Early Adolescence: Ages 10 to 13 Years

Early adolescence is a period of rapid growth and development. The physical changes involve all body systems but especially the cardiovascular, musculoskeletal, and reproductive systems. The adolescent’s self-image is affected as he or she attempts to incorporate both physical and psychological changes. These young adolescents have questions about menstruation, breast development, testicular and penis size, and wet dreams. They wonder whether they are normal and compare themselves with their peers. During early adolescence, exploratory sexual behavior may occur with friends of the same or opposite sex.

During this phase, thinking remains concrete, and the young teenager lacks the capacity for abstract thinking or introspection. The early adolescent has a rich fantasy life. Peer acceptance and conformity are important to the adolescent and may result in parental-adolescent conflict.

Middle Adolescence: Ages 14 to 16 Years

Physiologic growth and development of secondary sexual characteristics may be completed during this period. Middle adolescents focus on making their appearance as attractive as possible. At this time, in an effort to adjust to body changes, adolescents experiment with new images. They use peers to share experiences and try out new roles. Adolescents in this age group have the ability to think more abstractly and may begin to realize the limits of their potential. For those in disadvantaged situations, a feeling of hopelessness may begin. The middle adolescent may become increasingly self-centered and feel invincible. While testing the limits of power, teens may engage in high-risk behaviors. Experiments with drugs, alcohol, and sex are avenues for rebellion. This can be a period of great turmoil for the family as the adolescent struggles for independence and challenges family values and expectations. During this time, adolescents would like to be treated as adults; however, their behavior fluctuates. They may or may not recognize that risk-taking behaviors can bring negative consequences.

Late Adolescence: Ages 17 to 20 Years

Late adolescence is characterized by the ability to maintain stable, reciprocal relationships. The family becomes more important; however, independence from parents is a major part of the developmental task. By late adolescence, many teens have more realistic images of themselves and are more secure about their appearance.

Sexual identity is usually firmly established during late adolescence. Problem solving is used to view consequences of behavior, and plans are more future-oriented. Ideally, the late adolescent will have developed an ability to solve problems, assess many aspects of life situations, and delay immediate gratification. It is important for them to understand the impact of their choices on their future. For example, they need to think through the consequences of not using birth control; recognize that using contraception will prevent pregnancy; and be aware that unprotected sex can lead to illness, which may involve discomfort or be life threatening.

Prevention of Adolescent Pregnancy

Confidentiality and the Adolescent

Confidentiality laws differ in various states, meaning that some adolescents may not have access to confidential counseling and contraceptive advice. If the health care worker cannot ensure confidentiality, some teens will not seek health care. Adolescents are at greater risk for complications than adults because they are the least likely to seek early health care.

All 50 states have enacted legislation that entitles adolescents to consent to treatment with confidentiality for “medically emancipated conditions.” Although the law varies from state to state (see Online Resources), the list of medically emancipated conditions generally refers to contraception, pregnancy, pregnancy-related care, STIs, substance abuse, and sexual assault. The Health Insurance Portability and Accountability Act (HIPAA) ensures patient privacy in all adult cases. All 50 states allow confidential STI testing of adolescents.

Pregnancy and the Adolescent

Menstruation is a sign of a girl’s transition into womanhood and fertility and is celebrated in many cultures. However, in the United States, it is often viewed as a nuisance, stressful, and sometimes uncomfortable. Many young women opt to take medications to reduce the number of menstrual periods from the natural 12 times a year to 1 or 3 times a year. This may prevent unplanned pregnancies but these methods do not protect against STI infection.

Termination of Education

Teenage pregnancy remains the main cause of dropping out of school for adolescent girls. Sexual activity is often associated with poor school performance. The level of formal education is an important predictor of job advancement and earning potential. Adolescent girls who have not completed high school are more likely to be unemployed or employed in entry-level jobs, and lack job security. Generally, in addition to holding low-paying jobs, they may have no health care benefits for themselves and their children.

Adolescent Fathers

It is estimated that 1 in 15 boys fathers a child while he is a teenager. In general, the adolescent father faces sociologic and psychological risks. Many adolescent couples do not plan to marry; however, if the adolescent boy is from a rural area or a specific cultural group, marriage is more likely. Some adolescent fathers, even without marriage, may be involved in the adolescent girl’s pregnancy and child rearing.

