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Eastern University – Nicanor Reyes Medical Foundation 4 Larger, glans and breath increase in size
BASIC PEDIATRICS: ADOLESCENCE 5 Adult size
Dr. Caligagan, MD
SMR Testes
ADOLESCENCE 1 Preadolescent
- Period of Rapid Changes 2 Enlarged scrotum, pink, texture altered
- Second peak 3 Larger
- 10 to before 19 years old
4 Larger, scrotum dark
- 3 distinct periods:
5 Adult size
o Early, (10-13)
o Middle and (14-16)
o Late (17-18+) SMR of Males (left), Females (Right)
- Transition from childhood to adulthood
- Hormones set this developmental agenda
- individual variation is substantial, in both:
o timing of somatic changes and
o the quality of the experience
- pubertal changes follow a predictable sequence.
o Example: moustache
- Gender and subculture profoundly affect the developmental
course, as do physical and social stressors.
SMR Pubic Hair (Females)
PUBERTY 1 Preadolescent
- is the biologic process in which a child becomes and adult 2 Sparse, lightly pigmented, straight, medial border of labia
- These changes include
3 Dark, beginning to curl, increased amount
o appearance of secondary sexual characteristics,
o Somatic growth, and 4 Course, curly, abundant, but less than in adult
o Development of reproductive capacity 5 Adult feminine triangle, spread to medial surface

Adrenal production of androgen (chiefly dehydroepiandrosterone SMR Breast
[DHEAS]) 1 Preadolescent
- may occur as early as 6 years old. Maturation of 2 Breast and papilla elevated as small mound, diameter of
gonadotrophin releasing hormone (GnRH) pulse generator is areola increased
among the earliest neuroendocrine changes associated with 3 Breast and areola enlarged, no contour separation
the onset of puberty. 4 Areola and papilla form secondary mound
- Under the influence of GnRH, the pituitary gland secretes 5 Mature, nipple projects, areola part of general breast
leutenizing hormone (LH) and follicle stimulating hormone contour
(FSH).
- This initially occurs in a pulsatile fashion primarily during
sleep, but this diminishes throughout puberty.
- LH and FSH release corresponds to increases in gonadal
androgens and estrogens.

SEXUAL DEVELOPMENT
- The progression of the development of secondary sexual
characteristics may be described using the sexual maturity
rating (SMR) scale (ranging from 1, preadolescence, to 5,
sexual maturity), or Tanner stages.

SEXUAL MATURITY RATING
SMR Pubic Hair (Males)
1 None
2 Scanty, long, slightly pigmented
3 Darker, starting to curl, small amount
4 Resembles adult type, but less quantity, coarse, curly
5 Adult distribution, spread to medial surface of thighs

SMR Penis
1 Preadolescent
2 Minimal change/enlargement
3 lengthens

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Females:
- 1st visible sign of puberty and the hallmark of SMR2 is the
appearance of breast buds, between 8 and 12 yr of age
- Menses typically begins 2-2½ yr later, during SMR3-4
(median age, 12 yr; normal range, 9-16 yr).
- Less obvious changes include enlargement of the ovaries,
uterus, labia, and clitoris, and thickening of the endometrium
and vaginal mucosa.

Males:
- 1st visible sign of puberty and the hallmark of SMR2 is
testicular enlargement, beginning as early as 9½ yr.
- penile growth occurs during SMR3
- Peak growth occurs when testis volumes reach
approximately 9-10 cm3 during SMR4.
- Under the influence of LH and testosterone, the seminiferous

tubules, epididymis, seminal vesicles, and prostate enlarge.
- The left testis normally is lower than the right
- Some degree of breast hypertrophy, typically bilateral, occurs
in 40-65% of boys during SMR2-3 due to a relative excess of
estrogenic stimulation

Somatic Growth
- Growth acceleration begins in early adolescence for both
sexes
- Peak growth velocities are not reached until SMR 3-4
- Boys
o Boys typically peak 2-3 yr later than girls, begin this
growth at a later SMR stage
o Continue their linear growth for approximately 2-3 yr
after girls have stopped.

Developmental Trends
- Over the past 40 yrs, the average age for the onset of genital
and pubic hair development may have decreased by about a
year.
- The onset of puberty in African-American boys precedes that
in white boys by at least 6 mo.
- significant earlier onset of breast development
- Reasons for the larger decrease in age for breast
development may include:
o the epidemic of childhood obesity
o exposure to estrogen-like toxins in the environment
that include certain pesticides, plastics,
phytoestrogens, and industrial compounds along with
beef fattened with subcutaneous estrogen pellets.
- small secular trend toward decreasing ages for the onset of
pubic hair development and menarche.

