors does not mean suicide will occur. Refer to Box 29.6 for risk factors for suicide in adolescents (see Healthy People 2030). Most people are not comfortable discussing the topic of suicide and therefore do not communicate openly about it. It is important that health care providers address this important health problem and work to prevent suicide. The National Center for Injury Prevention and Control (NCIPC) is working to create awareness of suicide as a serious public health problem and is developing strategies to reduce injuries and deaths due to suicide.

Gastrointestinal System

The adolescent has a full set of permanent teeth with the exception of the last four molars (wisdom teeth), which may erupt between the ages of 17 and 20 years. The liver, spleen, kidneys, and digestive tract enlarge during the growth spurt in early adolescence, but do not change in function. These systems are mature in early school age.

Preventing Suntanning

Suntanning is popular among adolescents and is influenced by the media, which promotes a link between tan skin and beauty. There is no such thing as a good tan. Most exposure to ultraviolet rays occurs during childhood and adolescence, thereby putting people at risk for the development of skin cancer. However, it is difficult to convince adolescents that tanning is harmful to their skin and puts them at risk for skin cancer later in life (see Healthy People 2030). Educate teens about the benefits and effects of different sun protection products. Explain to them that sun damage and skin cancers can be prevented if sunscreens are used as directed on a regular basis. Encourage sunscreen or sunblock use for water sports, beach activities, and participation in outdoor sports. Also, make adolescents aware of allergies to some sunscreen products. See Teaching Guidelines 29.1 for additional information.

TAKE NOTE!

TAKE NOTE! African American girls on average reach menarche slightly earlier than Caucasian girls

Nutritional Needs

Teenagers have a need for increased calories, zinc, calcium, and iron for growth. However, the number of calories needed for adolescence depends on the teen's age and activity level as well as growth patterns. Teenage girls who are moderately active require about 2,000 calories per day (U.S. Department of Agriculture [USDA] and Health and Human Services [HHS], 2015). Teenage boys who are moderately active require between 2,200 and 2,800 calories per day (USDA and HHS, 2015). Of these calories, 45% to 65% should come from carbohydrates, 10% to 30% from protein, and 25% to 35% from fat (USDA and HHS, 2015). Adolescents require about 1,300 mg of calcium each day (USDA and HHS, 2015). Adolescents should be made aware of foods high in calcium, including fortified ready to eat cereals, cheese, yogurt, almond milk, white beans, and broccoli. Adolescent males require 11 mg of iron each day and females require 15 mg each day (USDA and HHS, 2015). Advise adolescents about foods high in iron (Box 29.3) (see Healthy People 2030). Protein requirements for adolescent girls, 14 to 18 years of age, are 46 g per day, and for adolescent boys, 14 to 18 years of age, 52 g per day (USDA and HHS, 2015). Some foods high in protein are meats, fish, poultry, beans, and dairy products.

Promoting Proper Media Use

Television, the internet, and other forms of media, such as smart phones, iPads, and social media sites, are a large force in teens lives today. Teenagers are immersed daily with a variety of different media. Seventy-five percent of teenagers own a smart phone, 76% of teens use at least one social media site and, about 25% of teens describing themselves as "constantly connected" (American Academy of Pediatrics, Council on Communications and Media, 2016). With greater technology and media access comes benefits such as enhancing communication skills, increasing social connections, and improving technical skills, but risks also exists, such as cyberbullying, sexting, exposure to inappropriate content, privacy issues, internet addiction, and sleep deprivation. Health care providers need to assess media use and advise parents on ways to decrease media risks. Parents should be advised to evaluate websites their adolescent wants to participate in and verify they are age-appropriate. Parents should talk to their adolescent children daily about online use and activity and help them to balance online and off line activity. They need to discuss the dangers of sharing too much information, posting images or photographs, and the fact that once something is online it is available for others to see and share. Parents need to be educated on the technology their children are using and encourage the development of a Family Media Use Plan (link found at ) that involves establishing consistent, reasonable rules about use of cell phones, texting, the internet and social media use, such as no media during meals and regular checking of privacy settings and online profiles for inappropriate content

Violence

The CDC's Injury Center defines youth violence as occurring when "young people between the ages of 10 and 24 years intentionally use physical force or power to threaten or harm others" (CDC, 2017a). More than 501,581 adolescents and young adults between 10 and 24 years of age were injured and treated in an emergency department as a result of injuries from physical violence in 2014 (CDC, 2016b). The issue of youth violence is a growing concern in America's communities. The health and well-being of adolescents and society are threatened by this violence. See Box 29.5 for factors contributing to adolescent violence. Health care providers need to provide education on the effects and ways to prevent youth violence along with supporting programs developed to curb youth violence.

