11.4 Adolescence

11.4 Adolescence
Oxford Textbook of Public Health


Joanne Barton and William Parry-Jones*

Definition and demography of adolescence
Social value attached to adolescence and youth
Adolescent growth and development
Clinical significance of maturational stress
Adolescent well being and the family
Problems in school

Ethical and legal issues
Adolescent health concerns and knowledge
Risk-taking behaviours
Violence by and against young people
Substance use and abuse
Adolescent sexuality and sexual risk-taking
Sexually transmitted diseases
Sexual offences
Adolescent medical disorders
Response to chronic illness and hospital admission
Adolescent surgery
Adolescent mental disorder
Emotional problems and disorders
Suicide and deliberate self-harm
Eating disorders
Hyperactivity disorders
Anti-authority and antisocial behaviour
Assessment and treatment
Adolescent health care services

Primary care services

Specialist medical services for adolescents and adolescent medicine

Adolescent psychiatric services

Services for adolescents with disability

Adolescent health-promotion and prevention programmes
Teaching and training of health care professionals
Chapter References

Adolescence is popularly conceptualized as a period of good health. However, there are a small but significant number of young people for whom adolescence is associated with considerable morbidity and concerns about medical issues. There are also those who are in jeopardy because of their own risk-taking and health-compromising behaviours. Adolescence is also typically believed to be a period of emotional turmoil associated with conflict within families, irrational thought, and poorly controlled behaviour (Freud 1958; Blos 1962), and in some cases this would be an accurate representation of the period of transition from childhood to adulthood. For the majority of young people, however, adolescence is not a tumultuous developmental period fraught with conflict and rebellious antiauthoritarian behaviour. Most young people are well adjusted within their sociocultural environment and get on well with their families and peers (Offer and Schonert-Reichl 1992).
As noted in the first edition of this chapter there has been a lack of recognition of the special health care requirements of adolescents. Whilst there has been some improvement in this area, particularly in the developed world, there continues to be an inequality of health care provision for this age group compared with adults and children. The Health of the Nation: A Strategy for Health in England (DoH 1992) highlighted a number of targets for improving the health of children and young people. These included a reduction in smoking by one-third, halving the rate of pregnancy in girls under the age of 16 years, and reducing the number of accidents. Whilst some progress has been made in achieving these targets, there are areas in which little improvement has been made (Troop and Green 1997). Recent efforts to promote the health of young people have focused on schools with the Department of Health and the Department of Education working together to develop a policy for healthier schools (DoH 1998). The most recent governmental White Paper on health, Saving Lives: Our Healthier Nation (DoH 1999) dismisses the targets set out in Health of the Nation and instead claims to set tougher targets, addressing the ‘main killers’ of cancer, coronary heart disease and stroke, accidents, and mental illness. The specific health needs of young people are not addressed.
The provision of health care services for young people requires urgent attention; adolescents are important as they represent a significant proportion of the population. Considerable resources are invested in them in terms of their education and training. They have substantial commercial power and patterns of behaviour established during this period are likely to continue into adulthood. However, despite this, the special health requirements of adolescents have been, and continue to be, neglected relative to other age groups (Bennett 1982).
This chapter will provide an overview of the particular issues relating to adolescent health and behaviours that are important in the planning of comprehensive health care services for this age group. The specific aims are:

to provide an overview of adolescent medical and surgical disorders, mental health problems, and risk-taking behaviours

to review the range of adolescent health care services and health-promotion programmes and to consider the future development of service planning for this age group

