Health professionals will care for young people in a variety of settings, across all fields of nursing and specialties. Understanding key elements of adolescent development will enhance practice and improve outcomes for young people (Colver and Longwell, 2013). Often young people's needs are overlooked, sometimes with fatal consequences (Pettit, 2014). Practitioners should have an awareness of young people's growth and development to be able to recognise and assess their physical, social, and emotional needs. This article provides an overview of adolescence and the implications for healthcare practice.
Adolescence is often characterised by biological growth and hormone changes, this period is commonly referred to as puberty (Sawyer et al, 2018). Sawyer et al (2018) claimed that this stage of development typically spans from 10-24 years old and is complete once there is epiphyseal fusion of long bones (Murray and Clayton, 2013). Adolescence is a period of immense change. These changes are physical, social and emotional, all of which have the possibility to present challenges and obstacles within a young person's life (Choudhury et al, 2008). Recent studies have also highlighted the importance of neurological changes in young people (Blakemore, 2018). To understand the complexity of adolescence, the sections below provide a brief overview of puberty, neurological, social, and emotional development.
Puberty, physical growth, and development
Puberty has been described as one of the most profound biological transitions in a person's life (Susman and Rogol, 2014). Among the many endocrine and paracrine activities, one catalyst for these changes is gonadotrophin hormone (GnRH) release (Murray and Clayton, 2013). GnRH is produced by the hypothalamus and controls the release of luteinizing hormone (LH) and follicle stimulating hormone (FSH), which are secreted by the pituitary gland. The release of GnRH is the most important control mechanism regulating sexual maturation and fertility (Child Growth Foundation, 2003). There are certain disorders that are prevalent in young people, although there is no definitive cause, rapid growth and development are indicated (Table 1).
Table 1. Examples of conditions with onset in adolescence
| Condition | Cause | Prevalence and onset |
|---|---|---|
| Idiopathic scoliosis | No definitive cause; rapid bone growth, genetics, hormones and environmental factors | Most common in children aged 10–15 years (NHS England, 2020)Higher prevalence in females (Konieczny et al, 2013) |
| Depression | No definitive cause, increased brain development and activity, overproduction of cortisol, no positive hormonal feedback mechanismRisk factors include genetic predisposing factors, trauma, chronic illness, alcohol or substance misuse, adverse childhood events | About 7.6% of children aged 12 years and older have had moderate to severe depression (Haefner, 2016)More common in females (National Institute for Health and Care Excellence, 2020a) |
| Crohn's disease | It is thought to be an auto-immune condition caused by environmental triggering events in genetically susceptible people (National Institute for Health and Care Excellence, 2020b) | About 20–30% of cases present before the age of 20 years (Oliveira and Monteiro, 2017) |
Puberty is characterised by physical changes, such as females starting their menstrual cycle and breast development, the descent and enlargement of testes in males, and growth in stature in both (Porta and Last, 2018). In addition, other significant changes include development of secondary sexual characteristics, such as hair growth, voice change and acne. These physical changes have been well documented, as seen in Marshall and Tanner's (1969; 1970) model of assessing puberty (Figure 1). The initial study was conducted over 20 years by Marshall and Tanner and, although dated, evidence suggested that these stages remain relevant and should be incorporated into growth charts (Cole et al, 2012). These are now added to the Childhood and Puberty Close Monitoring Chart (Royal College of Paediatrics and Child Health, 2013).
Figure 1. Tanner's model of sexual maturity
Neurological development
For many decades, the changes in young people's behaviour during adolescence were assigned to the flux of hormonal activity. However, recent evidence suggests that there are also changes in the brain during this period. For example, the pre-frontal cortex of the brain is remodeled during adolescence (Blakemore, 2018). This is the part of the brain that is involved in decision-making and is responsible for a young person's ability to plan and consider the consequences of their actions, as well as controlling impulses (Choudhury et al, 2008). Understanding neurological development during adolescence may help to understand a young person's thought processes and behaviour.
In England, on average more than 17 children and young people suffer a serious or fatal injury as a result of a road traffic accident every day (Public Health England, 2018), in part due to risk-taking behaviours. Such behaviours are commonly described as defiance, pushing the boundaries and/or identity development, often involving illicit activities (Leslie, 2008; Blakemore, 2018). Evidence suggests that risk-taking behaviour is a natural and necessary neurological process (Dumontheil, 2016), being described as ‘essential for the development of optimal social and psychological competence’ (Ben-Ari, 2004). Risk taking is often associated with negative behaviour; however, in the context of neurological development, risk taking is anything that pushes the young person out of their comfort zone. This could be a spectrum of activity, including starting a new school, making friends or trying different activities. The brain needs to exercise its neurological pathways to strengthen them.
