4 Adolescent Care

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Contents

• Objectives
• Adolescence and puberty
• Challenges of adolescence
• Adolescent sexuality
• Adolescent friendly care
• Case studies

Objectives

When you have completed this chapter you should be able to:

1. Give a definition of adolescence
2. List the important features of adolescence
3. Describe the changes of puberty
4. List the dangers of adolescence
5. Describe the problems of adolescent sexuality
6. List the problems adolescents face when they need health care
7. Explain how adolescent friendly health care services can be developed

Adolescence and puberty

4-1 What is adolescence?

The World Health Organisation (WHO) defines adolescence as the period between 10 and 19 years of age. It is the time of growth and development between childhood and adulthood. Adolescents are individuals who are no longer children but not yet adults. In many cultures adolescence is celebrated with some form of traditional rite of passage.

The WHO defines adolescence as the period between 10 and 19 years of age.

4-2 Why is adolescence important?

It is a time of enormous physical, emotional, intellectual and social change and maturity. It is the process of becoming independent. As a result of these many changes, adolescents need special care that is different to the care given to children or adults.

4-3 How many adolescents are there in South Africa?

It is estimated that there are about 10 million adolescents in South Africa. They make up almost 21% of the total population. Adolescents therefore form a large part of most communities.

4-4 What are the major features of adolescence?

• Puberty.
• A change from simple (concrete) thinking to more complex (abstract) thinking.
• Emotional and behavioural development and maturity.
• Development of sexual relationships.
• Greater self awareness.
• Increasing responsibilities.
• Eating disorders-too much or too little or induced vomiting.

4-5 What is puberty?

Puberty is the development of physical sexual characteristics and the onset of rapid growth. It is also a time when the person’s appearance changes from that of a child to an adult. Puberty is caused by the sudden increase in the secretion of sex hormones from the ovaries (oestrogen) or testes (testosterone). Puberty is often the first sign of the many changes that take place during adolescence.

Puberty is the development of physical sexual characteristics.

4-6 What are the signs of puberty?

The clinical signs of puberty present in an ordered way which are slightly different between boys and girls.

In girls:

• The first sign of puberty is development of the breasts
• Pubic hair starts to grow
• They suddenly grow taller
• Menstrual periods start

In boys:

• The first sign of puberty is enlargement of the testes
• This is followed by an increase in the size of the penis
• Pubic hair starts to grow at the base of the penis
• Facial hair starts growing
• They suddenly grow taller

4-7 When does puberty occur?

The age at the onset of puberty varies widely but has steadily decreased in many countries as childhood nutrition and health care have improved. Puberty starts during adolescence and is earlier in girls than boys. It usually begins between:

• 9.5 to 11.5 years of age in girls (average 10.5 years)
• 9.5 to 13.5 years of age in boys (average 11.5 years)

The average age at the start of puberty is 10.5 years in girls and 11.5 years in boys.

4-8 When do adolescents start to grow fast?

Early in puberty in girls and later in puberty in boys. Therefore girls grow faster and are taller than boys during the first years of adolescence. However by the end of adolescence boys have caught up and passed girls in height. As a result men are usually taller than women.

Girls grow faster and are taller than boys in early adolescence.

4-9 When does menstruation start in girls?

Menstruation (periods) start towards the end of puberty (about 12 years of age). However the time of onset of menstruation varies widely between individuals. From the time that menstruation starts it is possible for girls to fall pregnant. This is one of the reasons why sex education should start as soon as possible.

4-10 What are the nutritional needs of adolescence?

The nutritional assessment, counselling and support for adolescents should be given special attention. The nutritional needs of adolescents increase as they enter their growth spurt. Therefore the food intake should be increased to ensure that this growth spurt is supported. Adolescents should be counselled about a good diet and encouraged to adopt healthy eating habits.

Mid-upper arm circumference and BMI (body mass index) for age can be used to assess the nutritional status and screen adolescents for undernutrition and obesity.