Respiratory System

The adolescent years see an increase in diameter and length of the lungs. Respiratory rate decreases and reaches the adult rate of 15 to 20 breaths per minute. Respiratory volume and vital capacity increase. Volume and capacity are greater in boys than girls, which may be associated with increased chest and shoulder size in boys. The growth of the laryngeal cartilage, larynx, pharynx, vocal cords, and lungs produces the voice changes experienced in adolescence. These changes in the quality of the child's voice are often preceded with some voice instability where voice cracking is heard. Deepening of both male and female voices occurs but is more pronounced in boys.

Promoting Healthy Sleep and Rest

The average number of hours of sleep that teens require per night is nine to 10 (Paul & Wallace, 2019). The adolescent often experiences a change in sleep patterns that leads to feeling more awake at night and the desire to sleep later in the morning (Paul & Wallace, 2019). Also, in this independence-seeking phase of adolescence, the teen may stay up later to do homework, to complete projects or to participate in activities and may have difficulty awakening in the morning. Surveys show that 72.7% of high schoolers and 57.8% of middle schoolers do not get enough sleep on school nights (CDC, 2018f). Inadequate sleep leads to an increased risk of certain health and cognitive problems such as obesity, diabetes, poor mental health, problems with attention and negative effects on mood and motivation (CDC, 2018f). Early school start times contribute to this pattern of not getting enough sleep for adolescents. (See Healthy People 2030.) Teens will often try to make up for needed sleep by sleeping longer hours on the weekend. Rapid growth and increased activities may produce fatigue and the need for more rest. Parents may relate that the teen sleeps all the time and never has the time or energy to help with household chores. Explain to parents the need to discourage late hours on school nights because they may affect school performance. Encourage the teen to go to bed at the same time at night and awaken at the same time in the morning, even on weekends (CDC, 2018f). Provide advice to teens and parents about having realistic expectations; encourage them to agree on a level of normalcy and adequate rest for the teen so that he or she can still fulfil responsibilities in the home.

Motor Vehicle Safety

The largest numbers of adolescent injuries are due to motor vehicle crashes. When the adolescent passes his or her driving test, he or she is able to drive legally. However, driving is complex and requires judgments that the teen is often incapable of making. Also, the typical adolescent is opposed to authority and is interested in showing peers and others his or her independence. It is also normal for teens to take risks. These factors coupled with inexperience with driving may lead to underestimating hazardous and dangerous situations. Teenagers are the least likely age group to wear a seat belt (CDC, 2018c). Crashes involving adolescents are more likely to involve speeding, driving too fast for conditions, or following too close to the car in front of them (CDC, 2018c). More accidents occur when passengers, mostly other teenagers, are present in the car, during driving at night, or driving under the influence of alcohol or drugs It is essential to promote driver education, to teach about the importance of wearing seat belts, and to explain laws about teen driving and curfews (Fig. 29.8). See Teaching Guidelines 29.1 for additional information. TAKE NOTE! All states, though varied, have enacted a Graduated Driving License (GDL) program, which allows teens to gain driving experience and limits risky circumstances (such as nighttime driving and driving with passengers) by providing a license in three stages (learners' permit, provisional license, and full license) (CDC, 2018c). Studies have shown this program to be highly effective in reducing teen driver crashes (CDC, 2018c).

