Pediatrics
Adolescence
Dr.
 A period of development
 Time of significant physical & pyshosocial changes
beginning at age 10 years until 20 years and 364
days
3 Distinct Stages:
1. Early 10-13 years old
2. Middle 14-16 years old
3. Late 17-20 years old
ESSENTIAL TENETS OF ADOLESCENT GROWTH AND
DEVELOPMENT
1. Physical or biological development
2. Cognitive or moral development
3. Psychosocial development
PUBERTY
 Biological process in which a child becomes an adult
o Appearance of the secondary sexual
characteristics, increase to adult size, and
development of reproductive capacity
 Adrenal production of androgen [chiefly
dehydroepiandrosterone sulfate (DHEAS)] may occur
as early as 6 years of age, with development of
underarm odor and faint genital hair – adrenarche
 Levels of leutenizing hormone (LH) and follicle-
stimulating hormone (FSH) rise progressively
throughout middle childhood without dramatic effects
 Rapid puberty changes begin with increased
sensitivity of the pituitary to gonadotropi-releasing
hormone (GnRH)
 Pulsatile release of GnRH, LH and FSH during sleep
 And corresponding increases in gonadal androgens
and estrogens
 Timing for the onset of puberty in girls are
controversial
o Age of onset of breast development from
10-6 – 11.2 years of age, earlier age of
onset in African-American and white girls
 Trend toward decreasing age for the onset of pubic
hair development and menarche
 The average age for the onset of genital and pubic
hair development may decrease by about a year. The
onset of puberty in African-American boys precedes
that in white boys by at least 6 months
SEXUAL MATURITY RATING (SMR) OR TANNER STAGES
 Once the onset of puberty has begun, the resulting
sequence of somatic and physiologic changes gives
rise to the sexual maturity rating (SMR) or Tanner
stages
EARLY ADOLESCENCE
BIOLOGICAL DEVELOPMENT: GIRLS
 Breast buds – first visible sign of puberty and the
hallmark of SMR 2 is the 8-12 yrs old
 Menses typically begin 2-2 ½ years later, during SMR
3-4 (median age of 12 years; normal range 9-16
years)
 Enlargement of ovaries, uterus, labia and clitoris
 Thickening of the endometrium and vaginal mucosa
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BIOLOGICAL DEVELOPMENT: BOYS
 Testicular enlargement – first visible sign of
puberty and the hallmark of SMR 2 is – beginning as
early as 9 ½ yrs old
 Penile growth occurs during SMR 3
 Peak growth occurs when testis volumes reach
approximately 9-10cm3 during SMR 4
 Enlargement of seminiferous tubules, epididymis,
seminal vesicle and prostate
 The left testis normally is lower than the right
 Breast hypertrophy occurs in 40 – 65% during SMR
2-3
BIOLOGICAL DEVELOPMENT
 Growth and acceleration begins for both sexes
 Peak growth velocities are not reached until SMR
3-4
 Boys typically peak 2-3 years later than girls and
continue their linear growth for 2-3 years after girls
have stopped
 The asymmetric growth spurt begins distally, with
enlargment of the hands and feet, followed by the
arms and legs, and finally, the trunk and chest -
gawky appearance
 Pubertal growth accounts 20-25% of final adult
height
 Rapid enlargement of the pharynx, larynx and lungs
– changes in vocal quality
 Elongation of the optic globe – nearsightedness
 Dental changes: jaw growth, loss of the final
decidouos teeth, eruption of the permanent cuspids,
premolar and molars
COGNITIVE/MORAL DEVELOPMENT
 The ability to think abstractly is the hallmark of
adult cognitive activity
 Four primary stages:
1. Sensorimotor Birth – 2 years
2. Preoperational 2 – 7 years
3. Concrete 7 – 12 years
4. Formal Logical (Abstract) >12 years
 Adolescence has traditionally been described as the
time of transition from concrete operational thinking
to formal logical thinking
 Other processes include the important but distinct
contributions of reasoning (cognitive abilities) and
judgement (the process of thinking through the
consequences of alternative decisions and actions)
 Development of moral thinking roughly parallels
cognitive development
 Early adolescents are concrete thinkers
 Begin to perceive right and wrong as absolute and
unquestionable
 Despite their increasing abilities for complex
decision-making, adolescent decision-making
remains particulary susceptible to emotions
 Theorist argue that the transition from concrete to
formal operations follows from quantitative increases
in knowledge, experience and cognitive efficiency
 A steady rise in cognitive processing speed from late
childhood through early adulthood, associated with a
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 Pediatrics
Adolescence
Dr.