4-11 What are the stages of adolescent development?

Adolescence can be divided into 3 development stages:

1. Early adolescence from 10 to 14 years is mainly physical development.
2. Middle adolescence from 15 to16 years is mainly social development.
3. Late adolescence from 17 to 19 is mainly psychological development.

4-12 What are the features of early adolescence?

• Puberty starts.
• Girls are taller than boys.
• Adolescents are family orientated and still dependent on their parents but need their own privacy.
• They become very aware of their changing bodies. Anxiety about their physical appearance is common.
• Mood swings are common.
• Their friends are mainly of the same gender.
• The opinions of friends become very important
• They do not want to be different from their friends

4-13 What are the features of middle adolescence?

• Puberty is usually more advanced in girls than boys.
• Boys catch up in height and may become taller than girls.
• Girls start menstruating.
• Boys and girls become sexually mature.
• Friendships develop and “dating” starts.
• Sexual experimentation is common.
• This is the most difficult stage for both adolescents and their parents.
• Thinking about emotions and feelings. Romantic fantasy is common.
• Adolescents want to be independent and push the limits with their parents and other adults. They do not like being told what to do. Their behaviour is determined by their friends and they often want to break the rules made by adults. Rebellion against school and authority figures and poor compliance with health care and medication can be a problem.
• They need to be accepted by their friends. This is very important.
• They feel immortal (“it could not happen to me”).
• They love junk food.
• It is a time of fun and excitement without responsibility. The future is full of possibilities.

Teenagers in middle adolescence want to be adults but are not mature enough to take full responsibility for their thoughts and actions.

Middle adolescence is a difficult time of rapid behaviour change.

4-14 What are the features of late adolescence?

• Growth and sexual development are complete.
• Thinking turns to education, lifestyle, a career and the future.
• Individual friendships become more important than their friendship groups. They are usually more committed to their sexual partners and often make plans to leave home.
• Concern for others, real independence and personal identity are important features.
• They want to accept responsibility and be treated as adults.

Late adolescence is a time of accepting responsibility and building mature relationships.

4-15 What are the main tasks of adolescence?

• Forming a clear identity: “Who am I and what do I believe in?”, “What are my values and my goals in life?”.
• Becoming used to a new and changing body image.
• Emotional separation from parents and accepting the freedom and anxieties this brings.
• Managing social and financial responsibilities.
• Forming new relationships with both male and female friends.
• Learning to control behaviour and conforming to the norms of society.
• Developing a more mature way of thinking.

Challenges of adolescence

4-16 Is adolescence always difficult?

No. Most adolescents manage to negotiate their ways through the stages of adolescence without getting into trouble. They slowly accept many of their family values and reach early adulthood with a clear idea of who they are and what they want. The successful transition to adulthood is made easier in a secure and caring family and community environment.

4-17 What are the dangers of adolescence?

Increased risk taking is a common problem, especially in the middle stage of adolescence. The main dangers are:

• Unintended pregnancies
• Sexually transmitted infections (STIs)
• Alcohol and drug abuse
• Dropping out of school
• Depression and self harm including suicide
• Motor accidents and violence
• Lifelong body image problems and eating disorders

There are many sexual, behavioural and social challenges of adolescence.

Adolescent sexuality

4-18 What is adolescent sexuality?

Adolescent sexuality refers to sexual feelings, behaviour and development in adolescents. Adolescents are naturally curious about their own sexuality and that of others. They frequently explore different ways of sexual expression. It is important to promote healthy sexuality and sexual experimentation as part of a healthy lifestyle among adolescents. In order to do this, adolescents need a good knowledge of reproductive anatomy and functioning as well as safe and healthy sexual practices.

4-19 Where do adolescents learn about sex?

This should be learned in stages when questions are honestly answered by the family. Unfortunately many parents struggle to discuss sexual matters with their children. Traditional sex education at school is often absent or poorly done. Many communities are unhappy about sex education in schools as they fear this will promote early sexual activity. As a result many adolescents are ignorant or confused and obtain most of the sexual knowledge from friends. This is often inaccurate and dangerous.