Promoting Healthy Eating Habits

The nurse must understand normal growth and development of the adolescent in order to provide guidance that fits the quest for independence and the need for teens to make their own choices. Assess the eating habits and diet preferences of the adolescent. The assessment should include an evaluation of foods from the different food groups that the adolescent eats each day. Also, assess the number of times that fast foods, snacks, and other junk food are eaten per week. This assessment will help the nurse to guide the adolescent in making better food choices at home and in fast food establishments. Many fast food restaurants offer baked chicken sandwiches and salads with fewer calories and less fat. Adolescents may be guided in alternating hamburgers and fries with more nutritious choices. Remember that planning should always include the adolescent. The USDA provides a personalized food plan called MyPlatePlan based on an individual's age, sex, weight, height, and amount of physical activity. Refer to Figure 29.9 for an example. At http://www.choosemyplate.gov/myplate/index.aspx, the adolescent can create his or her customized food plan. Nurses may use the information in MyPlatePlan to help teens plan a healthy diet for themselves. See Healthy People 2030.

Musculoskeletal System

The ossification of the skeletal system is incomplete until late adolescence in boys. Ossification is more advanced in girls and occurs at an earlier age. During the growth spurt, muscle mass and strength increase. At similar stages of development, muscle development is generally greater in boys. Estrogen, progesterone, and testosterone (sex steroids) and other androgens are released from the gonads and affect changes in the muscles and bones. Low estrogen levels tend to stimulate skeletal growth, while higher levels inhibit growth. During middle adolescence, shoulder, chest, and hip breadth increase.

Preventing the Development of Overweight and Obesity

The prevalence of obesity in children aged 12 to 19 years old is 20.6% (CDC, 2018e). Although obesity has increased in all segments of the United States population, there are differences specific to race, ethnicity, and socioeconomic status. The prevalence of obesity is highest in Hispanic and non-Hispanic African Americans (CDC, 2018e). This increase in obesity in adolescents has led to increases in hypertension, heart disease, and type 2 diabetes. Influential factors causing obesity include poor food choices, unhealthy eating practices, and lack of exercise. Around 20% of teens reported drinking sugary beverages at least once a day and 48.2%% reported not attending physical education classes (Miller et al., 2017). Overall, measures of how well Americans food choices align with dietary guidelines have remained low (USDA and HHS, 2015). Adolescents are busy and eat on the run, with many meals from fast food facilities. In addition, many schools have decreased or discontinued physical education, which has resulted in a more sedentary lifestyle, leading to weight gain. Interest in computer games, smart phones, and television watching at home has decreased physical activity and exercise and further contributed to weight gain and obesity (see Healthy People 2030). Nurses must make parents and adolescents aware of factors leading to obesity. Nurses should recommend: Proper nutrition and healthy food choices Good eating habits, including eating a healthy breakfast daily Decreased fast food intake Physical activity for at least 60 minutes daily Parents/adolescents exercising more at home Parents living a healthy lifestyle Decreasing nonactive computer and smartphone use and video, DVD, and television viewing

PHYSIOLOGIC CHANGES ASSOCIATED WITH PUBERTY

The secretion of estrogen in girls and testosterone in boys stimulates the development of breast tissue in girls, pubic hair in both sexes, and changes in male genitalia. These biologic changes that occur during adolescence are known as puberty. Puberty is the result of triggers among the environment, the central nervous system, the hypothalamus, the pituitary gland, the gonads, and the adrenal glands. Gonadotropin-releasing hormone (GnRH), produced by the hypothalamus, travels to the anterior pituitary gland to stimulate the production and secretion of follicle-stimulating hormone (FSH) and luteinizing hormone (LH). The increased levels of FSH and LH stimulate the gonadal response. LH stimulates ovulation in girls and acts on testicular Leydig cells in boys, prompting maturation of the testicles and testosterone production. FSH with LH stimulates sperm production. Estrogen, progesterone, and testosterone and other androgens are released from the gonads and affect biologic changes and changes in various organs, including alterations in muscles, bones, skin, and hair follicles. Adolescents experience physical development, hormonal changes, and sexual maturation during puberty that correlate to Freud's genital stage of psychosexual development. The genital stage begins with the production of sex hormones and maturation of the reproductive system. Girls reach physical maturity before boys and menarche, the first menstrual period, usually begins between the ages of 9 and 15 years (average 12.8 years). Breast budding (thelarche) occurs at approximately age 9 to 11 years and is followed by the growth of pubic hair.

Fine Motor Skills

The use of computers has greatly increased the fine motor skills of teenagers (Fig. 29.3). In the early adolescent years, the teenager increases his or her ability to manipulate objects. The adolescent's handwriting is neat and he or she increases his or her finger dexterity. The middle adolescent years see the teenager refining his or her dexterity skills. By late adolescence, the teenager has developed precise eye-hand coordination and finger dexterity.