reduction in synaptic number and continued

CENTRAL ISSUES IN EARLY ADOLESCENCE
myelination of neurons
 Development of the dorsolateral prefrontal cortex
and the superior temporal gyrus, areas responsible
for higher-order associations, including ability to
inhibit impulses weigh the consequences of decision,
prioritize and strategize
 Adolescents may experience an increased intensity of
emotion and/or greater inclination to seek expirience
that create such high intensity emotions
 Cognitive development also differs by gender, with
girls developing at earlier age than boys

SELF-CONCEPT
 Self-awareness centers on external characteristics
 Preoccupied with their body changes, scrutinize their
appearance, and feel that everyone else is staring at
them (Elkind’s imaginary audience)
 Frequent comparison of own body with those of
other adolescents

RELATIONSHIPS WITH FAMILY, PEERS AND SOCIETY

 Become less interested in parental activites and
more interested in the peer group, typically with
peers of the same sex
 Often disregard parents’ advice about safety,
appearance, etiquette, and overall comportment and
display markedly different values, tastes, and
interests
 Seek more privacy
 The trend toward separation from family often
involves selecting adults outside of the family as role
models (e.g. teachers)
 Organizations (e.g. scouting, sports) can also
provide important sense of extrafamilial belonging MIDDLE ADOLESCENCE
 Socialize in same-sex peer groups
 Deepening relationships with peers contributes BIOLOGICAL DEVELOPMENT
importantly to their gradual individuation and
independence from families of origin  Growth accelerates above the prepubertal rate of 6-7
 Seek social approval cm (3 in) per year during middle adolescence
 Belonging is important o Average girl – growth spurt peaks at 11.5
 Female friendships center on emotional intimacy yrs at a top velocity of 8.3 cm (3.8 in) per
 Male relationshop focus more on activities year and then slows to a stop at 16 years
 Relationship to society centers on school o Average boy – growth spurt starts later,
peaks at 13.5 yrs at 9.5 cm (4.3 in) per
SEXUALITY year and then slows to a stop at 18 years
 Anxiety and interest in sex and sexual anatomy  Weight growth parallels linear growth, with a delay
increase of several months – first to stretch and then to fill
 Normal for young adolescents to compare out
themselves with others  Muscles mass increases, followed approximately 6
 Boys – ejaculation occurs for the 1st time, usually months later by an increase in strength; boys show
during masturbation and later as nocturnal emissions greater gain in both
and maybe a cause of anxiety

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 Pediatrics
Adolescence
Dr.

SEQUENCE OF PUBERTAL EVENTS

themselves, and to begin to understand their own
actions in a moral and legal contest
 Questioning moral convetions foters the
MALES FEMALES development of personal codes of ethics, which may
be similar to or different from those of their parents
 An adolescent’s new flexibility of thought can have
pervasive effects on relationship with the self and
others