to reflect on teaching, training, and research in relation to adolescents.
The literature on adolescent health and related issues is extensive and it would not be possible to produce an exhaustive review in this context. This chapter is intended as a primer providing a basis for further study. The focus is the position in the United Kingdom, but drawing upon the extensive experience of our colleagues in the United States.
Definition and demography of adolescence
Hall’s (1904) influential work at the turn of the last century identified adolescence as a distinct developmental stage although descriptions of adolescence have featured in earlier writings (Parry-Jones 1994). There was, however, comparatively little research into the adolescent age group until the last two decades when researchers became more interested in this developmental period. This interest has developed because of increasing recognition of the importance of this period and the impact of exposure to various stressors and influences on the risk of adverse outcomes.
However, a universally accepted definition of adolescence remains illusive. In many parts of the world adolescence is not clearly designated; children are introduced early to adult, social and economic responsibilities, with little transition between childhood and adulthood. From the physiological and psychological viewpoint, it is essential that the working definition used by clinicians takes into consideration the significance of two developmental transitions: that from childhood to adolescence, encompassing puberty, and that from an increasingly protracted adolescence and dependence, to adulthood. This coincides approximately with the age limits of 10 to 19 years used by the World Health Organization (WHO 1965), a period often subdivided into early, middle, and late adolescence. It is becoming evident that the transition to adulthood and the establishment of a fully mature relationship with parents, often in the mid or late twenties, can be more problematic than the intermediate adolescent years themselves. The increasing postponement of adolescent difficulties, associated particularly with the prolongation of formal education, and the delayed achievement of economic independence, heightens the obstacles to be overcome at the next developmental stage. Widening the age range of adolescence encourages the use of the alternative concept of youth, for young people aged 15 to 24 years (WHO 1989).
The world population currently stands at 5.9 billion persons and is growing at a rate of 1.33 per cent per year which represents an annual increase of 78 million people (UN 1998). The population of the United Kingdom is approximately 59 million of which 21 per cent are less than 16 years of age. Dramatic changes are taking place worldwide in the absolute and relative numbers of adolescents, especially in developing countries. Expected trends show increasing ageing of all populations, with wide variation in the proportions aged under 15 years. By the year 2025, for example, children and adolescents in more developed countries will form 19 per cent of the total population. In developing countries, the numbers will continue to rise, although the overall proportion will fall. The problems and health care priorities of adolescents, therefore, will continue to vary widely in terms of their geographical, social, economic, political, and cultural settings.
Mortality rates in the United Kingdom at ages less than 15 years have continued to fall. In developed countries the leading causes of death are accidents and suicide whilst in the United States, homicide is a major cause of death in the young (Frim Forman and Emans 1998). Cancer remains the next most common cause of death in young people in the West. In developing countries the picture is somewhat different with infection and pregnancy-related problems continuing to be a major cause of mortality.
Social value attached to adolescence and youth
The extent and adequacy of adolescent health care services and the scope for future development is inextricably linked with the relative significance attached by any society to adolescence as a distinct developmental period and to the health, welfare, education, and vocational training of teenagers. This includes the development of laws and policies covering health care and, while legislation focusing on adolescents has gathered momentum, this is still deficient in many countries (Paxman and Zuckerman 1987). In England and Wales, the Children Act of 1989 constituted a landmark in establishing the rights and interests of children up to the age of 18 years. It has considerable implications for health authorities, health professionals, and managers (DoH 1989).
Undoubtedly, the importance of the adolescent life period is becoming increasingly evident in all cultures of the world, especially as short, ritualized transitions from childhood to adulthood give way to more prolonged periods of adolescence in developing nations, consequent upon rapid industrialization, urbanization, and the erosion of traditional social structures. Although the demographic trend in Western society indicates falling numbers of young people, there is likely, nevertheless, to be a growing recognition of the social and economic importance of the health of teenagers. Furthermore, as child health interventions reduce mortality rates ensuring that most children reach adolescence, the quality of adolescent life assumes greater importance and the role of health care services, especially those concerned with mental health, increases correspondingly. Young people are being targeted increasingly by the music, fashion, and leisure industries, and this ‘youth industry’ shapes, to a considerable extent, the evolving patterns of youth culture. Despite such developments, however, adolescents are still likely to be perceived as a ‘social problem’ group, having negative correlations with disturbed behaviour, delinquency, drug taking, violence, and other manifestations of challenge to social order. This stereotyped image of the disturbed, and also disturbing, adolescent is more likely to result in public panic about the involvement of youth in sex, drugs, and crime and a call for tightening up ‘law and order’ in relation to this age group. It is less likely to generate pressures for enhanced health care programmes, or the modification of the environment in which adolescents are growing up.
Adolescent growth and development
Adolescence is characterized by rapid biological and psychological changes, intensive readjustment to the family, school, work, and social life, and an unrelenting process of preparation for adulthood. Emotional maturation carries with it growing understanding of the significance of affective experience and expression in oneself and others, the capacity to control impulses and to form meaningful emotional relationships. Cognitive changes include the acquisition of capability for abstract thought and hypothetical planning, and are associated with the often sudden development of spiritual, moral, and political thinking with the emergence of youthful idealism. Social maturation requires emancipation from the home; the establishment of an independent lifestyle, with a conscious sense of individual uniqueness; commitment to a sexual orientation and to a vocational direction; and the development of self-control. The achievement of these objectives requires experimentation with a variety of behaviour choices and role playing. If the process is to be successful, it calls for the confident acceptance of adult physiological, psychological and social experiences and roles, individual physical and personality characteristics, the ambiguity and frailty of human existence, and the responsibilities associated with personal autonomy. These processes take place gradually, involving a multiplicity of day-to-day decisions which carry identity-forming implications. Clinically, it is helpful to view adolescence as a sequence of stage-related developmental tasks, which have to be completed successfully if progress is to be made to the next stage. Although this approach is an oversimplification, it creates a frame of reference that health care professionals may find useful in structuring assessment and intervention. It requires a thorough familiarity with the phenomena and stages of normal adolescent development information about the lives of adolescents and their families in the context of their own communities and an appreciation of common internal and external stressors.
The profound maturational changes of this period can have far-reaching effects on the lives of young people and their families, with major implications for health and the planning of health care services. Although the theme of normal development appropriately pervades all aspects of adolescent medicine and psychiatry, it is not discussed at greater length in this chapter, since it receives comprehensive coverage in standard textbooks (Bancroft and Reinisch 1990; Coleman and Hendry 1990; Lewis and Volkmar 1990). Instead, emphasis is placed on the clinical aspects of adolescent development that have implications for causation, diagnosis, management of health problems, and also for the training of health care professionals.
Clinical significance of maturational stress
For most young people, the adolescent transition is one of natural orderly adjustment (Offer and Schonert-Reichl 1992) and not a time of storm, stress, identity crisis, and alienation. However, some degree of anxiety or stress is likely to be related to the need to cope psychologically with maturational changes and to rapidly develop a range of new capabilities, particularly since there are no clear-cut rules on how to progress to adulthood or to decide when this process is complete and the young person is fully grown up. Whilst unemployment rates appear to be falling in the United Kingdom, the labour market remains uncertain for many young people who therefore delay leaving the parental home, entering employment, and getting married, all of which are key symbols of adulthood. Furthermore, adolescents face a confusing range of legislation about the time at which the rights and obligations of full adult status are attained. Maturational stress is most likely to occur at times of transition, such as changing or leaving school, losing a close relationship, ending a period of being in institutional care, or the break-up of parental marriage. At such times, the anxiety of facing a new situation is added to other normative biological and psychological stresses. Therefore a range of adjustment difficulties, some of which may fulfil the criteria of mental disorder, can arise in response to adolescent development. For example, on entering puberty, children with pre-existing medical, psychiatric, developmental, or temperamental difficulties may experience particular problems. These may be related specifically to the timing of puberty, although all developmental changes have the capacity of being either stressful or supportive. Wide variation in age of onset and rate of growth spurt, for example, and the impact of both early and late physical development, may have positive or negative effects. In boys, delayed maturation can generate inferiority feelings and, in girls, early menarche may be experienced negatively or positively, because of the way it signifies maturity.
External stressors may operate within the family and, at all stages, adolescence is influenced by facilitating or obstructing family influences. In the assessment and management of adolescents therefore, this interactive process always needs consideration. Although a common occurrence, conflict between adolescents and parents is rarely long standing and generally parental influence remains significant throughout adolescence and young adulthood. Nevertheless, adolescent challenge to parental standards and attainments, which is an essential part of normal emancipation and detachment, may pose a major threat, because it can destabilize family homeostasis and lead to serious adjustment reactions, particularly in dysfunctional families. Therefore the parenting of adolescents can be demanding and stressful. Help-seeking is likely to be a more sensitive issue regarding adolescent problems than in relation to child-rearing difficulties, because it may expose a disabling sense of incompetence about parenting skills. Parents may seek help from a variety of sources, including family doctors, teachers, counsellors, books, and popular magazines. Parent-effectiveness training programmes have been developed and successful adolescent health promotion requires some intervention with parents.
Adolescent well being and the family