Cardiovascular System

There is an increase in size and strength of the heart. Systolic blood pressure increases and heart rate decreases. Blood volume reaches higher levels in boys than girls, which may be due to boys' greater muscle mass.

What Adolescents Need to Know About Tattooing

• Infections occur as a result of nonsterile equipment used in the procedure. • Tattoos are open wounds predisposing to infection; sites require proper care, keep bandaged for the first 24 hours then wash with soap and warm water several times per day and apply antibiotic ointment or fragrance-free lotion three times a day for the first week. • Do not let the tattoo dry out. Do not expose it to direct sunlight until fully healed and then keep it protected from the sun with sunscreen. • Avoid pools, hot tubs, or long baths/showers until healed. • For most people a tattoo is permanent; new procedures for removal are painful and expensive.

Promoting Safety

Unintentional injuries are the leading causes of death in adolescents (Curtin et al., 2018). Motor vehicle accidents are the leading cause of injury death followed by poisoning, primarily due to drug overdose from opioids (Curtin et al., 2018). Males are more likely than females to die of any type of injury (Curtin et al., 2018). Influencing factors related to the prevalence of adolescent injuries include increased physical growth, insufficient psychomotor coordination for the task, abundance of energy, impulsivity, peer pressure, and inexperience. Impulsivity, inexperience, and peer pressure may place the teen in a vulnerable situation between knowing what is right and wanting to impress peers. On the other hand, teens have a feeling of invulnerability, which may contribute to negative outcomes. Alcohol and other drugs are contributing factors in automobile and firearm accidents among adolescents. Most of the serious or fatal injuries in adolescents are preventable (Fig. 29.7). Nurses must educate parents and adolescents on car, gun, and water safety to prevent unintentional injuries. See Teaching Guidelines 29.1 for information on promoting safety.

Dating Violence

Violent behavior that takes place in a context of dating or courtship is not a rare event and can have serious short-term and lifelong effects. In a recent survey, approximately 12% of high school females reported physical violence and 16% reported sexual violence from a dating partner while more than 7% of high school males reported physical violence and about 5% reported sexual violence from a dating partner in the past 12 months (CDC, 2018h). Dating violence in the teen years is a risk factor for continued violence exposure in adulthood. Risk factors for dating violence include inadequate parental supervision, condoning violence, substance use, prior victimization, having violent peers or friends involved in dating violence, depression or anxiety, learning difficulties or problems at school, history of aggression or bullying, and risky sexual practices (CDC, 2018h). Nurses need to assess for and provide interventions to those teens experiencing dating violence or those at risk for being a victim or perpetrator. Education on development of healthy relationships is important. See Healthy People 2030.

Water safety

Water Safety Drowning is a needless cause of death in adolescents. Many drownings are a result of risk-taking behaviors. With the independence of the adolescent, many times, adult supervision is not prevalent and the teen takes a risk that results in drowning. Provide water safety education and proper supervision to decrease the incidence of risk taking. Teach about swimming lessons for nonswimmers. See Teaching Guidelines 29.1 for additional information. • Learn how to swim; if swimming skill is limited, must wear life preserver at all times. • Never swim alone—should, if at all possible, swim only where there is a life guard. • Learn basic cardiopulmonary resuscitation (CPR). • Do not run or fool around at edge of pool. • Drains in pool should be covered with appropriate cover. • Wear life jacket when on a boat. • Make sure there is enough water to support diving. • Do not swim if drinking alcohol or using drugs.

Fire safety

• All homes should have working smoke detectors and fire extinguishers. Change the batteries at least twice a year. • Have a fire-escape plan and practice the plan routinely. • No smoking in bed. • Teach what to do in case of a fire—use fire extinguisher, call 911, how to put out clothing fire. • All flammable materials and liquids should be stored safely. • Fireplaces should have protective gratings. • Avoid touching any downed power lines.

Bike: In traffic

• All traffic signs and signals must be observed. • If adolescent is riding at night, the bike should have lights and reflectors and the rider should wear light-colored clothes. • Should ride on the side of the road traveling with traffic and keep close to the side of the road in single file. • Should watch and listen for cars and never hitch a ride on any vehicle. • Should not wear headphones while riding a bike.

