Health Promotion of the Adolescent and Family



Health Promotion of the Adolescent and Family


Linda M. Kollar



image


evolve.elsevier.com/wong/essentials





Promoting Optimal Growth and Development


Adolescence is a period of transition between childhood and adulthood—a time of rapid physical, cognitive, social, and emotional maturation as boys prepare for manhood and girls prepare for womanhood (see Cultural Considerations box). The precise boundaries of adolescence are difficult to define, but this period is customarily viewed as beginning with the gradual appearance of secondary sex characteristics at about 11 or 12 years of age and ending with cessation of body growth at 18 to 20 years.



Several terms are used to refer to this stage of growth and development. Puberty refers to the maturational, hormonal, and growth process that occurs when the reproductive organs begin to function and the secondary sex characteristics develop. This process is sometimes divided into three stages: prepubescence, the period of about 2 years immediately before puberty when the child is developing preliminary physical changes that herald sexual maturity; puberty, the point at which sexual maturity is achieved, marked by the first menstrual flow in girls but by less obvious indications in boys; and postpubescence, a 1- to 2-year period after puberty during which skeletal growth is completed and reproductive functions become fairly well established. Adolescence, which literally means “to grow into maturity,” is generally regarded as the psychologic, social, and maturational process initiated by the pubertal changes. It involves three distinct subphases: early adolescence (ages 11–14), middle adolescence (ages 15–17), and late adolescence (ages 18–20). The term teenage years is used synonymously with adolescence to describe ages 13 through 19 years.



Biologic Development


The physical changes of puberty are primarily the result of hormonal activity under the influence of the central nervous system, although all aspects of physiologic functioning are mutually interacting. The obvious physical changes are noted in increased physical growth and in the appearance and development of secondary sex characteristics; less obvious are physiologic alterations and neurogonadal maturity, accompanied by the ability to procreate. Physical distinction between the sexes is made on the basis of distinguishing characteristics. Primary sex characteristics are the external and internal organs that carry out the reproductive functions (e.g., ovaries, uterus, breasts, penis). Secondary sex characteristics are the changes that occur throughout the body as a result of hormonal changes (e.g., voice alterations, development of facial and pubertal hair, fat deposits) but that play no direct part in reproduction.



Hormonal Changes of Puberty


The events of puberty are caused by hormonal influences and controlled by the anterior pituitary (adenohypophysis) in response to a stimulus from the hypothalamus. Stimulation of the gonads has a dual function:



The ovaries, testes, and adrenals secrete sex hormones. These hormones are produced in varying amounts by both sexes throughout the life span. The adrenal cortex is responsible for the small amounts secreted before the pubescent years, but the sex hormone production that accompanies maturation of the gonads is responsible for the biologic changes observed during puberty.


Estrogen, the feminizing hormone, is found in low quantities during childhood. This hormone is secreted in slowly increasing amounts until about age 11 years. In males, this gradual increase continues through maturation. In females, the onset of estrogen production in the ovary causes a pronounced increase that continues until about 3 years after the onset of menstruation, at which time it reaches a maximum level that continues throughout the reproductive life of the female.


Androgens, the masculinizing hormones, are also secreted in small and gradually increasing amounts up to about 7 or 9 years of age, at which time there is a more rapid increase in both sexes, especially boys, until about age 15 years. These hormones appear to be responsible for most of the rapid growth changes of early adolescence. With the onset of testicular function, the level of androgens (principally testosterone) in males increases over that in females and continues to increase until a maximum is attained at maturity.



Sexual Maturation


image The visible evidence of sexual maturation is achieved in an orderly sequence, and the state of maturity can be estimated on the basis of the appearance of these external manifestations. The age at which these changes are observed and the time required to progress from one stage to another may vary among children. The time from the appearance of breast buds to full maturity may be image to 6 years for adolescent girls. It may take 2 to 5 years for male genitalia to reach adult size. The stages of development of secondary sex characteristics and genital development have been defined as a guide for estimating sexual maturity and are referred to as the Tanner stages (Box 16-1). The usual sequence of appearance of maturational changes is presented in Box 16-2.




image Animation—Ovarian Growth



Sexual Maturation in Girls

In most girls, the initial indication of puberty is the appearance of breast buds, an event known as thelarche, which occurs between 8 and 13 years of age (Fig. 16-1). This is followed in approximately 2 to 6 months by growth of pubic hair on the mons pubis, known as adrenarche (Fig. 16-2). In a minority of normally developing girls, however, pubic hair may precede breast development. The average age of thelarche for white girls is 10 years, with a range of 8 to 12.75 years; for African-American girls, the average age of thelarche is earlier, around 9 years, with a range of 7 to 11 years (Herman-Giddens, 2006). The average age of thelarche for Hispanic girls falls somewhere between the other two groups.