SELF-CONCEPT
 More accepting of their own body changes and
become preoccupied with idealism in exploring future
options
 Affiliation with peer group is an important step in
confirming one’s identity and self-image
 Normal to experiment with different personas,
changing styles of dress, groups of friends, and
interests from month to month
 Philosophize about the meaning of life and wonder,
“Who am I?” and “Why am I here?”
 Intense feelings of inner turmoil and misery are
common
BIOLOGICAL DEVELOPMENT: GIRLS  Girls may tend to characterize themselves and their
 Subcutaneous fat accumulates peers according to interpersonal relationships (“I am
 Widening of the hips a girl with close friends”)
 Physiologic leukorrhea  Boys may focus on abilities (“I am good at sports”)
 Menarche  Adolescents who develop later than their peers may
o Achied by 30% of girls by SMR 3 and 90% experience poorer self-image and have higer rates of
by SMR 4 difficulty in school
o 95% of girls reach menarche at 10-5 – 14.5
yrs of age RELATIONSHIPS WITH FAMILY, PEERS AND SOCIETY
o Usually follows approximately 1 yr after the  “Steriotypical adolescence”
growth spurt begins  Relationship with parents become more strained and
o Common for cycles to be anovulatory during distant due to redirected energie toward peer
the 1st 2 years after menarch relationships and separation from the family
o Timing determine by genetics, adiposity,  20-30% of adolescents experience the steriotypical
chronic illness, nutritional status, type and “storm and stress”
amount of exercise, and emotional well-  Adolescents with visible differences are at risk for
being problems, such as not developing adequate social
skills and confidence and having more difficulty
BIOLOGICAL DEVELOPMENT: BOYS establishing satisfying relationships
 Increase in lean body mass  Begin to think seriously about what they want to do
 Widening of shoulders as adults
 The phallus lengthens and widens during SMR 3  The process involves self-assessment and
 Spermarche exploration of available opportunities
 Presence or absence of realistic models (as opposed
BIOLOGICAL DEVELOPMENT to idealized ones) can be crucial
 Doubling in heart size and lung vital capacity
 Blood pressure, blood volume, and hematocrit rise SEXUALITY
 Acne and body odor – androgenic stimulation of  Dating is common – assess their ability to attract
sebaceous and apocrine glands others
 Physiologic changes in sleep patterns and  Initiation of relationships and sexual activity
requirements may be mistaken for laziness –  Gay, lesbian, bisexual and transgender youth often
adolescents have difficulty falling asleep and waking acknowledge their attractions and sexual identity
up  Begin to sort out other important aspects of sexual
identity including beliefs about love, honesty, and
COGNITIVE AND MORAL DEVELOPMENT propriety
 Emergence of abstract thought (formal  Relationships are often superficial and emphasize
operations) attractiveness and sexual experimentation rather
 May perceive future implications but may not apply than intimacy
in decision-making
 Formal logical thinking – start to question and
analyze extensively
 Have the cognitive ability to understant the intricacy
of the world they live in, self-reflect, see beyond

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 Pediatrics
Adolescence
Dr.
CENTRAL ISSUES IN MIDDLE ADOLESCENCE
LATE ADOLESCENCE
BIOLOGICAL DEVELOPMENT
 Final stages of breast, penile, and pubic hair
development occurs by 17-18 years of age in 95%
 Minor changes in hair distribution often continue for
several years in males, including the growth of facial
and chest hair
 Acne occurs
COGNITIVE AND MORAL DEVELOPMENT
 Abstract (logical) thinkers
o Able to identify the difference between law
and morality
o Able to think things through independently
o More future-oriented and able to act on
long-term
o Plans, delay gratification, compromise, set
limits and think independelty
o Often idealistic but may also be absolutist
and intolerant of opposing views
PSYCHOSOCIAL DEVELOPMENT
 Slowing physical changes permit the emergence of a
more stable body image
 Begin the transition to adult roles in work and their
relationships
 Have more constancy in their emotions
 Peer group and peer values recede in importance
 Intimate relationships take precedence – involve love
and commitment
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CENTRAL ISSUES IN MIDDLE ADOLESCENCE
SEXUAL IDENTITY DEVELOPMENT
Sex – is multifaceted and has at least 9 components:
chromosomal sex, gonadal sex, fetal hormonal sex, internal
morphologic sex, external morphologic sex, hypothalamic
sex, sex of assignment and rearing, pbertal hormonal sex and
gender identity and role
Sexual identity – a self-perceived identification distilled from
any or all aspects of sexuality, and has at least 4
components: sex assigned at birth, gender identity, social sex
role and sexual orientation
SEX ASSIGNED AT BIRTH
 A newborn is assigned a sex before (ultrasound) or
at the time of birth bsed on the external genitalia
 Ambiguous genitalia – in case of a disorder of sex
development
o Additional components of sex (e.g.
chromosomal, gonadal, hormonal sex) are
assessed
o In consultation with specialist, parents
assign the child a sex that they believe is
most likely to be consistent with gender
identity, which cannot be assessed until
later in life
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 Pediatrics
Adolescence
Dr.