Risk taking allows the brain to develop lasting neural pathways to the pre-frontal cortex. The amygdala and the hippocampus control the emotional regulatory centres that form part of the limbic region of the brain (Colver and Longwell, 2013). This rapid fluctuation in emotions and mood, often seen in adolescence, is attributed to this age group having less capacity to regulate heightened emotional reactivity (Heller and Casey, 2016). Heller and Casey's work demonstrates the development of this area of the brain and the changes that occur during adolescence. The emphasis shifts during adolescence from a spontaneous emotional response to a more calculated, logical response.
Andersen (2016) describes the period of adolescence as a time of ‘synaptic exuberance’, and concludes that information from the maturational stages that precede or occur during adolescence is likely to hold the key to optimising development to produce a young person and adult who is resilient and well adapted to their environment. Current research using functional magnetic resonance imaging adds to the evidence that the capacity for social interaction develops, in a large part, from the changes that our brains go through during adolescence (Pandey et al, 2017). Ethological studies have found similar themes, however more often their emphasis has been on the early attachments in humans and the lasting impact of these (Bowlby, 1997.
According to Watanabe (2017), ‘the adolescent brain is undergoing an important and dramatic transition that leaves it vulnerable to a number of environmental influences that can push it into a negative trajectory’. Furthermore, according to other studies (Romeo, 2013), the young person's brain may not recover from acute and chronic stress as effectively as that of an adult may. This has significance when considering young people as patients—and a diagnosis at this stage in a young person's life needs a collaborative approach (Pettit, 2014). The neurological development in adolescence and increased brain activity is considered to be a contributing factor to the increased prevalence of mental illness in this age group (Table 1).
Social and emotional factors
Evidence suggests that young people are social and inter-dependent beings (Grant et al, 2008), and that social acceptance is a pivotal aspect in their lives and decision-making (Goddings, 2015). Steinberg (2016) highlighted this in the Stoplight task, which is a simple driving computer game in which players control the movement of a vehicle along a straight track. The research demonstrated that young people were three times more likely to take risks when they played the game with friends than when they were alone. Peers become a larger part of young people's lives, for example a young person with chronic illness will gain support from their peers and share experiences, hopes and fears freely (Teenage Cancer Trust, 2020).
Steinberg (2001) suggested that adolescence is associated with individuals beginning to examine and explore psychological characteristics of the self, questioning who they really are and discovering how they fit into the society in which they live. This internal, emotional turmoil was said to exhibit symptoms such as mood swings and rebelliousness, not unlike those caused by pubertal and neurological changes. Zwozdiak-Myers (2007) stated: ‘… each of us has experienced not one, but two childhoods, the first as a biological state of growth and development and the second as a social construction.’
As a child matures, the influences in their lives widen. Llorca-Mestre et al's research (2017) suggested that emotional and cognitive variables of parenting styles and peer attachment were equally significant as predictors of emotional instability in the children studied. The needs of a young person for family and friends, and attachment to others, is significant (Lee et al, 2018). Life is made up of many factors contributing to a person's story and their subsequent growth and development, and for young people these may include their peers, families and education. For some young people, however, contributing aspects may include a medical condition and/or illness.
An example of this is highlighted by Pini et al (2012) who, within their systematic review, identified issues surrounding young people who had been diagnosed with cancer. They identified that healthcare practitioners need to be able to assess the impact of the young person's illness on their normality, identity and independence. Pini et al recognised that young people with a chronic condition have fears such as absence from school, losing or missing friends, alongside having to accept the changes happening to their body due to puberty, as well as those due to their condition. The paper concluded that collaboration with healthcare providers, education professionals, parents and young people themselves is essential to minimise the impact of illness on their development.
Conclusion
This article has provided an overview of the evidence relating to adolescence. Understanding and an awareness of the needs of this age group will support clinical practice and help practitioners provide care that is evidence based. It should help practitioners to understand the physical and neurological changes that a young person is undergoing, ensuring that a young patient is supported not only to manage their health needs, but also with their social and emotional development.
LEARNING POINTS
- Assessment of a young person's growth and development is paramount in early identification of certain conditions, including endocrine and musculo-skeletal disorders
- Chronic illness, acute trauma and other adverse childhood events can have long-lasting impacts on young people
- Risk taking is normal in young people, and carers must create positive risk-taking opportunities to facilitate healthy development
CPD reflective questions
- How can you make your service young-person friendly?
- What factors do you need to consider when planning care for a young person with a chronic illness?
- What differences may you find when caring for a young person with a learning disability or sensory impairment?
- How would you ensure that peer relationships are maintained while a young person was in hospital?