The initial appearance of menstruation, or menarche, occurs about 2 years after the appearance of the first pubescent changes, approximately 9 months after attainment of peak height velocity, and 3 months after attainment of peak weight velocity. There is evidence that girls are developing secondary sex characteristics at a younger age with differences between white and African-American girls. The explanation for this is not yet clear but appears to be influenced by being overweight as well as environmental influences. The normal age range of menarche is usually image to 15 years, with the average age being 12 years, 4 months for North American girls (Wu, Mendola, and Buck, 2002). Ovulation and regular menstrual periods usually occur 6 to 14 months after menarche. Girls may be considered to have pubertal delay if breast development has not occurred by age 13 years or if menarche has not occurred within 4 years of the onset of breast development.



Sexual Maturation in Boys

The first pubescent changes in boys are testicular enlargement accompanied by thinning, reddening, and increased looseness of the scrotum (Fig. 16-3). These events usually occur between image and 14 years of age. Early puberty is also characterized by the initial appearance of pubic hair. Penile enlargement begins, and testicular enlargement and pubic hair growth continue throughout midpuberty. During this period, there is also increasing muscularity, early voice changes, and development of early facial hair. Temporary breast enlargement and tenderness, gynecomastia, are common during midpuberty, occurring in up to one third of boys. The spurts in height and weight occur concurrently toward the end of midpuberty. For most boys, breast enlargement disappears within 2 years. By late puberty, there is a definite increase in the length and width of the penis, testicular enlargement continues, and first ejaculation occurs. Axillary hair develops, and facial hair extends to cover the anterior neck. Final voice changes occur secondary to the growth of the larynx. Concerns about pubertal delay should be considered for boys who exhibit no enlargement of the testes or scrotal changes by image to 14 years of age or if genital growth is not complete 4 years after the testicles begin to enlarge.




Physical Growth


A constant phenomenon associated with sexual maturation is a dramatic increase in growth. The final 20% to 25% of height is achieved during puberty, and most of this growth occurs during a 24- to 36-month period—the adolescent growth spurt. This accelerated growth occurs in all children but, as in other areas of development, is highly variable in age of onset, duration, and extent. The growth spurt begins earlier in girls, usually between ages image and image years; on average it begins between ages image and 16 years in boys. During this period, the average boy gains 10 to 30 cm (4–12 inches) in height and 7 to 30 kg (15.5–66 pounds) in weight. The average girl, in whom the growth spurt is slower and less extensive, gains 5 to 20 cm (2–8 inches) in height and 7 to 25 kg (15.5–55 pounds) in weight. Growth in height typically ceases 2 to image years after menarche in girls and at age 18 to 20 years in boys.


This increase in size is acquired in a characteristic sequence. Growth in length of the extremities and neck precedes growth in other areas, and because these parts are the first to reach adult length, the hands and feet appear larger than normal during adolescence. Increases in hip and chest breadth take place in a few months followed several months later by an increase in shoulder width. These changes are followed by increases in length of the trunk and depth of the chest. This sequence of changes is responsible for the characteristic long-legged, gawky appearance of early adolescent children.



Sex Differences in General Growth Patterns

Sex differences in general growth and distribution patterns are apparent in skeletal growth, muscle mass, adipose tissue, and skin. Skeletal growth differences between boys and girls are apparently a function of hormonal effects at puberty and are evident primarily in limb length. The earlier cessation of growth in girls is caused by epiphyseal unity under the potent effect of estrogen secretion, and the hormonal effect on female bone growth is much stronger than the similar effect of testosterone in boys. In boys, the prolonged growth period before puberty and the less rapid epiphyseal closure are reflected in their greater overall height and longer arms and legs. Other skeletal differences are increased shoulder width in boys and broader hip development in girls.