GENDER IDENTITY, GENDER ROLE AND SOCIAL SEX ROLE WHAT DETERMINES GENDER IDENTITY?
 Remains unknown
Gender identity – A person’s basic sense of being a
 An interaction of biologic, environmental and
boy/man, girl/woman, or other gender (e.g. transgender)
sociocultural factors
Gender role – one’s role in society, typically either male or GENDER VARIANCE VS GENDER VARIANT
female role
 One’s presentation as a boy/man or girl/woman
Gender variance/gender role nonconformity
 Operate on the level of social sex role
Social sex role / Gender role behavior – characteristics in
 A child or adolescent might be gender role
personality appearance, and behavior that are, in a given
nonconforming, that is, a predominantly feminine
culture and time, considered masculine or feminine
boy or a predominantly masculine girl
 About the masculine and/or feminine characteristics
one exhibits in a given gender role
Gender variant/transgender identity
 Variation in core gender identity
SEXUAL ORIENTATION AND BEHAVIOR
Sexual orientation – Attractions, behaviors, fantasises, and GENDER VARIANCE/GENDER ROLE NONCONFORMITY AMONG
emotional attachments toward men, women or both CHILDREN AND ADOLESCENTS

Sexual behavior – any sensual activity to pleasure oneself  Prevalence

or another person sexually
GENDER VARIANT AND TRANSGENDER
Gender variant – any gender identity or role that varies
from what is typically associated with one’s sex assigned at
birth
Transgender – diverse group of individuals who cross or
transcend culturally defined categories of gender. May be
attracted to men, women, or other transgender persons.
Include:
 Transsexuals – love in the cross-gender role and
seek hormonal and/or surgical interventions to
modify primary or secondary sex characteristics
 Cross-dressers or transversities – who wear clothing
and adopt behaviors associated with the other sex
for emotional or sexual gratification and may spend
part of the time in the cross-gender role
 Drag queens and kings – female and male
impersonators
 Bigender – both man and woman
 Gender queer – gender variant
FACTORS THAT INFLUENCE SEXUAL IDENTITY
DEVELOPMENT
 During prenatal sexual development, a gene located
on the Y chromosome (XRY) induces the
development of testes
 These hormones produced by the testes direct sexual
differentiation in the male direction resulting in the
development of male internal and external genitalia
 In the absence of this gene in the XX chromosomal
females, ovaries develop and sexual differentiation
proceeds in the female direction resulting in female
internal and external genitalia
 Gender identity develops early in life and is typically
fixed by 2-3 year of age
 Gender labeling – children first learn to identify their
own and others’ sex
 Gender constancy - children learn that gender is
stable over time
 Gender consistency – children learn that gender is
permanent
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o More common in girls (7%) than boys (5%)
o Boys are referred more often for the
concerns regarding gender identity and role
 Gender variance as part of exploring one’s gender
identity and role is part of normal sexual
development
 May or may not persist into adolescence
 Marked gender variance in adolescence persists into
adulthood
 Etiology
o Prenatal hormones play a role in the
development of gender role nonconformity
o A heritable component of gender variant
behavior exists
o Maternal psychopatholigy and emotional
absence of the father are the only factors
shown to be associated; unclear whether
these factors are cause or effect
 Stigma
o Subject to ostracism from peers, which may
negatively impact their psychosocial
adjustment and lead to social isolation,
loneliness, low self esteem and behavioral
problems
GENDER VARIANT IDENTITY/TRANSGENDER CHILDREN AND
ADOLESCENTS
 Prevalence
o About 1.3% of parents of 4-5 year old boys
report that their son wished to be of the
opposite sex; 0% fir 12-13 year olds
o For girls, 5% for 4-5 years old and 2-7% for
12-13 years old
o Boys are referred more often than girls
o Only a minority of children’s gender identity
concerns persists into adolescence (20% in
1 study on boys)
o Persistence from adolescence into adulthood
is higher
 Etiology
o Unknown
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 Pediatrics
Adolescence
Dr.

o Environmental and biological factors are DSM IV Diagnosis Criteria for Gender Identity Disorder
hypothesized (American Psychiatric Association,2000)
o Have more trouble tha other children with
basic cognitive concepts concerning their
gender
o May experience emotional distance from
their father
o Boys with gender variant identity are more
physically attractive and hence solicit a
different response from parental
identification figures
o There may be an influence of prenatal and
perinatal hormones on sexual differentiation
of the brain