The role of the family in adolescent well being is increasingly recognized. The effect of family structure, family functioning, and parenting style on adolescent physical health, mental health, relational well being, and employment is the focus of increasing research attention (McFarlane et al. 1995; Spruijt and de Goede 1997). Many young people continue to live with their parents through their late teenage years and into early adulthood (Boyd and Noris 1999), thus, throughout adolescence, parents, especially mothers, continue to play an important role in the health of adolescents and in the identification of ill health The burden of adolescent ill health, particularly chronic illness, falls heavily on parents and siblings; families may be affected adversely and be at increased risks of psychiatric morbidity. Alternatively, family factors can precipitate, exacerbate, or maintain health-related problems in predisposed young people. In many situations, parents have to play a key part in supporting treatment, overcoming adolescent non-compliance, and as agents of change. Some degree of challenge and confrontation is appropriate to adolescent maturation. It is a considerable developmental challenge for parents to make the necessary adjustments to their perception of their child, who is becoming an adult, and to understand the challenges and conflicts, not as personal assaults, but as part of the process of maturation. A positive view of adolescence, as a creative force in the family, is beneficial, and parental morale and successful coping has to be fostered as part of adolescent health care and health-promotion programmes.
Problems in school
School is commonly the focus of adolescent disturbance, which may be characterized by disenchantment with conventional compulsory education, academic underachievement, disruptive behaviour, bullying, loneliness, association with delinquent peers, and truancy. It is not easy to assemble the profile of the disruptive teenager, because the causation is multifactorial (Parry-Jones and Gay 1984). From a clinical viewpoint, disruptiveness needs to be differentiated from both conduct disorder and maladjustment, in that it is usually a transient phenomenon, not necessarily reflecting individual psychopathology or forming part of identifiable antisocial behaviour. Although teachers commonly view disruptiveness as a consequence of the adolescent’s abnormality and the dysfunctional home background, the ethos of the school and the management of disruptiveness by teachers themselves can play a significant part in the generation and perpetuation of problems.
Ethical and legal issues
In all aspects of adolescent health care, legal, and ethical issues need to be given thorough consideration. The maintenance of privacy and confidentiality, for example, are of vital importance in all professional interventions, with clarification of the extent to which any personal revelations made to health care professionals will remain private. Boundaries of personal and public thoughts and feelings in families need to be reflected explicitly in the stage-management of any individual and joint interviews. Nevertheless, reassurance about confidentiality has to be tempered by reality since, under certain circumstances, information may have to be disclosed to parents or others. When contacting schools or employers, written consent is always preferable.
The question of an adolescent’s ability to seek, consent to, or refuse treatment without the knowledge or agreement of his or her parents is an important but highly controversial issue. There are wide cross-national differences in the legal rights of children and adolescents and health care practitioners have to develop familiarity with locally applicable legal and ethical principles and practices. In the United Kingdom, current practice has been influenced considerably by a number of high-profile cases such as the Gillick case in 1985 which concerned the prescription of contraceptive and pregnancy counselling services to under-16-year-olds. More recently controversy has surrounded issues such as heart transplantation and treatment for anorexia nervosa against the wishes of young people (Geist et al. 1996; Dyer 1999). Young people under the age of 16 years who are deemed capable of understanding the procedures involved can seek medical care and consent to treatment. Paradoxically this does not mean that treatment can be vetoed and courts have considerable over-riding powers.
The consent of 16- or 17-year-olds is sufficient in itself and separate permission from parent or guardian is unnecessary. Imposition of intervention without consent occurs only when emergency action is needed. It is conventional under such circumstances, with young people under 16 years, to accept the authority of a parent or guardian as an exercise of their parental responsibility. If such consent is absent and there is a psychiatric emergency with young people over 16 years, appropriate compulsory powers are provided by mental health legislation (Children’s Legal Centre 1991).
Adolescent health concerns and knowledge
Adolescents hold diverse views about health and health problems depending on their developmental stage, gender, racial, social, economic, and educational status (Epstein et al. 1989), but generally their definitions of health and illness are similar to those of adults. During early and mid adolescence, normal heightened introspection can be associated with increased somatic concerns and many adolescents, especially females, are worried about their health. Their extensive interest in the subject is reflected in the proliferation of health-related articles in popular, teenage magazines. Younger adolescents are unlikely to acknowledge that they are having problems and usually find it difficult to seek help themselves. Self-referral is infrequent, but when help is sought the reasons are likely to reflect a pressing need for reassurance, guidance, explanation, protection, or relief. With progression through the teenage years, there is increasing acceptance of personal responsibility for health and recourse to health care services. Presenting complaints, however, may continue to mask underlying problems. Many studies have shown concerns about a wide range of general health issues, such as body shape and weight, acne, aches and pains, depression and other emotional problems, interpersonal relationships, adaptation to school, work and unemployment, dental problems, HIV/AIDS, and aspects of sexuality, particularly contraception (Porteus 1979; Millstein 1993). Concerns that are sensitive and more difficult to disclose are often undivulged and, therefore, tend to be ranked low. Adolescent girls report physical and psychological problems more frequently than boys, who tend to display disturbance by acting-out behaviour (Dubow et al. 1990; Offer and Schonert-Reichl 1992). The predominant ‘personal’ concerns are usually those bearing on immediate issues, such as appearance, peer relations, independence, and sexuality, rather than diagnosable clinical disorders with long-term health consequences, likely to be identified by health care professionals. This dichotomy has fundamental implications for the design and approach of health-promotion strategies. There may be mistrust of doctors and cynicism about the advice of ‘experts’, especially if the focus of health education is on the possibilities of harming health in the remote future. Therefore there are dangers of overselling health promotion and in mounting strategies that are counterproductive to long-term objectives (Challener 1990). Above all the attitudes and health concerns of adolescents need to be respected.
Risk-taking behaviours
High-risk behaviours such as violence, alcohol and substance use and abuse, sexual exploration, and associated risks of sexually transmitted disease and pregnancy, together with less typical behaviours such as financial risk-taking are characteristic of adolescence. Whilst they may be viewed as reactions to developmental and situational stress they are nevertheless anxiety provoking and can result in significant morbidity and mortality in this age group. Health care providers involved in the management of young people must therefore be aware of these behaviours and their associated risk factors.
It is a commonly held belief that adolescent risk-taking is mindless. However, in a study of 58 college-aged females Shapiro et al. (1998) found that risk-taking behaviour was largely goal oriented and that the behaviour was either a means to an end or reflected a preoccupation with a personal need. Males and females are equally likely to engage in risk behaviour but the reasons for engaging in such behaviour may reflect gender-specific issues (Sarigiani et al. 1999).
The number of homeless young people is increasing and they are more likely, out of necessity, to engage in health-compromising activities such as drug abuse and prostitution, thus exposing them to the risk of HIV infection. In general, this group tend not to seek help and to be underserved in terms of health and social welfare provision. Existing evidence suggests that the homeless population is characterized by higher levels of childhood adversity (particularly physical and sexual abuse) and psychiatric disorder (Craig and Hodson 1998).
Effective prevention of risk behaviours in young people requires comprehensive intervention. Of importance is the recognition that risk behaviours cluster: young people who smoke are likely to use alcohol and illicit drugs, to engage in unsafe sex, and to be violent. Therefore, targeting one risk behaviour is unlikely to promote healthy lifestyles overall. The role of individual, school, and community factors must be recognized; effective prevention and intervention programmes require collaborative endeavour by both social and behavioural scientists together with health-care professionals (Yach and Ferguson 1999).
Violence by and against young people
Young people perpetrate and are the victims of a great deal of violence. Between 1985 and 1994 arrests of people under the age of 18 years in the United States for murder increased by approximately 75 per cent. Similarly the rate of violent crime increased by 68 per cent in this age group between 1988 and 1992. Young people under the age of 18 years account for 19 per cent of violent crime, however, it is likely that this reflects an underestimate of youth criminal activity. Approximately half of all violent crimes are committed by young men (Cohall et al. 1998). Whilst the epidemic of youth homicide appears to be a predominantly American phenomenon, youth violence is a cause for concern internationally (Rae-Grant et al. 1999).
Risk factors for violence include experience of violence in the home and neighbourhood, drug and alcohol abuse, involvement in other criminal activities, and association with other delinquent adolescents. Youth violence is costly at a personal familial and societal level. It must also be remembered that delinquent youths present with high levels of psychopathology which must be treated.
A variety of prevention programmes have been described. In general evaluation of such intervention programmes is limited and there is a need for further rigorously executed investigation in this area. The most promising interventions to date would seem to be multisystemic therapy, a comprehensive intervention addressing the multiple determinants of delinquency and involving aggressive case management and family therapy (Borduin 1999).
There is limited information available regarding predictors of dangerousness in adolescents, most of the literature describes adult males. However, certain clinically determined factors are significantly associated with future risk of dangerousness in young people. Recent research has looked at the evaluation of short-term risk which is relevant to the day-to-day management of young people (Sheldrick 1999). Further research is required to improve our understanding of the causation of delinquent behaviour, including the biological basis, and to develop effective interventions.
Substance use and abuse
The use and abuse of substances such as tobacco, illicit and prescription drugs, inhalants, and alcohol is becoming more common. Substance use amongst eighth, tenth, and twelfth graders in the United States increased significantly for tobacco and illicit drugs, especially marijuana, and remained stable for alcohol between 1991 and 1997 (Windle and Windle 1999). Alcohol and cigarettes are the most commonly used and abused legal substances. The immediate risks of substance use include accidents, violence, risky sexual behaviour, and exposure to HIV. Clinicians working with youth must be aware of patterns of use, socio-environmental risk factors and comorbid behavioural disturbance (Bravender and Knight 1998).