Hypertrophy of the laryngeal mucosa and enlargement of the larynx and vocal cords occur in both boys and girls to produce voice changes. Girls’ voices become slightly deeper and considerably fuller, but the effect in boys is striking. The change in the voice of adolescent boys occurs between Tanner stages 3 and 4, with the voice often shifting uncontrollably from deep to high tones in the middle of a sentence. The average lengthening of the vocal cords is 10.9 mm (0.4 inch) for boys and 4.2 mm (0.17 inch) for girls.


Growth of lean body mass, principally muscle, which tends to occur after the bone growth spurt, takes place steadily during adolescence. Lean body mass is both quantitatively and qualitatively greater in boys than in girls at comparable stages of pubertal development. Muscle development, under the influence of androgenic hormones, increases steadily. Muscles become remarkably well developed in boys, but in girls, muscle mass increase is proportionate to general tissue growth.


Nonlean body mass, primarily fat, is also increased but follows a less orderly pattern. There may be a transient increase in subcutaneous fat just before the skeletal growth spurt, especially in boys. This is followed 1 to 2 years later by a modest to marked decrease, which is again more marked in boys. Later, variable amounts of fat are deposited to fill out and contour the mature physique in patterns characteristic of the adolescent’s sex, particularly in the regions over the thighs, hips, and buttocks and around the breast tissue. It should be noted, however, that pediatric obesity is steadily on the increase in the United States, and obesity can change the timing and sequence of puberty. Girls with thelarche as the first sign of puberty have earlier menarche and greater body fat and body mass index (BMI) at menarche than girls with adrenarche as the first pubertal sign. This may have long-term effects for increased risk of adult adiposity and obesity (Biro, Lucky, Simbarti, and others, 2003). Kaplowitz (2008) states that evidence indicates a causal relationship between obesity and onset of early puberty in girls rather than earlier puberty causing an increase in body fat; no correlations between body fat and earlier puberty in boys have been reported.


Hormonal influences during puberty cause acceleration in growth and maturation of the skin and its structural appendages. Sebaceous glands become extremely active at this time, especially those on the genitalia and in the “flush areas” of the body (i.e., face, neck, shoulders, upper back, and chest). This increased activity and the structural nature of the glands are extremely important in the pathogenesis of a common problem of puberty: acne (see Chapter 30). The eccrine sweat glands, present almost everywhere on the human skin, become fully functional and respond to emotional as well as thermal stimulation. Heavy sweating appears to be more pronounced in boys than in girls. The apocrine sweat glands, nonfunctional in childhood, reach secretory capacity during puberty. Unlike the eccrine sweat glands, the apocrine glands are limited in distribution and grow in conjunction with hair follicles in the axillae, around the areola of the breast, around the umbilicus, on the external auditory canal, and in the genital and anal regions. Apocrine glands secrete a thick substance as a result of emotional stimulation that, when acted on by surface bacteria, becomes highly odoriferous.


Body hair assumes characteristic distribution patterns and changes texture during puberty. Under the influence of gonadal and adrenal androgens, hair coarsens, darkens, and lengthens at sites related to secondary sex characteristics. Pubic and axillary hair appears in both sexes, although pubic hair is more extensive in males than in females. Beard, mustache, and body hair on the chest, upward along the linea alba, and sometimes on other areas (e.g., back and shoulders) appears in males and is androgen dependent. Extremity hair appears in varying amounts in both males and females but is also more prolific in males.



Physiologic Changes


A number of physiologic functions are altered in response to some of the pubertal changes. The size and strength of the heart, blood volume, and systolic blood pressure increase, and the pulse rate and basal heat production decrease (see Appendix E and inside back cover). Blood volume, which has increased steadily during childhood, reaches a higher value in boys than in girls, a fact that may be related to the increased muscle mass in pubertal boys. Adult values are reached for all formed elements of the blood. Respiratory rate and basal metabolic rate, decreasing steadily throughout childhood, reach the adult rate in adolescence. Respiratory volume and vital capacity are increased and to a far greater extent in males than in females. During this period, physiologic responses to exercise change drastically: performance improves, especially in boys, and the body is able to make the physiologic adjustments needed for normal functioning after exercise is completed. These capabilities are a result of the increased size and strength of muscles and the increased level of cardiac, respiratory, and metabolic functioning.