CLINICAL PRESENTATION
May experience 2 sources of stress:

 Distress inherent to the incongruence between sex

assigned at birth and gender identity (gende
dysphoria)
o Discomfort with the developing primary and
secondary sex characteristics and gender
role assigned at birth
 Distress associated with social stigma
o Feeling different, not fitting in, peer
ostracism, and social isolation, and may
result in shame, low self-esteem, anxiety,
or depression

BOYS
 May at an early age identify as a girl, expect to grow
up female, or express the wish to do so
 May experience distress about being a boy and/or
having a male body, prefer to urinate in a sitting
position, and express a specific dislike of their male
genitals
 May dress up in girls’ clothes as part of playing dress
up or in private
GIRLS
 May identify as a boy, expect or wish to grow up
male
 May experience distress about being a girl and/or
having a female body, pretend to have a penis, or
expect to grow one
 May express a dislike of feminine clothing and
hairstyles
 May struggle with a number of general behavior problems
 Predomenance of internalizing (anxious and depressed) as
opposed to externalizing behavioral difficulties
 More peer relationship difficulties
TRANSGENDER IDENTITY DEVELOPMENT
 A stage model of "coming out"
 Pre-coming out stage - the individual is aware that
their gender identity is different from that of most
boys and girls; some are also gender role non-
conforming; may face teasing, ridicule, abuse and
rejection
 Coming out - involves acknowledging one's
transgender identity to self and others
 Exploration Stage - a time of learning as much as
possible about being transgender, getting to know
similar others, and experimenting with various
options for gender expression.
 Once gender dysphoria has been alleviated, the
individual can proceed with other human
development tasks, including dating and
relationships in the intimacy stage.
 Integration Stage - transgender is no longer the
most important signifier of identity but one f several
important parts of overall identity.

ADOLESCENT HOMOSEXUALITY

 Sexual Orientation - a persistent pattern of physical

and/or emotional attraction to members of the same
or opposite sex.
 Homosexuality - a persistent pattern of same-sex
arousal, accompanied by weak or absent
heterosexual arousal
 Bisexual - attractions for both genders

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6
 Pediatrics
Adolescence
Dr.

ADOLESCENT HOMOSEXUALITY: IMPLICATIONS FOR HEALTH IDENTIFIED RISK AND PROTECTIVE FACTORS FOR
 Homophobia - Irrational fear, hatred, or otherwise ADOLESCENT HEALTH BEHAVIORS
distorted perception of homosexuality that can Behavior Risk Factors Predictive Factors
manifest in personal discomfort, stereotypes, Smoking Mental health Family connected
prejudice, and violence. problems e.g. ness
depression, alcohol Higher parental
 Social Issues - Academic underachievement,
use expectations
truancy, dropping out as consequences of abuse and Disconnectedness Low prevalence of
violence. from school and smoking in school
 Mental Health Issues - Substance abuse, anxiety, family
depression, suicide attempts, disordered eating Low school
behaviors. achievement
 Medical Threats to Health - risky sexual behaviors Peer smoking
Alcohol and Drug Same as above Connectedness with
endanger health.
Misuse Easy access to school and family,
alcohol religious affiliation
Working outside of
THE EPIDEMIOLOGY OF ADOLESCENT HEALTH PROBLEMS
school
Teenage Pregnancy Deprivation, City
Globally (WHO) Residence, Low
Top 5 causes of death in adolescents aged 10-19 years educational
1. Road Traffic Injuries expectations, drug
2. Lower Respiratory Infection and alcohol use
Sexuall Transmitted Mental health
3. Self-harm
Infection problems and
4. Diarrheal Diseases substance abuse
5. Drowning
MAIN HEALTH ISSUES (GLOBALLY)
HEALTH OF ADOLESCENTS IN THE PHILIPPINES (DOH)
1. Early Pregnancy and childbirth
 In 2008, adolescents aged 10-19 years account for
- leading cause of death for ages 15-19 years
21% of estimated 90M Filipinos
globally
 Young people aged 10-21 years account for 30.5%
- complications form pregnancy and chldbirth
of the population
2.HIV
MORTALITY RATES (PER 1,000,000) OF THE LEADING
- more than 2M adolescent are living with HIV
CAUSES OF DEATHS AMONG ADOLESCENTS
AGED 10-19 YEARS IN 2005
- HIV death among adolescents are rising (due to
lack of adequate care and support) and
Causes 10-14 years 15-19 years
adequate and correct information.
Transportation 2.7 6.2
accidents -160,000 girls with HIV
Pneumonia 3.6 4.1
Accidental 3.4 2.7 3. Mental Health
Drowning - Depression- 3rd leading cause of disease and
Chronic Rheumatic 2.4 3.4 disability
Heart Disease
Congenital 3.0 2.2
- Suicide- 3rd lelading cause of death in adolescent
Anomalies
Source: DOH Philippine Health Statistics ages 15-19 years.