Most young people who use drugs do not progress to substance use disorders. Methodological problems limit the studies which have examined the prevalence of substance use disorders but Cohen et al. (1993) found marijuana substance use disorder in 2.9 per cent of 17-year-olds surveyed. Comorbidity, particularly with conduct disorder and mood disorders is common.
The causation of substance use disorder is probably multifactorial but with increasing evidence for a neurobiological basis (Altman et al. 1996). Substance use, on the other hand, is more related to peer and social factors. Of increasing interest and importance is the identification of resilience or protective factors. Intelligence, problem-solving ability, a supportive family, and positive role models all seem to be important in this regard.
A variety of prevention programmes have been described (Blum 1997). School-based interventions utilizing an interactive rather than a didactic model and covering general lifeskills as well as resistance, combined with adequate follow-up periods of at least 2 years seem to be most effective (Tobler and Stratton 1997). Other forms of intervention have received less attention, particularly drug treatment. There is considerable evidence relating to the effectiveness of drugs such as methadone and naltrexone in the detoxification of adults but there is a paucity of clinical trials of these agents in the adolescent population.
Cigarette smoking represents a significant threat to the health of young people. As many as 90 per cent of tobacco smokers begin their use before their eighteenth birthday, but if smoking does not start during adolescence, it is unlikely to occur. Even experimental smoking during adolescence increases the risk of adult smoking. Prevention of the onset of adolescent smoking is therefore of major importance. There are numerous studies describing the predictors of adolescent smoking (Williams and Covington 1997; Flay et al. 1998). The prevalence of smoking is increasing amongst children and young people with 33 per cent of girls and 25 per cent of boys becoming regular smokers by the age of 15 years. The likelihood of becoming a regular smoker increases between the ages of 11 and 15 years, but girls tend to smoke fewer cigarettes than boys (47 per week compared with 56 on average) (Office for National Statistics 1996).
Preventing smoking during childhood and adolescence is a vital component of an overall strategy to reduce mortality and morbidity from this dangerous habit. Various clinicians can play a role in smoking prevention by carrying out thorough assessments and counselling individuals (Sockrider 1997). Educational programmes have demonstrable short-term efficacy in reducing adolescent smoking, but their long-term effectiveness is less clear (Tyas and Pederson 1998). Certain components seem to be essential in order that sustained reduction in consumption can occur. These include policies to increase the price of tobacco, bans on advertising, limited availability, and readily available methods for supporting stopping smoking (Yach and Ferguson 1999).
Adolescent sexuality and sexual risk-taking
Adolescence is a critical period in the development of sexuality, attitudes to sex, and sexual behaviours. The sexual behaviour of young people may expose them to the risk of sexually transmitted diseases including HIV, unwanted pregnancy, date rape, and sexual violence. Despite increasing sexual liberation and more open discussion of sexual matters, coping with sexual development remains a silent solitary experience for many adolescents. They may feel anxious, frightened, and guilty about sexual thoughts and activities. The initial response to sexual development may take the form of denial of interest, withdrawal from all personal and social implications of genital sexuality, even to a self-abnegating lifestyle. Problems generated in this way, however, are much less likely to attract attention than difficulties in controlling sexual drives, in directing them into socially desirable channels, and in conforming to conventional sex roles.
Data regarding the occurrence of homosexuality during adolescence is limited, although a significant percentage of young people identify themselves as homosexual, or having had a sexual experience with a person of the same sex, or are confused about their sexual orientation. Specific sexual behaviours pose medical risks especially that of HIV/AIDS. In addition, stress related to isolation and stigma may predispose homosexual adolescents to social and emotional problems such as depression, school problems, running away, and illegal behaviour (Stronski Huwiler and Remafedi 1998).
Actual or anticipated promiscuity in girls, and fears about pregnancy or sexually transmitted diseases, may be an urgent reason for parents to seek help. In some respects, increased sexual permissiveness has complicated sexual adjustment, encouraging earlier sexual experimentation and coital experience. Such activities, entered into to test masculinity and femininity, may leave adolescents feeling guilty and disillusioned, but this needs to be differentiated from promiscuous behaviour which is typically symptomatic of emotional dysfunction and disturbed identity formation. From a medical viewpoint, problems associated with adolescent sexual activity are increasing, including sexually transmitted diseases and teenage pregnancy.
Considerable progress has been made over the last two decades in the investigation of unprotected sex and pregnancy in the teenage years. As a result there is a better understanding of the epidemiology and demographics of teenage pregnancy, its complications, and the effects of improving adolescent knowledge of and access to contraception. What works in terms of intervention/prevention programmes is now better understood with programmes to reduce sexual risk-taking behaviour and teenage pregnancy. However, pregnancy amongst teenage girls continues to be a problem in most countries. The teenage birth rate is high in many developed and developing countries (United States, 5.3 per cent; United Kingdom, 3.2 per cent; The Netherlands, 0.6 per cent) although there is evidence that the rate has decreased over the last 6 years. The birth rate amongst unmarried teenagers has increased (Kirby 1999). The majority of teenage pregnancies are unwanted and may have medical, psychological, and social repercussions, including lack of appropriate prenatal care, disruption of the young person’s life, disruption of family life and possible abandonment of the young person by their family, and abandonment of the baby.
As many as 50 per cent of teenage mothers in the United States will present with a repeat pregnancy within 2 years. Certain factors predict rapid repeat pregnancy including younger age, low socio-economic status, low education of the teenager’s mother or head of household, marriage, and intended or wanted first pregnancy (Rigsby et al. 1998).
Sexually transmitted diseases
Adolescents are at risk of acquiring sexually transmitted diseases and high prevalence rates for the various sexually transmitted diseases make prevention programmes essential for this age group. In recurrent sexually transmitted diseases, HIV infection should always be considered. Information regarding trends in HIV incidence in young people are imprecise (Rosenberg and Biggar 1998) and it is likely that some adult patients with AIDS were exposed to the virus as teenagers. Many adolescents, particularly runaways, the homeless, and gay males, are exposed to HIV infection by risky sexual behaviour and drug abuse. Young male prostitutes are particularly vulnerable (Markos et al. 1994). This highlights the need to identify these youth and to develop effective behavioural change programmes. Adolescents are increasingly concerned about sexually transmitted diseases, particularly because HIV infection is becoming a reality among relatives, friends, and cult figures. Although most teenagers are likely to know that the disease is transmitted by sexual intercourse and reused needles, there may be continuing misconceptions and ignorance. The prevalence of unprotected or ‘unsafe’ sex is high (West et al. 1993) and knowledge about safer-sex practices is likely to be limited.
Extensive health education and preventive programmes are required to reduce sexually transmitted diseases, using the mass media-, school-, and community-based strategies, with sensitive consideration of the developmental needs of different age groups. These should aim at increasing awareness about the risks of HIV infection, discouraging promiscuity and promoting safer-sex practices through the use of condoms. Monitoring HIV/AIDS prevention programmes is methodologically difficult and probably the best measure is the occurrence of other sexually transmitted diseases (D’Souza and Shrier 1999).
Sexual offences
Although the physical and psychological consequences of sexual abuse in adolescents may be just as serious as those in children, they have attracted relatively less attention (Glaser 1993) and, by late adolescence, few young people remain on child protection registers. The prevalence of sexual abuse and assault of adolescents remains unclear because of under-reporting. Sexual offences by adolescents include rape and ‘date rape’, incest, paedophilia, sexual killing, and involvement in pornography and prostitution. The treatment of adolescent sex offenders and abusers presents major difficulties (Davis and Leitenberg 1987). Some obtrusive adolescent sexual problems, such as indecent exposure, generally reflect clumsy immature attempts to achieve sexual gratification and recognition. Cases of voyeurism and touching or fondling of strangers may be similarly explicable.
Adolescent and young adult women are more likely to be the victims of sexual assault than women of all other ages. Lifetime prevalence in adolescents varies from 20 to 68 per cent. Increased vulnerability is associated with younger age at first date, early sexual activity and earlier age at menarche, past history of sexual abuse or sexual victimization, and a greater acceptance of violence towards women. Other risk factors include alcohol and date behaviour, such as who initiated the date and who paid expenses. Further research is required to provide better understanding of sexual violence among adolescents and young adults (Rickert and Wiemann 1998).
Adolescent medical disorders
The range of physical disorders encountered in adolescence is covered in specialized textbooks of adolescent medicine (Friedman et al. 1992; Brook 1993) and is outside the scope of this chapter. Instead, the focus here will be on issues relating to medical disorders which occur in adolescence, or develop for the first time during this period including the impact of chronic illness on adolescent development.
Common medical problems encountered during this period include chronic disorders such as asthma, diabetes mellitus, and epilepsy either continuing from childhood or developing for the first time. Delayed or atypical pubertal maturation, functional menstrual disorders, sexually transmitted diseases, pregnancy, various musculoskeletal disorders, including overuse syndromes and sports injuries, obesity and eating disorders, and skin disorders, especially acne, are also seen.
In addition to providing appropriate medical and surgical intervention for the wide range of commonly presenting conditions, the management of adolescent patients requires special consideration of the potentially adverse psychological responses to, and treatment of, acute and chronic physical disorders. It is particularly necessary to consider the impact of chronic illness or disability, which affects 5 to 10 per cent of adolescents, since the numbers of subjects are growing as modern treatments modify previously fatal conditions, such as congenital heart disease and cancer. Improved long-term survival rates may be accompanied by psychosocial adjustment difficulties associated with uncertain life expectancy and ongoing treatment. Similarly conditions such as epilepsy, diabetes mellitus, asthma, chronic inflammatory bowel disease, and rheumatic disorders may be associated with psychological disturbance, such as lowering of self-esteem or the feeling of loss of control, and complex adjustment and compliance problems, although these are by no means inevitable. A range of both predisposing and protective factors may influence individual vulnerability (Mullins et al. 1997; Seiffge-Krenke 1998).
Response to chronic illness and hospital admission
Illness, especially when it is life-threatening or chronic, can provoke reactive psychopathology; it can also interfere less obviously with normal adolescent psychosocial maturation. Two aspects warrant special consideration.