Psychosocial Development


Developing a Sense of Identity (Erikson)


Traditional psychosocial theory holds that the developmental crisis of adolescence leads to the formation of a sense of identity. Throughout childhood, individuals have been going through the process of identification as they concentrate on various parts of the body at specific times. During infancy, children identify themselves as being separate from the mother; during early childhood they establish gender role identification with the appropriate-sex parent; and in later childhood, they establish who they are in relation to others. In adolescence, they come to see themselves as distinct individuals, somehow unique and separate from every other individual.


Adolescence begins with the onset of puberty and extends to relative physical and emotional stability at or near graduation from high school. During this time, adolescents are faced with the crisis of group identity versus alienation. In the period that follows, individuals strive to attain autonomy from the family and develop a sense of personal identity as opposed to role diffusion. A sense of group identity appears to be essential to the development of a personal identity. Young adolescents must resolve questions concerning relationships with a peer group before they are able to resolve questions about who they are in relation to family and society.



Group Identity

During the early stage of adolescence, pressure to belong to a group is intensified. Teenagers find it essential to belong to a group from which they can derive status. Belonging to a crowd helps adolescents establish the differences between themselves and their parents. They dress as the group dresses and wear makeup and hairstyles according to group criteria, all of which are different from those of the parental generation. Language, music, and dancing reflect a culture that is exclusive to adolescents. When adults begin to emulate these fashions and interests, the style changes immediately. The evidence of adolescent conformity to the peer group and nonconformity to the adult group provides teenagers with a frame of reference for self-assertion and rejection of the identity of their parents’ generation. To be different is to be unaccepted and alienated from the group.



Individual Identity

The quest for personal identity is part of the ongoing identification process. As adolescents establish identity within a group, they also attempt to incorporate multiple body changes into a concept of the self. Body awareness is part of self-awareness. In their search for identity, adolescents consider the relationships that have developed between themselves and others in the past, as well as the directions they hope to take in the future.


Significant others hold expectations for the behavior of adolescents. Often these expectations or demands are persistent enough that individuals make certain decisions that they would not make if they were solely responsible for identity formation. Adolescents may find it too easy to slip into the roles expected by others without incorporating their own personal goals or questioning decisions. Thus, individuals may become what parents or others wish them to be based on these premature decisions. Young persons might form a negative identity when society or their culture provides them with a self-image that is contrary to the values of the community. Labels such as “juvenile delinquent,” “hoodlum,” or “failure” are applied to certain adolescents, who then accept and live up to these labels with behaviors that validate and strengthen them.


The process of evolving a personal identity is time consuming and fraught with periods of confusion, depression, and discouragement. Determining an identity and a place in the world is a critical and perilous feature of adolescence (see Critical Thinking Case Study). However, as the pieces gradually shift and settle into place, a positive identity emerges. Role diffusion results when the individual is unable to formulate a satisfactory identity from the multiplicity of aspirations, roles, and identifications.





Emotionality

Adolescents vacillate in their emotional states between considerable maturity and childlike behavior. One minute they are exuberant and enthusiastic; the next minute they are depressed and withdrawn. Unpredictable but essentially normal, mood swings are common during this time. As the tension is relieved, emotion is brought under control, and individuals retreat to review what has happened, to attempt to master their anger, and to grow in their ability to control their emotions and gain from the new experience. Because of these mood swings, adolescents are frequently labeled as unstable, inconsistent, and unpredictable. Little things can cause an emotional upheaval and, depending on the teenager’s interpretation, can mean a great deal.


Teenagers are better able to control their emotions in later adolescence. They can approach problems more calmly and rationally, and although they are still subject to periods of sadness, their feelings are less vulnerable, and they begin to demonstrate the more mature emotions of later adolescence. Whereas early adolescents react immediately and emotionally, older adolescents can control their emotions until socially acceptable times and places for expression present themselves. They are still subject to heightened emotion, and when it is expressed, their behavior reflects feelings of insecurity, tension, and indecision.



Cognitive Development (Piaget)


Cognitive thinking culminates with the capacity for abstract thinking. This stage, the period of formal operations, is Piaget’s fourth and last stage. Adolescents are no longer restricted to the real and actual, which was typical of the period of concrete thought; now they are also concerned with the possible. They think beyond the present. Without having to center attention on the immediate situation, they can imagine a sequence of events that might occur, such as college and occupational possibilities; how things might change in the future, such as relationships with parents; and the consequences of their actions, such as dropping out of school. At this time, their thoughts can be influenced by logical principles rather than just their own perceptions and experiences. They become increasingly capable of scientific reasoning and formal logic.