Important information about puberty, sexuality, pregnancy, oral contraception and condom use, sexually transmitted infections and contraception after sexual intercourse (morning-after pill) are often not provided to adolescents.

Sexual knowledge should be obtained in the home and at school rather than from misinformed friends and other individuals at school. “Sex education” and life skills training are an important part of the school curriculum.

Good sexual education is important for all adolescents.

4-20 When do adolescents first have sexual intercourse?

The age of first penetrative sexual intercourse varies widely between different individuals and communities. Sexual intercourse is common during adolescence in South Africa and many adolescents have had their sexual intercourse (sexual debut) before the age of 16 years.

4-21 What are the dangers of adolescent sexual intercourse?

Important dangers are:

1. Unintended pregnancy.
2. Sexually transmitted infections.
3. Physical and emotional abuse.

4-22 What is the age at which adolescents can legally consent to sex?

Under South Africa law a person under 16 years cannot consent to “sexual activity”. Therefore sexual intercourse involving a person under 16 years is illegal. However while all sexual activity under 16 years is illegal in South Africa, an exception will be made for individuals between 12 and 16 years provided the sexual activity is consensual and the age difference between sexual partners is not greater than 2 years.

4-23 When are adolescents old enough to ask for contraception?

Under the new South African Child Act, any person of 12 years or older can access contraception, including condoms, provided they are of “sufficient maturity”. This means they do not have to tell their parents or get their parents’ permission. However it is preferred to involve the parents in this decision if possible.

4-24 When are adolescents old enough to give consent for an HIV test?

As with contraception, any person of 12 years or older can give consent for an HIV test provided they are of “sufficient maturity”. Again this means they do not have to tell their parents or get their parents’ permission.

Adolescents of 12 years and older can give consent for contraception and HIV testing.

4-25 How common are adolescent pregnancies?

About 16% of pregnant women in South Africa are adolescents. By the age of 20 years, 1 in 3 women in South Africa will have a child. Therefore adolescent pregnancies are very common.

4-26 What are the dangers of an adolescent pregnancy?

• Often the pregnancy is unintended and unwanted.
• Adolescent pregnancy may also be the result of a physically or emotionally abusive relationship.
• An adolescent pregnancy carries a number of medical and emotional risks.
• Adolescent pregnancy may lead to an unsafe abortion.
• It is often a social and financial disaster for the girl and her family.
• Schooling is interrupted and may not be started again.
• The infant is at increased risk of poor clinic attendance for immunisation, and abuse and abandonment while poor family support is common.

4-27 How can adolescent pregnancy be prevented?

• Good “sex education”
• Abstinence (no sex)
• Contraception
• The “morning after” pill is available at all clinics and can prevent pregnancy if taken between 12 hours and 5 days of unprotected sex. The sooner the better.

4-28 Is termination of pregnancy allowed for adolescents?

Free abortion on demand up to 12 weeks after the start of the last menstrual period is available in South Africa. Any pregnant women can give consent herself as there is no legal age limit. However she must be counselled and advised to consult her parents. Adoption may also be an option.

4-29 Why are sexually active adolescents at risk of sexually transmitted diseases?

• Adolescents are immature and too inexperienced to negotiate a safe sexual relationship.
• Girls often attract older male partners (”sugar daddies”).
• Transactional sex is common (sex for presents).
• They often do not see the consequences of their decisions and actions.
• Poverty.

Abuse and rape of adolescent girls are common.

4-30 How can sexually transmitted disease be prevented?

• Abstinence.
• A single, faithful sexual partner who does not have a sexually transmitted infection.
• Always use a condom.

Oral contraception will prevent pregnancy but does not give protection against sexually transmitted infections.

Adolescent friendly care

4-31 Why do adolescents need special care?