COMMON ADOLESCENT COMPLAINTS 4. Violence

 Depression - leading cause of death in older adolescent male
 Suicide
 Violent Behavior 5. Alcohol and Drugs
 Anorexia nervosa and Bulimia - primary cause of injuries, violence, and premature
 Menstrual Problems deaths
 Pregnancy
 Sexually Transmitted Disease 6. Unintentional Injuries
 Substance Abuse - leading cause of death and disability among
adolescents.
SUBSTANCE ABUSE - In 2015, more than 115,000 adolescents died as a
 alcohol result of road traffic accidents.
 tobacco -Drowning- -also a major cause of death among
 marijuana adolescents, 2/3 are boys
 inhalants 7. Malnutrition and obesity
 hallucinogens - make them moore vulnerable to disease early
 cocaine death
 amphetamines 8. Exercise and malnutrition
 opiates - foundations for good health
 anabolic steroids 9. Tobacco Use
- globally at least 1 in 10 adolescents aged 13-15 yo

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7
 Pediatrics
Adolescence
Dr.

ADOLESCENT HEALTH CARE drugs, parental

(PPS Preventive Pediatric Health Care Handbook) rules,chronically ill physically
The Society of Adolescent Medicine of the Philippines, or mentally challenged parent
Inc. recommends annual health screening and preventive Friends: peer cliques and
services for adolescents (observing confidentiality and configuration( "preppies",
privacy), which includes the following: "jocks" "nerds"
 Complete history-taking and risk Image Ht. and wt. perceptions, body
assessment/screening (HEADSFIRST) musculature and physique,
 Physical Examination appearance (including dress,
 Laboratory Tests jewelry, tattoos, body
 Immunization Update piercings as fashion trends or
 Anticipatory Guidance and Counseling other statement)
Recreation Sleep, exercise, organized or
ADOLESCENT HISTORY TAKING unstructured sports,
 Primary source of information- adolescent recreational activities (tv,
 Confidentiality of information and respect for privacy video games, computer
are important games,interne and chat
 Limits of confidentiality should be defined rooms, church or community
 The parents should be interviewd with the adolescent youth group activities
or before the adolescent to ensure that the (boy/girl scouts, big brother/
adolescent does not perceive a breach of sister groups, campus
confidentiality groups), how many hours per
 Take time to listen and avoid judgemental day, days per week involved?
statements, use of street jargon and show respect Spirituality Use HOPE or FICA acronym;
for the adolescent's emerging maturity and adherence, rituals, occult
 Use of open-ended questions Connectedness practices, community service
or involvement
HEADS/SF/FIRST
Home Space, privacy,frequent HOPE: Hope or Security for
geographic moves, the future; Organized
neighborhood religion; Personal spirituality
Education/ Frequent school changes, and practices; Effects on
School repetition of a grade/each medical care and end of life
subject, teachers' reports, issues
vocational goals, after-school
educational clubs (language FICA: Faith beliefs,
speech,math etc.) Importance and influence of
Abuse Physical, sexual, emotional, faith; Community support
verbal abuse; parental Threats and Self-Harm or harm to others,
discipline Violence running away, cruelty to
Drugs Tobacco, alcohol, marijuana, animals, guns, ,fights,
inhalants, "club drugs", arrests, stealing, fire setting,,
"rave" parties, other. Drug of fights in school
choice, age at initiation,
frequency, mode of intake, PSYCHOSOCIAL ASSESSMENT: HEADS/ SF/ FIRST
rituals, alone or with peers, HOME
quit methods, and number of Space, Privacy, Geographic moves, neighborhood
attempts  Who lives with you?
Safety Seat belts, helmets, sports  Do you have your own bedroom? If none, who do
safety measures, hazardous you share it with?
activities, driving while  Is your privacy respected at home?
intoxicated  Have you moved in recently to a new neighborhood?
Sexuality/ Reproductive health (use of
Sexual contraceptives, presence of EDUCATION/ SCHOOL
Identity sexually transmitted School changes, repetition of a grade level, teacher's
infections, feelings, report, vocational goals, after-school educational clubs,
pregnancy) learning disabilities screen
Family and Family: Family constellations,  Are you currently attending school? What school? If
Friends genogram, single/married/ not, are you presently employed? Where and with
separated/ divorced/ blended what job?
family/ family occupations  What year are you now?
and shifts; history of  How are your grades?
addiction in 1st and 2nd  Have you failed any subject?
degree relation, parental  Have you ever been suspended from school?
attide toward alcohol and  What are your plans for college?