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- secular trend for decreasing age for onset of puberty in boys - It is normal for young adolescents to compare themselves
(less clear). with others.
- Masturbation is common
Asymmetric Growth spurts begins distally - Infatuation: Romantic relationships lack depth
- Enlargement of the hands and feet
- Arms and legs Cognitive and Moral Development
- Trunk and chest - From concrete operational thinking to formal logical thinking
(abstract thought)
Changes in Vocal Quality - Other processes include the important but distinct
- Rapid enlargement of the larynx, pharynx and lungs contributions of reasoning (cognitive abilities) and judgment
(the process of thinking through the consequences of
Nearsightedness alternative decisions or actions)
- Elongation of the optic globe - These processes may develop at very different rates, young
adolescents may be able to apply formal logical thinking to
Dental Changes schoolwork, but not to personal dilemmas.
- jaw growth, - When emotional stakes are high, adolescents may regress to
- loss of the final deciduous teeth, more concrete operational and/or magical thinking.
- eruption of the permanent cuspids, premolars, and finally - This can interfere with higher-order cognition and ultimately
molars affect the ability to perceive long-term outcomes of current
- Orthodontic appliances may be needed, secondary to growth decision-making.
exacerbations
Self-Concept
EARLY ADOLESCENCE (10-13 years old) - It is normal for early adolescents to be preoccupied with
Relationships with Family, Peers, and Society their body changes, scrutinize their appearance, and feel that
- less interested in parental activities and more interested in everyone else is staring at them (Elkind's imaginary
the peer group audience).
- peers of the same sex - The media has a profound influence on cultural norms and an
- often disregard parents’ advice about safety, appearance, adolescents’ sense of identity.
etiquette, and overall comportment and display markedly - Internet, Cellphones, Social networking sites
different values, tastes, and interests. - This exposure may cause girls to develop a distorted sense of
- Superficial differences may spark conflicts that are truly femininity
about power or difficulty accepting separation - they may be at risk for viewing themselves as overweight,
- Other core individual characteristics, like sexual identity, leading to eating disorders and depression
might become a source of conflict with potentially damaging - Similarly, boys may have difficulties with self-image.
and long-lasting consequences for the entire family. - Images of masculinity may be confusing, leading to self-
- Adolescents also seek more privacy, which may contribute to doubt, insecurity, and misleading conceptions about male
family discord. behavior.
- The trend toward separation from family often involves - Adolescents who develop earlier than their peers, especially
selecting adults outside of the family as role models and girls, may have higher rates of school difficulty, body
developing close relationships with particular teachers or the dissatisfaction, and depression.
parents of other children. - These adolescents look like adults and may have adult
- Organizations such as scouting or sports teams can also expectations placed on them, but are not cognitively or
provide an important sense of extra familial belonging psychologically mature.
- Deepening relationships with peers contributes importantly
to their gradual individuation and independence from EARLY ADOLESCENCE SUMMARY
families of origin. SMR - 1-2
- Indicative of increasing sexual awareness, teasing directed Somatic - Secondary sex characteristics
against the other gender, homophobic comments and acts, - Beginning of rapid growth
and sexually-related are common, gossip - Awkward appearance
- Belonging is all important. Cognitive and - Concrete operations
- An early adolescent's relationship to society centers on Moral - Unable to perceive long-term outcome
school. of current decision-making
- Change in school structure mirrors and reinforces the - Conventional morality
changes involved in separating from the family. Self- - Consciousness about appearance and
concept/identity attractiveness
formation - Fantasy and present-oriented
Friendship difference between boys and girls
Family - Increased need for privacy
- Female friendships may center on emotional intimacy
- Increased bid for independence
- Male relationships may focus more on activities
Peers - Seek same-sex peer affiliation to counter

instability
Sexuality
Sexual - Increased interest in sexual anatomy
- Anxiety and interest in sex and sexual anatomy increase - Anxieties and questions about genital
during early puberty. changes, size