Most adolescents feel they are too old to be regarded as children while too young to be managed as adults. Therefore they have special needs. The needs of adolescents vary depending on the individual’s sex, age and stage of development.

Fortunately most adolescents enjoy good health. However, there is a great need for health and social services in both clinics and hospitals that are “adolescent-friendly”. Most societies neglect adolescent health and health care services are unfriendly to adolescents.

4-32 What problems do adolescents often face when they need health care?

1. Inconvenient clinic times, often during school hours.
2. Clinics often far away requiring travel which is expensive.
3. No privacy as adolescents have to sit with adults who may be neighbours.
4. Unfriendly attitude of staff who are rude, judgmental, intolerant and impatient.
5. The physical environment is unattractive and unfriendly.
6. Information is unavailable, inappropriate or difficult to understand.
7. Long queues and waiting times with hurried consultations.
8. Language is often a barrier.
9. Medication is not available.

In many countries the health needs of adolescents are not met. As a result many adolescents do not seek health care or receive poor quality of care.

4-33 What is an adolescent-friendly health care service?

An adolescent-friendly health care service is a service which is accessible, acceptable and appropriate for adolescents. Adolescents should participate in planning adolescent services. If possible these services should be comprehensive and meet all the health needs of adolescents. However the service must still be part of the service to the general public.

An adolescent-friendly care service is urgently needed.

4-34 What are the features of an adolescent-friendly health service?

1. The service must be provided at a site which is accessible to adolescents. This usually is close to schools.
2. Opening times must be convenient, usually after school hours.
3. The service must be affordable as many adolescents cannot afford private health care.
4. The service should be only for adolescents. This may be in a separate part of a general clinic so that adolescents do not have to share the reception, waiting and clinical areas with adults.
5. The building should be relaxing for adolescents. Often there is an informal area for games (e. g. table tennis or darts). Coloured walls and curtains are helpful.
6. Trained and motivated staff who can provide a service which is adolescent-friendly. The attitude of all the staff (receptionists, nurses, doctors, social workers) is very important.
7. Relevant information must be available in language that can be easy to read and understand.
8. A healthy lifestyle must be promoted and unhealthy behaviours discouraged.

4-35 What are the characteristics of an adolescent-friendly staff?

1. Staff must be able to communicate with adolescents without being judgmental or patronising (do not “talk down” to adolescents). They should have good listening skills and be able to identify the underlying problem and not just the presenting complaint. Staff must remember that adolescents are often confused and anxious.
2. The staff must have a good knowledge of adolescent growth and development and the emotional and social problems common in adolescence. In addition the staff should provide high quality medical care and know where to refer adolescents with specific problems (e.g. mental).
3. They must be able to explain information in a way that young people can understand and help them to be positive and motivated.
4. They must not allow their personal beliefs and values to create communication barriers and interfere with the advice and care they provide.

4-36 What clinical problems are addressed by adolescent-friendly health services?

An adolescent-friendly health service is one which specifically recognises the challenges and addresses the health needs of adolescents. It should deal with:

1. Growth and nutrition.
2. Puberty.
3. Emotional, social and intellectual changes.
4. Sexuality and pregnancy.
5. Sexually transmitted infections.
6. Mental health.
7. Physical illnesses.
8. Schooling problems.
9. Alcohol and drug abuse.
10. Violence and suicide.

4-37 What role can community health workers play in promoting adolescent friendly care?

• They should have a clear vision of what adolescent friendly care is.
• They should promote this vision among their colleagues.
• They should help educate adolescents and their parents about the challenges and problems during adolescents.
• They should help adolescents obtain the healthcare they need.
• They should help provide counselling around adolescence.
• They should assess nutritional status and promote a health diet.
• They should promote early booking if the adolescent becomes pregnant.
• They should encourage a healthy lifestyle.

4-38 How can community health workers promote a healthy lifestyle?