Adolescent fathers tend to achieve less formal education than older fathers, and they enter the labor force earlier and with less education. The stresses of pregnancy on the male adolescent come from several sources. He is likely to face a negative reaction from his own family and from the girl’s family. The young girl’s parents may refuse to let him see their daughter, which often makes him feel isolated, alone, and unable to give her support. His future career may be threatened by early marriage or quitting school to support the pregnant girl and new child. Also, his relationship with his peers is altered.

The lack of responsibility shown by some adolescent fathers is a reflection of cultural and community attitudes. Sometimes an adolescent’s ability to impregnate may be viewed, among peers, with a sense of pride and as a sign of manhood.

As part of counseling, the nurse should assess the young man’s stressors, his support system, and his plans for involvement in the pregnancy. If the father is involved in the pregnancy, the young mother may feel less alone and may be better able to discuss her future plans. The young father should be welcomed in the prenatal sessions.

A sizable number of fathers are 6 or more years older than the adolescent mother. Some younger girls are more likely to have much older sexual partners. Older sex partners may be supportive of the pregnant adolescent before the delivery, but their relationship with the mother and newborn may weaken over time. Before delivery, many unwed fathers may plan to contribute to the support of the mother and newborn, but during delivery, most adolescent girls select their mothers as their support person.

Antepartum Care of Adolescents

Care of the Adolescent During Labor and Delivery

The adolescent is often modest and may not tolerate pain well. Breathing and relaxation and concentration techniques require patience that many teens lack. Pain control and adequate coaching are essential, especially if a support person is not present. Suggestions to an adolescent support person must be given in a clear, concrete, detailed manner and involve specific directions and activities. The nurse must carefully explain to the adolescent in labor what is being done and what can be expected in order to prevent fear from developing and establish a trusting patient-nurse relationship.

Care of the Postpartum Adolescent

The adolescent may have inadequate coping skills to manage the transition to parenthood and parenting responsibilities. She may feel overwhelmed. Issues of child care, finances, schooling, and family dynamics need to be addressed. Encouragement, support, instruction, and an opportunity to practice perineal self-care and care of the newborn should be provided. The nurse can help adolescent parents integrate the newborn into their lives and offer them resources in the community for follow-up care. Grandparents who take over the complete care of the newborn may interfere with the teen’s development of parent-newborn attachment and adversely affect the teen’s self-image and future parenting skills. Grandparents can be encouraged to help with household tasks and offer positive suggestions and guidance that enable the teen parent to develop coping and parenting skills.

Adolescent Parenting

The transition to parenthood is not easy for adolescents. Often they still have unmet needs in their own phase of development. Acceptance of the role of parenting, including the responsibility of newborn care and their changed self-image, now sets them apart from their peers. Often they feel excluded from desirable “fun” activities characteristic of others their age because they are prematurely forced into the adult role.

Parenting programs available for adolescent mothers may be limited or nonexistent in the community. Adolescent mothers may also find they have little social and financial support. Many adolescent girls welcome the assistance of newborn care offered by their mothers, aunts, or grandmothers. In some cultures, a designated member of the family may accept the complete responsibility of rearing the child.

Many adolescent mothers tend to have repeated pregnancies that are closely spaced, which increases the risks to their health, continued education, and economic future. These factors create family instability and further impair good parenting. If the couple marries as teenagers, divorce tends to be more common.

Characteristic adolescent mother child-rearing practices have been identified, including insensitivity to newborn behavioral cues (e.g., crying, soiling diaper), pattern of limited nonverbal interaction, lack of knowledge of child development, preference for aggressive behavior and physical punishment, and limited learning in their home environment. Adolescent mothers tend to be at risk for non-nurturing behaviors, particularly in areas of inappropriate expectations. They may expect too much of their children because of limited knowledge of child developmental tasks. Adolescents often characterize their newborns as being “fussy.” This description may relate to lack of knowledge that newborn crying is expected behavior. These findings suggest a need for parenting classes for high school students.

Nurses must understand that the adolescent faces many hardships of living in two worlds—adolescence and motherhood. Appointment schedules need to be flexible, or follow-up care may not be sought. Support groups and child care resources may be needed so the adolescent can finish school and participate in some adolescent-type activities. Referral to agencies or professionals to help the adolescent develop coping skills and adapt to the parenting role may be necessary to develop a plan for a more positive future.

Urinary Tract Infections