Prolongation of dependence on parents: at home and in hospital, parents and staff are involved in doing things to, or for, the adolescent in ways that can foster increased dependence and encourage infantilization. In serious illness situations, parents tend to become more protective, more indulgent, and less strict. This can reach the stage when age-appropriate adolescent challenge and emancipation may be discouraged actively and ordinary, independent, teenage activities restricted unnecessarily. Such parental, and sometimes family, responses can generate behaviour problems that are very difficult to overcome at a later stage.

Interference with peer group activities: chronic illness and repeated hospital admission and treatment interfere in the teenager’s involvement with other young people, particularly by prolonged school absences and restriction of ordinary socialization. Relationships may be complicated by fears of being thought of as weak, by embarrassment about appearance or the possibility of being regarded as physically unattractive, or even frightening, owing to treatment side-effects, such as hair loss or disfiguring operations like amputation.
The adolescent’s coping capacity needs to be an important focus of clinical attention. The seriously or chronically ill adolescent who learns to live successfully with disability, develops for themself a number of effective coping responses to illness. Their acquisition is ill-understood but appears to be determined by personality, previous experiences, and family and social influences.

Increased stress tolerance: successful coping with mild stress strengthens the ability to cope subsequently and increases tolerance. This process probably explains why there may be less evidence of disruption when chronically ill adolescents have problems, than when healthy adolescents have to cope with relatively minor illnesses.