Adolescents are capable of mentally manipulating more than two categories of variables at the same time. For example, they can consider the relationship between speed, distance, and time in planning a trip. They can detect logical consistency or inconsistency in a set of statements and evaluate a system or set of values in a more analytic manner. For instance, they question the parent who insists on honesty in the youngster but at the same time cheats on an income tax report or expense account.


In adolescence, young people begin to consider both their own thinking and the thinking of others. They wonder what opinion others have of them, and they are able to imagine the thoughts of others. With this capacity comes the ability to differentiate between others’ thoughts and their own and to interpret the thoughts of others more accurately. They are able to understand that few concepts are absolute or independent of other influencing factors. As they become aware that other cultures and communities have different norms and standards from their own, it becomes easier for them to accept members of these other cultures, and the decision to behave in their own culture in an accepted manner becomes a more conscious commitment.



Moral Development (Kohlberg)


Although younger children merely accept the decisions or point of view of adults, adolescents, to gain autonomy from adults, must substitute their own set of morals and values. When old principles are challenged but new independent values have not yet emerged to take their place, young people search for a moral code that preserves their personal integrity and guides their behavior, especially in the face of strong pressure to violate the old beliefs. Their decisions involving moral dilemmas must be based on an internalized set of moral principles that provides them with the resources to evaluate the demands of the situation and to plan actions that are consistent with their ideals.


Late adolescence is characterized by serious questioning of existing moral values and their relevance to society and the individual. Adolescents can easily take the role of another. They understand duty and obligation based on reciprocal rights of others and the concept of justice that is founded on making amends for misdeeds and repairing or replacing what has been spoiled by wrongdoing. However, they seriously question established moral codes, often as a result of observing that adults verbally ascribe to a code but do not adhere to it.



Spiritual Development


As adolescents move toward independence from parents and other authorities, some begin to question the values and ideals of their families. Others cling to these values as a stable element in their lives as they struggle with the conflicts of this turbulent period. Adolescents need to work out these conflicts for themselves, but they also need support from authority figures or peers for their resolution.


Adolescents are capable of understanding abstract concepts and of interpreting analogies and symbols. They are able to empathize, philosophize, and think logically. Most teens search for ideals and speculate about illogical statements and conflicting ideologies. Their tendency toward introspection and emotional intensity often makes it difficult for others to know what they are thinking. They tend to keep their thoughts private, fearing that no one will understand these feelings that they perceive to be unique and special. However, they may reveal deep spiritual concerns. They need support and encouragement in their struggle for understanding and the freedom to question without censure.


Generally, the stated importance of participation in organized religion declines somewhat during the adolescent years. More high school students than postsecondary school young people attend religious services regularly, and, not surprisingly, the younger the adolescents, the more likely they are to view religion as being important to them. Among older adolescents, the importance of organized religion declines more among college students than among those not in college. Late adolescence appears to be a time when individuals reexamine and reevaluate many of the beliefs and values of their childhood. Consistent with developmental changes in value autonomy, the religious beliefs of young people are likely to become more personalized and less bound to the traditional religious practices they may have been exposed to when they were younger.


Greater levels of religiosity and spirituality are associated with fewer high-risk behaviors and more health-promoting behaviors, especially for youth living in environments lacking positive influences (Regnerus and Glen, 2003). Nurses play an important role for teens by providing an opportunity to discuss issues regarding spirituality.



Social Development


To achieve full maturity, adolescents must free themselves from family domination and define an identity independent of parental authority. However, this process is fraught with ambivalence on the part of both teenagers and their parents. Adolescents want to grow up and to be free of parental restraints, but they are fearful as they try to comprehend the responsibilities that are linked with independence. Feelings of immortality and exemption from the consequences of risk-taking behavior, although viewed as negative, can serve an important developmental function at this time. These feelings give adolescents the courage to separate from their parents and become independent. Part of this emancipation involves developing social relationships outside the family that help teenagers identify their role in society. Adolescence is a time of intense sociability and often a time of equally intense loneliness. Acceptance by peers, a few close friends, and the secure love of a supportive family are requisites for interpersonal maturation.



Relationships with Parents


During adolescence, the parent–child relationship changes from one of protection–dependency to one of mutual affection and equality. The process of achieving independence often involves turmoil and ambiguity as both parent and adolescent learn to play new roles and work toward this end while at the same time resolving the often painful series of rifts essential to establishing the ultimate relationship.