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 Pediatrics
Adolescence
Dr.

 Do you have lots of friends in school? IMAGE

 How are you getting along with your classmates?
Teachers?
ABUSE
Physical, Sexual, Emotional, Verbal, Parental discipline
 Have you ever experienced physical, emotional,
verbal abuse? From whom?
 Has anybody ever touched you in your private parts?
without your consent?
 How does parental discipline take place in your
home?
DRUG, ALCOHOL, TOBACCO USE
 What drugs are common in your campus?
 Has any of your friends tried shabu & the like?
 How do you handle the situation when your friends
are using drugs? Did you ever try?
 Do you smoke? How many stickes a day?
 How much alcohol do you drink in a week?
 Did you ever try to quit smoking? Drinking? Illicit
drug use?
SAFETY
Use of seatbelts, helmets, sports safety measures,
hazardous activities, driving while intoxicated
 Do you use helmet, seatbelt, sports safety
measures?
 Do you participate in hazardous activities?
 Do you text while walking/ crossing the street/
driving?
 Do you obey traffic rules?
 Do you drive while intoxicated?
 Do you use the pedestrian lane or foot bridge?
Ht. and wt. perceptions, body musculature and physique,
appearance including dress, jewelry, tattoos, body piercings,
fashion trends
 How do you perceive yourself in terms of your
present weight/height?
 Is there anything you would like to change about
yourslef? What is it and why?
RECREATION
Sleep, exercise, organized or unstructured sports,
recreational activities (tv, video games, computer
games,interne and chat rooms)
 What do you do after school?
 What do you do for fun? With whom?
 What are your hobbies?
- Do you participate in any sports activities?
- What kind of book, music & dance do you like?
- How much time do you spend in watching TV, using
your gadgets?
SPIRITUALITY AND CONNECTEDNESS
Use HOPE and FICA bacronyms
Hope or security for the future
Organized religion
Personal spirituality and practices
Effects on medical care and end of life issues
Faith beliefs
Importance and influence of faith
Community support
 Are you involved in any church or community
services?
 Do you go to mass? regularly?

SEXUALITY THREATS AND VIOLENCE

 Are you going out with anyone right now? With a boy
or with a girl? What is this person's name? How
many relationships have you had in the past?
 There are a few teens who are sexually active. Are
many of your friends sexually active? Have you
handled this part of your relationship with your loved
one?
 Did you ever have any vaginal/ penile discharge?
Itchiness?
Self-harm or harm to others, running away, cruelty to
animals, guns, fights, arrests, stealing, fire setting, and fights
in school
 Have you ever thought about hurting/killing yourself
or others? Why?
 Have you tried? How many times?
 Have you ever been involved in any fight? Fire
setting? Vandalism? Stealing?
 Are you fond of animals? How do you treat them?