Adaptive denial: failure to ‘take in’ the threatening aspect of the reality of illness, or choosing not to do so, can contribute to a de-emphasis on illness and an apparent lack of concern about the diagnosis, even about death, that is often displayed by adolescents with life-threatening disorders. This process may be associated with overcompensation in other areas of life, such as school attainment or sporting activities. Younger adolescents are more likely than older patients to reject discussion and information about their illnesses, simply to avoid truths that might be distressing, especially in the acute phases. However, such denial needs to be viewed positively as a helpful part of effective adaptation, and should only become a matter of clinical concern if it is the adolescent’s invariable response, or it interferes with treatment compliance.

Intermittent regression: all seriously ill young people may show childish, dependent, and manipulative behaviour at times of particular stress. Such regressive coping responses may be upsetting and annoying to parents and staff, but they may need to be recognized and permitted at particular times, such as immediately after diagnosis or during relapses.

Intellectualization: some teenagers may use intellectualization to help them overcome illness-related anxiety, by concentrating on the factual and rational aspects of a disorder in an apparently emotionally-detached fashion.
Surviving a potentially fatal illness presents significant challenges, not least of which may be the requirement that the young person copes with the sequelae of treatment including disfigurement, sterility, and the fear of recurrence. There may also be a protracted dependence on parents and a reluctance to form close relationships with others.
Scientific literature concerning terminal illness and death in adolescence is limited. During this period the adolescent and his or her family may continue to pursue aggressive therapies to prolong life and with ever-developing treatment protocols, this may be a possibility. This raises some ethical dilemmas in terms of the young person’s ability to give informed consent to such interventions. The caring physician must assess and facilitate the adolescent’s decision-making process and help families to accept the adolescent’s point of view.
The primary concerns of the terminally ill adolescent focus commonly on worry about separation from friends, conflict about loss of control, concern about ordinary developmental needs and practical issues, such as how one actually dies, and funeral arrangements. Some adolescents may choose to talk about their impending death but many do not.
Adolescent surgery
The range of surgical procedures undertaken with adolescents varies little from those utilized with adults. Predictably, head injuries, especially resulting from motor vehicle accidents, are one of the main causes of morbidity and mortality in adolescents. Orthopaedic problems are common, especially in teenage athletes, and injury prevention and rehabilitation form major components of sports medicine (Nelson 1992). Plastic surgery may be sought in adolescence for the correction of birth defects, breast reconstruction, body contouring, or rhinoplasty. The preparation of teenagers for surgery needs to be pitched at an age-appropriate level and special attention given to the assessment, monitoring, and relief of postoperative pain since there may be a lack of familiarity with adolescent communication styles (Savedra et al. 1988). The hospital setting in the United Kingdom is likely to be either a paediatric or an adult ward, because there are very few separate surgical facilities for adolescents.
The increasing sophistication of transplant surgery (heart, lung, liver, renal, bone marrow, and so on) and the resultant prolongation of life expectancy of young people with previously terminal disorders poses a particular challenge to the clinician. The psychological functioning of young people before and after surgery and their subsequent adjustment must form part of the overall assessment and management of such young people (Tornqvist et al. 1999; Walker et al. 1999).
Adolescent mental disorder
There is a natural reluctance to diagnose mental disorder in adolescents from fears of the adverse effects of labelling, and of stigmatizing young people by identifying them as psychiatric patients. Nevertheless, a transition point has to be recognized at which what might be regarded as ‘normal’ mental health problems become mental ‘disorders’, despite the fact that this is difficult to operationalize. Applying the criteria for clinical significance in current psychiatric classification systems, the term mental disorder is used to refer to a clinically recognizable set of symptoms or behaviours associated with distress and interference with personal functions. This establishes a threshold for disorder and distinguishes those conditions and ‘problems’, which are not inherently pathological, and would not warrant labelling as disorder. This distinction is crucial in the planning of professional roles, approaches, and responsibilities within tiered multidisciplinary child and adolescent mental health services (NHS Health Advisory Service 1995).
Mood may fluctuate even in undisturbed adolescents, with periods of isolation and withdrawal alternating with bursts of energy and high spirits. Preoccupation with health, body shape, and complaints about cosmetic problems like acne are common. Feelings of sadness, apathy, emptiness, loneliness, boredom, and isolation from peer groups may appear in normally adjusted young people. Persistent low self-esteem, feelings of being different, of being unimportant in the lives of others, self-consciousness, and social sensitivity may all lead to periods of despondency. Furthermore, the prospect of leaving the security of home may result in regressive symptoms, such as sulking, temper tantrums, and obsessional activities. Therefore a fundamental task for the clinician confronted by alleged disturbance is disentangling essentially normal age-appropriate states of mind and behaviours from psychopathology.
The range of psychiatric disorders is encountered in adolescence, including those with onset specific to childhood and adolescence (emotional and behavioural, hyperkinetic, conduct, and pervasive developmental disorders) and those characterized under adult psychiatric disorders (anxiety, psychotic, eating, substance use, and adjustment disorders). During early adolescence, the main manifestations are of childhood disorder in conjunction with the emergence of disorders such as anorexia nervosa, substance use, and stress-related disorders accompanying biological and social change. By late adolescence disorders such as schizophrenia and manic–depressive disorder begin to emerge with their associated significant clinical continuities onwards from adolescence into adulthood (Robins and Rutter 1990).
No single theory provides a sound rationale for assessment, classification, and management in dealing with the diverse presentations encountered in adolescent psychiatry. Rather, the most satisfactory model is all-encompassing, involving interaction of biological, psychological, and social factors in the predisposition to, and the precipitation and maintenance of problems. There is growing evidence that early behavioural responses in childhood, such as aggressiveness and antisocial behaviour, are strong predictors of disorders occurring in adolescence and adulthood.
Prevalence rates for psychiatric disorders in the adolescent population range from 8 to 22 per cent. Estimation of the actual prevalence and incidence of adolescent mental health problems is difficult, especially in specific populations such as those with mental retardation or developmental disabilities. Variations in prevalence rates relate to differences in sampling methods, case definition criteria, and assessment procedures. Anxiety, conduct, hyperkinetic, and mood disorders are the most commonly encountered and comorbidity is frequent. Gender differences have been described, with depression and anxiety occurring more frequently in girls than boys whilst conduct disorder and hyperkinetic disorder are more common in boys.
Detailed descriptions of causation, presentation, and management of adolescent psychiatric disorders can be found in standard textbooks (Lewis 1991; Parry-Jones 1993; Rutter et al. 1994). Here, emphasis is placed on the distinctive features of adolescent presentations and on disorders prominent in this age group. Those disorders which attract attention, because the adolescent’s behaviour becomes obtrusive, are described in the section on risk-taking behaviours.
Emotional problems and disorders
Anxiety and depression are common symptoms, especially in mid and late adolescence. Anxiety disorder may be amongst the most common psychiatric disorders in adolescence, affecting as many as 22 per cent of young people (Verhust et al. 1997). The features of anxiety disorder include excessive worrying, nervousness, irritability, sleep disturbance and fatigue, muscle tension, and other physical symptoms. Specific disorders include generalized anxiety disorder, post-traumatic stress disorder, obsessive–compulsive disorder, panic disorder, and phobias.
Major depressive disorder is identified in 3 to 9 per cent of adolescents (Lewinsohn and Hops 1993). Symptoms include sadness, irritability, reduced interest in activities, difficulties in concentrating, reduced or increased appetite, lack of energy, disturbed sleep (insomnia or hypersomnia), and low self-esteem. Depression in adolescents is also frequently associated with substance abuse and anxiety. Dysphoria is common amongst adolescents and therefore cannot be used per se as an indicator of mental health disturbance in this age group. Rather, the duration and pervasiveness of symptoms must be considered (Goodyer 1995). Serious mood disturbance may be associated with self-destructive ideation, self-mutilation, or attempted suicide.
Suicide and deliberate self-harm
The phenomena of suicide and deliberate self-harm or parasuicide have received considerable academic and political attention. The literature describing adolescent suicide and deliberate self-harm is extensive and the government in the United Kingdom have again identified a reduction in the rate of suicide as a priority (DoH 1999). However, suicide remains one of the leading causes of death in the adolescent age group (Rosewater and Burr 1998) and is therefore a cause for considerable concern (Barton 1995).
Thoughts of self-harm are common amongst adolescents; studies report that up to 40 per cent of adolescents will think about harming themselves at some point. Suicide before the age of 12 years is rare, but thereafter rates increase. Between 1980 and 1995, 1854 young people in England and Wales aged 11 to 19 years killed themselves (Roberts et al. 1998). The incidence of deliberate self-harm or parasuicide is difficult to determine in view of the fact that some parasuicidal activity will be concealed. In general, however, parasuicide attempts are between 10 to 20 times more common than actual suicides. Deliberate self-harm is more common in females whilst suicide is more common in males. Death by suicide is more common amongst young people who have tried to harm themselves in the past; 30 to 47 per cent of suicides occur in people who have tried to kill themselves before (Gunnell et al. 1995).
There are gender differences in the method of suicide. Males tend to use more violent methods such as jumping off buildings and hanging themselves; in the United States, where guns are more freely available, suicide by firearm is the most common method. Females are more likely to kill themselves by self-poisoning. Many suicides are completed under the influence of alcohol but very few young people who commit suicide have established psychiatric diagnoses or are in psychiatric treatment at the time of their deaths (J. Barton, unpublished data, 1995).
The range of motives described by young people who try to kill themselves includes relief from intolerable stress, retaliation, and manipulation in response to precipitating situations such as family rows, rejection by peers, break-up with a boy- or girlfriend, or some significant personal failure. There may have been feelings of being unwanted, unloved, persistently worthless, and socially alienated, and there may be evidence of uncharacteristically dangerous behaviour, risk-taking, or alcohol and drug abuse.
A variety of approaches to the management of adolescent suicidal behaviour have been described, including inpatient treatment programmes, school-based programmes, telephone hotlines, and pharmacological intervention (Greenhill and Waslick 1997). The most effective interventions are based on rigorous systematic screening which in turn has a high propensity for hospital admission (Shaffer and Craft 1999).
Reliable assessment of suicide risk in adolescents is difficult and, ideally, should be undertaken by psychiatrists or other experienced mental health professionals. All threats and warning signs of suicide need to be taken seriously, particularly when the adolescent displays an overwhelming sense of hopelessness, has attempted suicide before, and has difficulties in family and peer relationships. Admission to hospital for at least 24 hours should follow attempted suicide to permit full psychiatric and social assessment and family interviews. Assessment difficulties are compounded by the considerable geographical variation in the location of hospital departments and staff groups likely to be involved in catering for adolescents and young people. Parents have a key role in helping to prevent teenage suicides by encouraging adolescents to discuss what is bothering them, helping children to accept failure, reducing accessibility to the means for suicide, and trying to provide a role model for successful stress management.
Eating disorders
Concerns about weight and body shape are common amongst young people. Thirty to forty per cent of junior high school girls in the United States report worries about weight (Childress et al. 1993), and 40 to 60 per cent of high school girls have dieted to lose weight (Field et al. 1993). Problems concerned with eating and weight have increasingly become frequent reasons for the referral, or occasional self-referral, of young people (Steinhausen 1994). Anorexia nervosa is more common in girls especially during late adolescence and prevalence rates of 0.5 to 1.0 per cent have been recorded. Bulimia nervosa occurs chiefly in an older age range and has a prevalence of approximately 1 per cent in late adolescence.
The prevalence of obesity in young people is increasing, with 10.9 per cent of young people being above the 95th percentile for weight (Troiano et al. 1995; Hughes et al. 1997). Despite this, obesity remains an uncommon reason for referral to clinicians. Obesity is associated with significant short- and long-term health risks in addition to the effects on self-esteem and body image. The explanation for this trend requires careful consideration, but existing evidence suggests that a reduction in energy expenditure is the most important determinant of the increase in obesity in young people (Jebb 1997). The promotion of healthy lifestyles is an important challenge facing health care professionals with efforts to increase physical activity to address this problem.
Hyperactivity disorders