Foods High in Iron

• Beef, chicken, seafood, liver • Tofu • Nuts and seeds • lentils and legumes • Eggs • Dark leafy vegetables such as spinach • Iron fortified cereals, whole-grain breads, and pastas

Factors Contributing to Adolescent Violence

• Crowded conditions/housing • Low socioeconomic status • Limited parental supervision/involvement • Single-parent families/both parents in workforce • History of violent victimization • Poor family functioning • Access to guns or cars • Drug or alcohol use • Low self-esteem • Racism • Peer or gang pressure • Aggression

Risk Factors for Gang Involvement

• Delinquency involvement, especially at a young age • History of or victim of physical violence or aggression • Alcohol and drug use; drug dealing • Associated with delinquent or aggressive peers • Poverty/low socioeconomic status • Family with criminal history, drug or alcohol problems, violence in the home • Poor parental supervision/involvement • Poor academic performance • Living in a community with a large number of troubled youth, access to firearms and drugs

Risk Factors for Suicide in Adolescents

• Depression or other mental illness • Mental health changes • Family history of suicide • History of previous suicide attempt • Poor school performance • Family disorganization • Substance abuse • LGBTQ • Giving away valued possessions • Being a loner/having no close friends • Changes in behavior • Incarceration

Safety Issue Bike: General

• Have a well-maintained and appropriate-sized bike for adolescent. • Adolescent should demonstrate his or her ability to ride bike safely before being allowed to ride on street. • Safe areas for bike riding should be established as well as routes to and from area of activities. • Should not ride bike barefoot, with someone else on bike, or with clothing that might get entangled in the bike. • Should wear sturdy, well-fitting shoes and Consumer Product Safety Commission (CPSC) or Snell-approved helmets. • Proper fitting helmet should: sit level, not tilted, and firmly and comfortably on the head; have strong wide Y-shaped straps and when you open your mouth should pull down a bit; not move with sudden pulling or twisting; never be worn over anything else (hat, scarf, etc.). • Bike should be inspected often to ensure it is in proper working order. • A basket should be used to carry heavy objects.

Adolescent Sexuality

• It should be your choice to engage in sexual relations. Do not be influenced by peers. When you say "no," be firm and clear about your position. • Pregnancy, sexually transmitted infections, and HIV infection can occur with any sexual encounter without the use of barrier methods of contraception. Use appropriate contraception if sexually active. Discuss abstinence as a contraceptive method. • Sexual activity in a mature relationship should be pleasurable to both parties. If your sexual partner is not interested in your pleasure, you need to reconsider the relationship.

Ways to Improve Communication with Teens

• Set aside appropriate amount of time to discuss subject matter without interruptions. • Talk face to face. Be aware of body language. • Ask questions to see why he or she feels that way. • Ask him or her to be patient as you tell your thoughts. • Choose words carefully so he or she understands you. • Tell him or her exactly what you mean. • Give praise and approval to your teenager often. • Speak to your teenage as an equal—don't talk down to him or her. • Be aware of your tone of voice and body language. • Don't pretend you know all the answers. • Admit that you do make mistakes. • Set rules and limits fairly.

All-terrain vehicles

• Should not be operated by an adolescent younger than 16 years of age. • Take a hands-on safety course before riding. • Helmet and protective coverings required. • No nighttime or double riding. • Not for use on public roads or if teen has been drinking or using drugs. • Do not stand up in the vehicle or ride in a person's lap.

Toxins

• Teach the hazards of accepting illegal drugs, alcohol, dangerous drugs. • Store potential dangerous material in safe place.

Machinery

• Use safety devices. • Receive training on how to use equipment. • Do not use when alone.

Sun

• Use sunscreen with both ultraviolet A (UVA) and ultraviolet B (UVB) protection. • Apply sunscreen prior to going out and reapply sunscreen often. • Limit sun exposure, especially between 10 a.m. and 2 p.m. • Wear protective clothing, hat and sunglasses while outside. • Do not suntan and avoid using tanning beds

Skateboards/skates

• Wear helmet, and protective padding on knees, elbows, and wrists. • Do not skate in traffic or on streets or highways. • Skating on homemade ramps could be dangerous—assess ramps for any hazards before skating.