FAMILY
Family constellations, blended family, occupation, ADOLESCENT PHYSICAL EXAMINATION
parenteral rules, physically or mentally challenged patient  BMI measurement
 Who lives with you?  BP determiantion
 How are you getting along with your parents or  Hearing and Vision Testing
siblings?  Sexual maturity rating (Tanner Stage)
 Over what issues do family arguments occur?  Breast examination
 To whom are you closer, to mom or dad? why?  Examine the spine and shoulder for scoliosis
 To whom do you tell your problems, secrets?  Inspection of the genitals
 A more thorough exam is warranted in symptomatic
FRIENDS patients
Peer cliques (preppies, jocks, nerds, computer geeks) gang
or cult affiliation
 Do you have a best friend with whom you can tell CLASSIFICATION OF SEXUAL MATURITY STAGES IN GIRLS
your problems? share secrets? Is she in the same
SMR Pubic Hair Breasts
school?Is this person a girl or a boy?
Stage
1 Preadolescent Preadolescent
2 Sparse, lightly Breast and papilla
pigmented, straight, elevated as small

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 Pediatrics
Adolescence
Dr.

medial border of the moound; diameter of

labia
3 Darker, beginning to
curl, increased amount
4 Coarse, curly,
abundant, but less than
in adult
5 Adult feminine triangle,
spread to medial
surface of thighs
From Tanner, JM: Growth and Adolescence, Ed.2, Oxford, England, 1962,
Blockwell Scientific
areola increases
Breast and areola
enlarged, no contour
spearation
Areola and papilla from
secondary mound
Mature nipple projects,
areola part of general
breast contour

CLASSIFICATION OF SEXUAL MATURITY STATES IN BOYS

SMR Pubic Hair Penis Testis BREAST EXAMINATION
Stage
With the patient lying down in supine position:
1 None Preadolescent Preadolescent  palpate with both axilla, supraclavicular &
2 Scanty, long, Minimal change/ Enlarged infraclavicular areas
slightly enlargement scrotum, pink,  to examine the right breast, place a small pillow
pigmented texture altered under the patient's right shoulder; place her right
3 Darker, Lengthens Larger arm above her head and turn her chin to the left
starting to  using the flat palmar surface of your hand and
curl, small fingers, gently palpate the entire breast using small,
amount circular movements in concentric circles or using a
4 Resembles Larger, glans Larger, scrotum similar pattern to the spokes of the wheel starting
adult type, and breadth dark from the periphery of the breast to the nipple in a
but less increase in size clockwise manner
quantity;  gently place pressure in the areola to detect
coarse, curly discharge from the nipples
5 Adult Adult size Adult size  do the same procedure on the left breast with the
distribution, patient's left arm above her head
spread to
medial
surface of
thighs

SCREENING FOR SCOLIOSIS

With the patient standing exmaine
her back

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 Pediatrics
Adolescence
Dr.

Forward Bending Test

The adolescent bends forwards at the waist, with trunk
parallel to the floor, legs straight and arms dangling with
fingers and palms together.

COMMON DIAGNOSTIC/ LABORATORY TESTS

 Complete blood count at every stage of adolescence
 Urinalysis on 1st visit
 TB testing
 STD screening
 Urine test for substance abuse
 HIV testing
 Pap's smear
 Pregnancy test
 Dyslipidemia screening
 Oral health
 Audiometry
 Vision testing
 Spine x-ray

HEALTH ENHANCEMENT
 Adolescents may not utilize routine preventive health
care, incorporating these services into the episodic
"sick visit" optimizes comprehensive adolescent
health care delivery
 Offer needed immunizations

IMMUNIZATION UPDATE
 Tdap/Td
 HPV
 Annual Influenza
 2nd dose Varicella
 2nd dose MMR
 Hepatitis B, if not previously given
 Hepatitis A, if not previously given

ANTICIPATORY GUIDANCE AND COUNSELING

 Breast self-examination
 Healthy lifestyle- exercise, nutritious, well-balanced
diet, avoidance of alcohol, tobacco and illicit drugs
 Sexual behavior and the risk of acquiring STDs
including HIV
 Pregnancy prevention
 Injury and accident prevention- use of sports
protective gears, seat belt, helmet, no driving under
the influence of alcohol, no access to handgun
 Emotional, physical and sexual abuse

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