Some tips to a healthy lifestyle for adolescents include:

• An adequate, well-balanced diet.
• Maintain a normal body weight.
• Get regular exercise.
• Avoid alcohol, smoking and illicit drugs.
• Delay the onset of sexual intercourse.
• Use contraception and condoms if sexually active.
• Read every day.
• Stay in school.
• Get 8 hours sleep.

Community health workers should promote a healthy lifestyle.

Case study 1

A community health worker visits a home where the mother is worried that her 11-year-old daughter has not started puberty yet. Most of her daughter’s friends have already started and one has even begun having menstrual periods. The mother mentions that her son started puberty when he was 12 years old.

1. Is puberty the same as adolescence?

No. Adolescence is the time period between 10 and a19 years while puberty is the development of physical sexual characteristics with rapid growth.

2. Should girls start puberty by the age of 12 years?

The average age at the start of puberty is 10.5 years but there is wide variation from 9.5 to 11.5 in girls. It is therefore normal that this young girl has no started puberty yet.

3. Did her son start puberty abnormally late?

No. Boys usually start puberty later than girls. The normal age for the start of puberty in boys is 9.5 to 13.5 years.

4. Will her daughter start having periods when puberty begins?

The earliest sign of puberty in girls is breast enlargement. One breast may start to enlarge before the other. This is common and normal. Menstrual periods usually start towards the end of puberty at about 12 years of age.

5. At what stage of puberty does rapid growth start?

Boys and girls start to increase in height towards the end of puberty.

6. At what stage of adolescence can girls fall pregnant?

As soon as they start having periods it is possible for girls to fall pregnant.

Case study 2

Parents bring their 16-year-old son to the clinic as they are worried about his behaviour. He is doing badly at school, coming home late over weekends and playing a game of running in front of oncoming cars to impress his friends. He refuses to discuss his behaviour with his parents.

1. Is this common behaviour in boys of 16?

This is typical behaviour during middle adolescence which makes it a most difficult time for the family. It is a time of rapid behaviour change when teenagers take risks and want to be admired by their friends.

2. Why do adolescents often not obey their parents?

Because they are trying to be independent and do not like being told what to do. They take advice from their friends rather their family or teachers. They want to be adults but lack the maturity and experience to take full responsibility for their thoughts and actions.

3. What are the main risks to an adolescent boy that parents worry about?

Parents worry that their son may be injured or even killed by irresponsible behaviour. Dropping out of school, alcohol and drug abuse or getting a girl pregnant are also concerns.

4. What are the main adolescent tasks that this boy faces?

He needs to learn to control his behaviour and conform to the norms of society. He also needs to accept social and other responsibilities and take charge of his own life. This is usually achieved during the late stage of adolescence.

5. What can a community health worker do to help these parents?

The community health worker can advise the parents to send their son to an adolescent-friendly clinic where he can get counselling and talk about his frustrations at home.

Case study 3

A girl of 17 attends an adolescent-friendly clinic as she is worried that she may be pregnant. She says she has been having sex with an older man who buys her clothes and CDs.

1. What are the major risks of girls at 16?

This may lead to unwanted pregnancy, sexually transmitted infections and abuse.

2. Is she old enough to legally have sex?

Yes as adolescents of 16 years or older can have sex legally. However she should have the knowledge to use condoms as protection against sexually transmitted infections and take a reliable form of contraception.

3. How common are adolescent pregnancies in South Africa?

About 16% of pregnant women in South Africa are adolescents.

4. What are the problems of an adolescent pregnancy?

The pregnancy is often unintended and unwanted which leads to an interruption of schooling and financial and family problems. Adolescent pregnancy is commonly the result of a physically or emotionally abusive relationship. There are also medical risks especially if she gets an unsafe abortion. Pregnancy in young adolescents can result in undernutrition and stunting.

5. Is she old enough to ask for a termination of pregnancy?

Any women, whether an adolescent or adult, can ask for a free abortion up to 12 weeks of pregnancy. Although it is advisable, an adolescent does not need her parent’s permission.