Most behavior observed in the adolescent is related to the struggle for independence and the external restrictions and checks that are placed on this spontaneous maturation process. On the one hand, adolescents are accepted as maturing preadults. They are allowed privileges heretofore denied, and they are provided with increasing responsibilities. On the other hand, because of their unpredictability and insecurity in evaluating situations and making sound judgments, they must conform to regulations and restrictions set by adults. This state of affairs is particularly exemplified by the struggle between parents and adolescents concerning the nightly curfew.


As teenagers assert their rights for grown-up privileges, they frequently create tensions within the home. They resist parental control, and conflicts can arise from almost any situation or any subject. Favorite topics of dispute include use of the home telephone, Internet use, the need for a personal cellular telephone, manners, dress, chores and duties, homework, disrespectful behavior, friendships, dating and relationships, money, automobiles, alcohol and other substance abuse, and time schedules. Present in these areas of conflict are the overriding arguments that “Everyone else has one” or is allowed the desired item or privilege and the ever-present assertions that “You don’t understand me or trust me” and “You always treat me like a baby.” Spoken or unspoken, parents’ reactions consist of “Is this all the thanks I get for what I have done for you?”


Teenagers’ earliest attempts to achieve emancipation from parental controls are manifested in a period of rejection of the parents. They absent themselves from home and family activities and spend an increasing amount of time with the peer group. They confide less in their parents, but parents continue to play an important role in the personal and health-related decision making of adolescents.


With advancing adolescence, teenagers become more competent, and with this competence comes a need for more autonomy. Although they may be psychologically prepared for independence, they are often thwarted in their efforts by lack of money or other parental barriers. Conflict arises in relation to the teenagers’ outside activities and the elements of privacy and trust. Parental monitoring remains important throughout adolescence and may have a direct influence on adolescent sexual and substance use behavior. Parents should be guided toward an authoritative style of parenting in which authority is used to guide the adolescent while allowing developmentally appropriate levels of freedom and providing clear, consistent messages regarding expectations. Authoritative style of parenting has been shown to have both immediate and long-term protective effects toward adolescent risk reduction (DeVore and Ginsburg, 2005). However, to gain the trust of adolescents, parents must respect their adolescent’s privacy and show an honest and sincere interest in what the adolescent believes and feels (see Family-Centered Care box).




Relationships with Peers


Although parents remain the primary influence in their lives, for the majority of teenagers, peers assume a more significant role in adolescence than they did during childhood. The peer group serves as a strong support to teenagers, individually and collectively, providing them with a sense of belonging and a feeling of strength and power. The peer group forms the transitional world between dependence and autonomy.



Peer Group

Adolescents are usually social, gregarious, and group minded. Thus, the peer group has an intense influence on adolescents’ self-evaluation and behavior. To gain acceptance by a group, younger teenagers tend to conform completely in such things as mode of dress, hairstyle, taste in music, and vocabulary. Teenagers use the peer group as a yardstick of what is normal.


The school is psychologically important to adolescents as a focus of social life. Teenagers usually distribute themselves into a relatively predictable social hierarchy. They know to which groups they and others belong. A sense of school connectedness and optimal social connectedness is associated with positive outcomes for school completion, positive mood, and decreased high-risk behavior in adolescents (Bond, Butler, Thomas, and others, 2007). School connectedness is correlated with caring teachers and the absence of prejudice or discrimination from peers. A sense of school connectedness is less dependent on class size, attendance, academic preparation, and parental involvement (Maes and Lievens, 2003).


Within the larger groups are smaller, distinct, and exclusive crowds or cliques of selected close friends who are emotionally attached to one another. The selection is based on common tastes, interests, and background. Although cliques may become formalized, most remain informal and small. However, each has an identifying feature that proclaims its difference from others and its solidarity within itself in much the same manner as the adolescent generation as a whole sets itself apart from the adult generation. Cliques are usually made up of one sex, and girls tend to be more cliquish than boys and to have a greater need for close friendships (Fig. 16-4). Within the intimacy of the group, adolescents gain support in learning about themselves, consideration for the feelings of others, and increased ego development and self-reliance.


Jan 16, 2017 | Posted by in NURSING | Comments Off on Health Promotion of the Adolescent and Family
Premium Wordpress Themes by UFO Themes