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. 35-1). This is followed in approximately 2 to 6 months by growth of pubic hair on the mons pubis, known as adrenarche (Fig. 35-2). In a minority of normally developing girls, however, pubic hair may precede breast development. The average age of thelarche for Caucasian girls is 10 years, with a range of 8 to 12¾ 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.

FIG 35-1 Development of the breast in girls—average age span: 8 to 13 years. Stage 1 (prepubertal, elevation of papilla only) is not shown. (Adapted from Daniel WA, Paulshock BZ: A physician’s guide to sexual maturity, *Patient Care* 13:122–124, 1979; Marshall WA, Tanner JM: Variations in pattern of pubertal changes in girls, *Arch Dis Child* 44:291, 1969.)

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 noted between Caucasian 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 10½ 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. 35-3). These events usually occur between 9½ 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 13½ to 14 years of age or if genital growth is not complete 4 years after the testicles begin to enlarge.

FIG 35-3 Developmental stages of secondary sex characteristics and genital development in boys—average age span: 12½ to 16 years. (Adapted from Daniel WA, Paulshock BZ: A physician’s guide to sexual maturity, *Patient Care* 13:122–124, 1979; Marshall WA, Tanner JM: Variations in pattern of pubertal changes in girls, *Arch Dis Child* 44:291, 1969.)

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 9½ and 14½ years; on average, it begins between ages 10½ 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 2½ 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.

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, whereas 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 notable in boys. Later, variable amounts of fat are deposited to fill out and contour the mature physique in patterns characteristic of the adolescent’s gender, particularly in the regions over the thighs, hips, and buttocks and around the breast tissue. It should be noted, however, that pediatric obesity has increased in the United States, and it is believed that obesity can change the timing 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. Kaplowitz (2008) points out that there is evidence of 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 47). The eccrine sweat glands, present almost everywhere on the human skin, become fully functional and respond to emotional and 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 very 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 appear 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 the male.

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, whereas the pulse rate and basal heat production decrease (see Appendix C). 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 (Erikson, 1963). 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 a 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, the adolescent is faced with the crisis of group identity versus alienation. In the period that follows, the individual strives 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 sense of 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. Adolescents find it essential to have a group to which they feel they can belong and that provides them with 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 the adolescent. 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 in which they can display their own self-assertion while they reject 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 adolescent’s behavior. Often these expectations or demands are persistent enough to result in certain decisions that might be made differently or not at all if the individual could be solely responsible for identity formation. It is all too easy to slip into the roles that are expected by these external influences without incorporating personal goals or questioning these decisions. Thus individuals may become what parents or others wish them to be, based on these premature decisions. Adolescents 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 “loser,” “punk,” “troublemaker,” 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 eventually emerges. Role diffusion results when the individual is unable to formulate a satisfactory identity from the multiplicity of aspirations, roles, and identifications.

Critical Thinking Case Study

Discussing the Future

Jeremy, age 17, will be graduating from high school in the spring. His mother, a single parent, tells you that she is concerned because graduation is quickly approaching and Jeremy has made no plans for what he will do with his life after graduation. Whenever Jeremy mentions the topic, his mother tells him “This is what you must do” and begins to outline the steps he must take. Jeremy just walks away. She asks, “What should I do?” What advice should you give Jeremy’s mother?

1. Evidence—Is there sufficient evidence to draw any conclusions about what advice the nurse should give Jeremy’s mother?

2. Assumptions—Describe an underlying assumption about each of the following issues:

a. Adolescents and the search for personal identity

b. The influence of others on the adolescent’s search for personal identity

c. Ways to communicate with adolescents

3. What implications and priorities for nursing care can be drawn at this time?

4. Does the evidence objectively support your argument (conclusion)?

Sex-Role Identity.

Adolescence is the time for consolidation of a sex-role identity. During early adolescence, the peer group begins to communicate expectations regarding heterosexual relationships, and as development progresses, adolescents encounter expectations for mature sex-role behavior from both peers and adults. Expectations vary from culture to culture, among geographic areas, and among socioeconomic groups.

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 increase 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 more mature emotions. 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 now 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 high 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 teenager but at the same time cheats on an income tax report or expense account.

In adolescence, young people begin to think about 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, as well as 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 some 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 adhere 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 post–secondary 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. As adolescents mature and form an identity, they may either reject their family’s traditional beliefs or they may decide to conform to those beliefs (Neuman, 2011).

Neuman (2011) suggests that adolescents, who are searching for an identity and personal growth, may perceive God as one who accepts them and confirms their self-identity. Religious beliefs in adolescence are also strongly influenced by interpersonal relationships with peers as well as adults in their environment.

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.