The term hyperactivity has become a familiar part of everyday language and thus its usefulness as a term to describe a symptom or syndrome has been greatly reduced. Attention-deficit hyperactivity disorder and hyperkinetic disorder are increasingly common reasons for referral to psychiatric clinics, and the assessment and management of these disorders in primary school-age children is well established. The literature describing their presentation and management in the adolescent age range is less extensive as it was thought that in many cases children outgrew hyperactivity disorders before they reached adolescence. However, it is increasingly recognized that these disorders can and do persist into adolescence, and may cause significant disability and dysfunction in terms of educational achievement and family and social functioning. Comorbidity is common especially with conduct disorder, and this combination has the worst prognosis (Hill 1998).
Anti-authority and antisocial behaviour
Antisocial behaviour in adolescents may arise initially in this age period or be a continuation from childhood. Its significance may be difficult to assess in that some degree of ‘unreasonable’ behaviour and poor impulse control is likely to occur during adolescence and complaints by adults may reflect their own low threshold of tolerance. Therefore common transient manifestations and occasional minor incidents of public disorder have to be distinguished from persistent and pervasive symptoms of antisocial behaviour that would justify the formal diagnosis of conduct disorder. Delinquency involves offences against the law and delinquent acts do not necessarily indicate the presence of conduct disorder. The clinical implications of antisocial behaviour become quite different if there is evidence of abnormally dangerous behaviour, such as fire-setting, long-standing aggression, or persistent delinquent activities, which warrant detailed psychiatric appraisal.
Conduct disorder is amongst the most common reasons for referral to psychiatry, representing up to 50 per cent of referrals in some clinics. It affects between 1.5 and 3.4 per cent of children and young people and is more common in males than females (sex ratio 5:1). Low socio-economic status and poverty are commonly associated with conduct disorder, although it is widely accepted that conduct disorder is a heterogeneous disorder where genetic liability may be triggered by environmental factors. Treatment of conduct disorder requires multimodal intervention, often over the long term. The best results seem to be achieved through the combination of intensive individual work and targeted family intervention (Steiner 1997).
Conduct disorder is amongst the most costly of psychiatric disorders in terms of cost to the affected individual, their family, and society. It is also one of the most difficult disorders to treat. The majority of young people affected by conduct disorder continue to experience dysfunction in some aspect of their lives and 40 per cent will go on to develop antisocial personality disorder.
Assessment and treatment
Assessment of mental health in young people includes the use of interviews, rating scales, and observational measures. Information should be obtained from as many perspectives as possible (the adolescent, their parent/guardian, and teachers).
A variety of treatment approaches have been applied to adolescent mental health problems (psychotherapy, family therapy, cognitive behaviour therapy, and pharmacotherapy). Evidence supports the fact that mental health treatment is better than no mental health treatment. However, there are insufficient rigorous evaluations to identify which treatments work best for which disorders presenting in which adolescents in which contexts (Weist et al. 1999).
Adolescent health care services
The general objectives of adolescent health care are the promotion of optimal physical and psychological development, the prevention of morbidity in adolescent or adult life, and the provision of services to achieve maximal physical and mental health. The attainment of these objectives necessitates a comprehensive multidisciplinary tiered approach to service provision and delivery, ranging from primary care and community-based health-promotion projects, to highly specialized hospital care. It requires continuity of care and good communication between health and other agencies. In this chapter, the status and effectiveness of these services are reviewed briefly.
Primary care services
Services delivered at primary level should be central to the health care of adolescents, offering the opportunity for prevention and early intervention. This is of particular importance since adolescent medicine is relatively undeveloped, yet family doctor consultation rates are low. Research, especially qualitative research examining the reasons why adolescents do not attend their primary care physician, is limited. Available evidence suggests that adolescents are concerned about issues such as being taken seriously, having their problems listened to, and being treated with respect (Rosenfeld et al. 1996). Many physicians feel ill equipped to deal with adolescent patients, acknowledging that their training in adolescent health care is inadequate (Veit et al. 1996). The nature of health service provision may be a further barrier to adolescents utilizing primary care. In private health care systems, adolescents are more likely to be uninsured or be part of a family insurance package such that they cannot gain access to health care without the knowledge of their family.
Adolescents may instead rely on the more anonymous accident and emergency department for their primary health care needs. This has implications for the training of accident and emergency staff who must be aware of the complex psychosocial needs of the adolescent as well as issues relating to consent (Melzer-Lange and Lyle 1996).
Guidelines produced recently in the United States have recommended the adoption of a staged approach to adolescent health care, describing three age groups: early (11–14 years), middle (15–17 years), and late (18–21 years). Analysis of primary care attendance by these age groups supports the targeting of services to these age groups (Ziv et al. 1999). During early adolescence the most common reasons for attendance are respiratory, dermatological, and musculoskeletal problems. Similar problems are responsible for attendance by middle and late adolescent males. Gynaecologial examination and diagnosis of pregnancy are the most common problems presented by middle and late adolescent females (Veit et al. 1996).
Various strategies have been employed to engage teenagers in the primary care system. School-based health centres have been reported to be highly successful in increasing adolescent utilization of medical, mental health and substance abuse counselling and intervention (Anglin et al. 1996; Kaplan et al. 1998).
Specialist medical services for adolescents and adolescent medicine
Children aged up to 13 or 14 years are customarily regarded as the responsibility of paediatric services. In some centres, older children may continue to be seen on an outpatient basis after the normal cut-off age, but the timing of transition to an adult clinic is likely to differ widely. Although the decline in childhood disorders is encouraging, paediatricians now need to divert more attention to adolescents. There is considerable variation in the extent to which adolescents are catered for on a separate basis, the majority being incorporated into general adult services. This means that in many medical specialties, the care of adolescents falls uneasily between paediatric and adult services.
The first steps in the organization of the special clinical care of adolescents began at the end of the nineteenth century and in the early decades of the twentieth century, following the emergence of the first scientific papers on adolescent growth and development. The establishment of the Medical Officers of Schools Associations in Great Britain in 1884 is often regarded as one of the first indicators of this process. However, subsequent progress took place largely in the United States (Heald 1992), where the Society for Adolescent Medicine was formed in 1968 and the clinical and professional boundaries of adolescent medicine began to be delineated (Blum 1987a). In 1980, the Journal of Adolescent Health Care began publication as the official voice of the Society. In the United Kingdom, despite explicit recommendations in numerous reports for specialized adolescent services (British Paediatric Association 1985), limited development has taken place. In general, professional interest and concern for adolescent health and welfare is reflected in growing scientific literature, textbooks and journals (Friedman et al. 1992; Brook 1993).
Teenagers require hospital admission for a wide variety of medical and surgical purposes (Henderson et al. 1993) and special consideration needs to be given to whether they should be nursed with younger children, with adults, or with other teenagers. The adult ward is generally inappropriate, especially for younger adolescents, because of possible juxtaposition with adults with degenerative and terminal disease, lack of a peer group, greater separation from parents through less flexible visiting arrangements, and staff unfamiliarity with age-appropriate responses and needs. Conversely, a paediatric setting can fail similarly to meet the psychological needs of teenagers in terms, for example, of independence, privacy, communication of feelings and information, consent to treatment, freedom from restrictive rules necessary for younger children, and even practical issues such as the size of the bed (Gillies and Parry-Jones 1992). Theoretically, services which assist in the transition from child to adult health care for young people with chronic disorders are identified as being of value. In practice they are limited in terms of their achievement of co-ordinated and integrated services (Scal et al. 1999).
Therefore there is a strong case for the use of separate purpose-designed adolescent wards, despite major implications for funding, human resources, and organizational and structural change. This view is supported by widespread experience in the United States and in the United Kingdom. In all outpatient or inpatient settings, there is a strong case for a multidisciplinary approach to the management of adolescents and their families, including input from child and adolescent psychiatrists, psychologists, psychiatric nurses, teachers, and social workers. Psychiatric liaison with adolescent services is much less frequent than with paediatrics and there are fewer examples of good practice (Black et al. 1990). The timing of transfer to adult services in adolescents who have built up strong attachment to their treatment teams, for example in cystic fibrosis or chronic renal failure, can generate problems. In general, the transfer date is best decided on an individual basis and needs to be backed by careful preparation. In many services problems are minimized by close liaison between paediatric or adolescent clinical teams and adult services.
Adolescent psychiatric services
Specialization in adolescent psychiatry has only a brief history (Parry-Jones 1994). During the second half of the nineteenth century, childhood mental disorders began to be described systematically, recognizing psychological and organic factors. Puberty became regarded increasingly as a physiological cause of mental disturbance, and pubescent or adolescent insanity began to be referred to frequently. Adolescents were admitted routinely to asylums and received no special age-related care until the late 1940s, when the first adolescent units opened. In the United Kingdom, exclusively adolescent inpatient services developed rapidly in the late 1960s in response to concern about the welfare of adolescents in adult mental hospital wards. Subsequently, there has been remarkable growth of adolescent outpatient, day patient, and inpatient services, and hospital treatment of serious adolescent psychiatric disorder is usually undertaken in age-appropriate surroundings. Nevertheless, significant deficiencies remain, reflecting the tendency for health services to be slower in providing for adolescents than for children or adults. Psychiatric services remain variable and incomplete, especially for acute disturbance, emergencies, rehabilitation and long-term care. Particular shortcomings include limited provision for older adolescents and young adults, the mentally retarded, aggressive conduct-disordered teenagers, and substance abusers, all of whom are difficult to place in other residential settings and who may need specialized secure facilities. Accessibility of services, especially inpatient units, is often unsatisfactory and overlap with adult services is inadequate and unplanned. Joint planning and co-ordination of services delivered by mental health, education and social services, and the voluntary organizations can be limited (Health Advisory Service 1986). The viability of inpatient units continues to challenge health care providers and many are threatened with closure (Parry-Jones 1995). Nevertheless, current guidelines for health service commissioning authorities in the United Kingdom (Health Advisory Service 1995) emphasize the fact that young people under the age of 16 years should only exceptionally be accommodated in adult wards and that commissioning or purchasing authorities should make provisions for the mental health problems of young people up to the age of 24 years.
Services for adolescents with disability
Good-quality services for adolescents with physical and learning disabilities requires a network of primary and specialist health care provisions, including rehabilitation facilities. It is particularly important to ensure the continuity of the health care of adolescents during the immediate postschool period as they transfer from child to adult services, and for there to be appropriate liaison with education authorities and social service departments (Fiorentino et al. 1998). The special health care requirements of adolescents with learning disability are complex and can only be provided on an individualized basis following assessment (Goh and Holland 1994).
Adolescent health-promotion and prevention programmes
Adolescence offers a unique opportunity for health promotion. The concept of adolescent health promotion, incorporating various prevention strategies, health education, and health protection programmes, is receiving increasing attention from health care policy-makers and providers, educators, and health and social scientists. In particular, significant morbidity and mortality amongst adolescents results from their participation in high-risk behaviours. Health-promotion activities have addressed these concerns in addition to the more conventional concern to prevent the development of disease in adulthood.
The subject is complex and compounded by inherent difficulties in the definition of health (especially mental health), uncertainty about the salience of health for adolescents, and controversy about the effectiveness of and justification for preventive intervention. It is not possible to establish a single set of universal objectives especially since health-promotion goals have to be seen in the perspective of the changing developmental stages of adolescence and the substantial influence of social, cultural, and economic factors. There is, for example, considerable evidence of the poor/non-poor differential in adolescent health status (Klerman 1993). The attitudes of teenagers to health advice and the response to information about what endangers health are extremely complex. Generally, it has proved difficult to gain access to the most vulnerable adolescent groups through health-promotion and health education programmes and, particularly, to demonstrate consistently the effectiveness of prevention and health-promotion programmes in reducing behavioural and lifestyle problems.
The interrelationship between health-promotion objectives and normal adolescent development is crucial and, in this context, Crockett and Petersen (1993) have suggested the following broad goals:

to promote physical health and well being through proper nutrition and exercise, development of a positive body image and healthy sexuality, and adoption of a healthy lifestyle

to promote cognitive maturity, including the capacity for abstract, formal reasoning, social-cognitive skills, and autonomous decision-making

to promote self-esteem and a positive sense of personal identity, including positive future goals and a sense of self-efficacy and social responsibility

to promote supportive relationships with family, peers, and other important adults

to provide opportunities for educational and occupational success

to avoid pitfalls that would interfere with the positive developmental outcomes.
Inevitably, such objectives are difficult to translate into large-scale prevention programmes.
There is a voluminous literature relating to prevention and health education. One prominent section is concerned principally with preventing or minimizing the adverse effects of risk-taking behaviours, such as dangerous driving, experimentation with smoking, drugs and alcohol, promiscuous sexual activity, and violence. The impact of intervention has often appeared to be disappointing, with particular difficulties in ensuring that the benefits of preventive programmes actually reach adolescents who come from impoverished, dysfunctional families or who are socially alienated. While the concept of the health-compromising lifestyle has been constructive, evidence of the effectiveness of intervention in such situations remains patchy. It may well be that since childhood behavioural responses predict psychopathological outcomes, the focus of intervention should be on a much earlier developmental stage. A second major section of the health-promotion literature is concerned specifically with the maintenance of sound general health, growth, and nutrition, and generally influencing attitudes to causes of future morbidity.
The application of health-promotion principles to adolescent mental health has been particularly challenging. Despite considerable advances in the understanding of the concept of mental health in this age group, there are formidable tasks facing mental health and other professionals in their efforts to promote optimal psychological development. These have to be based on an agreed definition of positive mental health, which Compas (1993) has described as ‘a process characterized by development toward optimal current and future functioning in the capacity and motivation to cope with stress and to involve the self in personally meaningful instrumental activities and/or interpersonal relationships’. Optimal functioning is relative and depends on the goals and values of the interested parties, appropriate developmental norms, and one’s sociocultural group. Intervention strategies based broadly on this model are usually concerned with lifeskills training and they have a particular role, for example in substance abuse prevention, by fostering skills for resisting social pressures to initiate abuse.
Many attempts have been made to identify factors and themes which contribute to successful programmes. In general terms, strategies should be acceptable to the individuals, cultural groups, and communities involved; adolescents should be involved actively in the process, and programmes should take into detailed consideration the needs of adolescents at different developmental stages (Hamburg et al. 1993). In an analysis of 100 prevention programmes for high-risk behaviours, Dryfoos (1990) identified a number of common strategies that appeared to contribute to success: one-to-one individual attention and support by trained staff, active involvement of parents, educational and non-educational interventions in schools, and finally, community-wide multiagency approaches. In general, the focus of intervention has to be on the antecedents of deviant behaviours, not the presenting problems. Health-promotion and education projects mounted simply at a local level are unlikely to be successful without the backing of substantial central government support for the enforcement of social policies. This may include laws against drunken driving and restrictions on cigarette advertising (Macfarlane 1993; Nutbeam et al. 1993).
Adolescent health promotion is a relatively new field for research. There is an urgent demand for better data, for example concerning the health status and the impact of health promotion on adolescents under conditions of poverty. There continues to be a need for exploration of the complex personal, interpersonal and sociocultural processes that encourage teenagers to persist with health endangering behaviours, despite having the relevant information about the risks involved. Evaluation studies remain an urgent priority.
Teaching and training of health care professionals
Many of the professionals involved in the health care of adolescents are nlikely to have day-to-day contact with members of this age group and have identified the need for more training at both undergraduate and postgraduate level in the management of adolescents. This compounds what appears to be a widespread neglect of teaching and training specifically about adolescent health issues, at either general professional or in-service training levels. There is an urgent need therefore to develop curricula for the training of physicians and other health care professionals that address the fact that adolescents present a spectrum of problems that extends beyond traditional medical practice (Blum 1987b). Training programmes need to cover a number of issues, including the following.

The changes associated with normal adolescent development and the way these affect and are affected by illness.

Information about adolescents in the local community, causes of illness, disability, and death, specific health needs, and available resources.

Preparation for the professional contact with adolescents and the all-important development of a therapeutic relationship. The face-to-face interview can be daunting for some adolescents and the clinician must be prepared to make imaginative use of anxiety-reducing moves, with particular attention given to establishing trust and confidence in adolescents who are withdrawn, uncommunicative, or fearful.

The management of the full range of medical and surgical disorders, with particular emphasis on the psychological consequences of long-term illness.

The management of the full range of psychosocial problems and mental disorders.

Information about the most effective strategies for health promotion.
In this chapter, evidence is presented about the extent and the implications of physical, psychological, and social morbidity during adolescence and youth, and the slow, fragmented, and uneven response of health care providers. The magnitude of the psychological and social problems and health hazards facing adolescents and the existence of highly vulnerable groups of young people warrant urgent recognition by health care policy-makers, professionals, and managers. Worldwide, access for all adolescents to comprehensive age-appropriate health services must be a priority. In addition, programmes for reducing hazardous, high-risk behaviours and targeted interventions for the most vulnerable groups must be developed according to nationally determined priorities. Adolescent health care must be provided by specially trained professionals and designed to meet individual developmental, cultural, ethnic, and social needs. To meet this challenge, concerted action in relation to a set of central goals is imperative in order to improve the quality of adolescent health care throughout the world. These goals are set out below. Whilst they are universally applicable, priorities will be determined at national level.

Recognition of the social value attached to adolescence and youth: the expansion and promotion of adolescent health care services is linked closely with the significance given by any society to adolescence as a distinct developmental period, and to the health, welfare, education, employment, and general status of teenagers.

Enhancement of the status of adolescent medicine: the key to improving medical services for adolescents lies not only in enhancing the status of adolescent medicine as an independent specialty but also in addressing the needs of adolescents in the paediatric, general medical, and primary care setting.

Expansion of adolescent psychiatry: when viewed in global perspective, adolescent psychiatry presents an extremely varied picture. Its establishment and expansion, in any country, depends on the funding for mental health services as a whole and on the legislative provisions for the care of mentally ill young people.

Accommodation of adolescent needs within service delivery: adolescent needs should be recognized and met in all outpatient, inpatient, and community services. Some changes, such as the development of dedicated adolescent medical wards, will require substantial expansion of resources. Others, such as the improvement of facilities for adolescents, the establishment of outpatient services for young people suffering from the same medical disorder, joint hand-over clinics with adult specialists during a transitional period, and self-referral clinics, may require only modest additional funding and organizational change if existing services are reasonably well developed.

Inclusion of ‘normal adolescence’ and adolescent health issues in the teaching and training of health care professionals: there is scope for at least an introduction to the special needs of normal adolescents in the teaching of all medical students, nurses, and other health care providers, as well as in postgraduate and in-service training. This provides an essential frame of reference for the identification, diagnosis, and management of adolescent health problems. In addition, all staff working directly with adolescents should receive specialized training.

Increased investment in prevention and health promotion: the justification for early detection, preventive intervention, and health promotion in adolescence and young adulthood is powerful. However, adolescents are low users of health care; primary care services frequently fail to meet their common health concerns and young people often prove difficult to engage. Therefore adolescents require imaginative, developmentally appropriate, and culturally sensitive school- and community-based programmes of health education and health promotion if their interest, trust, and commitment is to be gained.

Expansion of research: there is extensive scope for research in adolescent medicine and adolescent health promotion, and for the assembly of reliable data on all aspects of adolescence and youth. Continuities and discontinuities with the health problems of childhood and adulthood, for example, need to be traced, with special emphasis on factors during childhood that influence adolescent and adult adaptation. Of fundamental importance is the continuing clarification of the developmental variation of medical and psychiatric disorders and the impact of normal development, maturational stress, and social and cultural factors on health care knowledge and attitudes, and response to illness. There needs to be verification of the nature and extent of the health problems and dysfunctional states experienced by adolescents in different cultures, the identification of the most vulnerable groups of young people and families, and the development of effective methods for the measurement of difficulty, distress, and quality of life. A major area of deficiency is the lack of information about what teenagers think about illness and the threat of disability or death. Hitherto, rigorous evaluation of preventive programmes has been lacking.

Collaboration between multiple agencies and services: the problems and needs of adolescents impinge on many different agencies and services outside the health sector, involving schools, youth and social services, and a wide range of other community organizations. Consequently, in order to ensure comprehensive care, particularly as resources grow more scarce, there needs to be emphasis on the joint planning, co-ordination, and implementation of services.

Enhanced public policy considerations: the need to raise the profile of adolescents and the improvement of adolescent health status on national political agendas calls for concerted representation and advocacy by all professional organizations concerned with their health and welfare. Innovative successful solutions for the improvement of adolescent health and the modification of high-risk behaviours are available and urgently await recognition, funding, and implementation. Many of the health-related problems of teenagers, especially those that make their behaviour obtrusive and disturbing within society, are associated with poverty, unemployment, homelessness, environmental deprivation, and racism. Therefore they are major public policy issues requiring intervention by governments followed by social change.

*This chapter represents a revision of the chapter on ‘Adolescence’ which appeared in the first edition of this book. I have been privileged to work on the original text written by my friend and mentor, William Parry-Jones, who died in July 1997 before work on the second edition was commissioned. It is a reflection of the rigorous and meticulous approach that William applied to all aspects of academic endeavour that I have had merely to update some sections of the text. His insights into the health needs of young people are as pertinent today as when the chapter was first published.
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