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- Limited dating and intimacy - Many philosophize about the meaning of life and wonder,
Relationship to - Center to school “Who am I?” and “Why am I here?”
Society - Intense feelings of inner turmoil and misery are common.
Body Image - Undergo rapid physical changes - Girls characterize themselves according to interpersonnal
- May express uncertainty relationships
- Boys tend to focus on abilities.
MIDDLE ADOLESCENCE (14-16 years old) - Boys who develop later than their peers may experience
Biologic Development poorer self-image.
- Growth accelerates above the prepubertal rate of 6-7 cm (3
in) per year during middle adolescence. Relationships with Family, Peers and Society
o In the average girl, the growth spurt peaks at 11.5 yr at a - Middle adolescence refers to “stereotypical adolescence”
top velocity of 8.3 cm (3.8 in) per year and then slows o Relationships with parents become more strained and
to a stop at 16 yr. distant due to redirected energies toward peer
o In the average boy, the growth spurt starts later, peaks relationships and separation from the family.
at 13.5 yr at 9.5 cm (4.3 in) per year, and then slows to - Dating can become a lightning rod for parent-child battles, in
a stop at 18 yr. which the real issue may be the separation from parents
- Weight gain parallels linear growth, with a delay of several rather than the particulars of “with whom” or “how late.
months, so that adolescents seem first to stretch and then to - The majority progress through adolescence with minimal
fill out. difficulties rather than experiencing the stereotypical “storm
- Muscle mass also increases, followed approximately 6 and stress.”
months later by an increase in strength - Only 20-30% approximately experience stress and struggle
o Lean body mass, increases to 90% in boys and decreases through this period who require support.
to 75% in girls as subcutaneous fat accumulates. - at risk for problems if:
- Widening of the shoulders in boys and the hips in girls is also o not developing adequate social skills and confidence
hormonally determined. o having more difficulty establishing satisfying
o Doubling in heart size and lung vital capacity. Blood relationships.
pressure, blood volume, and hematocrit rise, - Begins to think seriously about what they want to do as
particularly in boys. adults.
- Androgenic stimulation of sebaceous and apocrine glands - The process involves self-assessment and exploration of
results in acne and body odor. available opportunities.
- Physiologic changes in sleep patterns and requirements may - The presence or absence of realistic role models, as opposed
be mistaken for laziness. to the idealized ones of earlier periods, can be crucial.
- Menarche is achieved by 30% of girls by SMR3 and by 90% by
SMR4 (95% of girls reach menarche at 10.5-14.5 yr of age). Sexuality
o Menarche usually follows approximately 1 yr after the - Dating becomes a normative activity as middle adolescents
growth spurt begins. assess their ability to attract others.
o Appears to be determined by: - Gay, lesbian, bisexual, and transgender youth often
§ genetics acknowledge their attractions and sexual identity during this
§ adiposity, period.
§ chronic illness, - Begin to sort out other important aspects of sexual identity,
§ nutritional status, including beliefs about love, honesty, and propriety.
§ type and amount of exercise, and - Relationships are often superficial and emphasize
§ emotional well-being attractiveness and sexual experimentation rather than
§ intimacy.
Cognitive and Moral Development
- Questions and analyzes extensively. MIDDLE ADOLESCENCE SUMMARY
o Understands the intricacy of the world they live in, self- SMR - 3-5
reflect, see beyond themselves, and begin to Somatic - Height growth peaks
understand their own actions in a moral and legal - Body shape and composition change
context. - Acne and odor
- Questioning moral conventions fosters the development of - Menarch/spermarche
personal codes of ethics. Cognitive and - Emergence of abstract thought (formal
Moral operations)
Self-Concept - May perceive future implications but
- More accepting of their own body changes may not apply indecision-making
- Become preoccupied with idealism in exploring future - Questioning mores
options. Self- - Attractiveness increasing
o Affiliation with a peer group is an important step in concept/identity - Introspection
formation - “sterotypical adolescent”
confirming one's identity and self-image
Family - Conflicts over control and independence
- It is normal for middle adolescents to experiment with
- Struggle for acceptance of greater
different personas, changing styles of dress, groups of
autonomy
friends, and interests from month to month.
Peers - Intense peer group involvement

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- Preoccupation with peer culture - Focus on intimacy and formation of
- Peers provide behavioral example stable relationships
Sexual - Testing ability to attract partner - Planning for future and commitment
- Initiation of relationships and sexual Relationship to - Career decisions (e.g., college, work)
activity Society
- Questions of sexual orientation Body Image - Shifting balance toward introspection
Relationship to - Gauging skills opportunities - Its what on the inside that counts
Society
Body Image - Do I look attractive to others? PSYCHOSOCIAL ASSESSMENT
- Strong emphasis on physical appearance - The HEADS/SF/FIRST mnemonic, basic or expanded, can be
useful in guiding the interview of adolescents in order to
LATE ADOLESCENCE (17-18+ years old) identify problems.
Biologic Development Home life - space, privacy, neighborhood
- The somatic changes in this period are modest by Education - school transfer, grades, after school
comparison to earlier periods. activities
- The final stages of breast, penile, and pubic hair Abuse - Physical, sexual, verbal, emotional
development occur by 17-18 yr of age in 95% of males and
females. Drugs - includes tobacco and alcohol, age of
- Acne occurs in the majority of adolescents, particularly initiation, frequency, done alone or with
a group
males.
Safety - sports and motor vehicle safety
- Emergence of a more stable body image.
measures, hazardous activities

Sexuality/Sexual - Reproductive health issues
Psychosocial Development
identity
- Cognition tends to be less self-centered, with increasing
Family - Family genogram /structure, history of
thoughts about concepts such as justice, patriotism, and addiction/alcohol/drug use, parenting
history. concerns
- Older adolescents are more future-oriented and able to act Friends - Peer group, gang, cult
on long-term plans, delay gratification, compromise, set Image - Body perceptions, appearance, fashion
limits, and think independently. trends or other statements
- Often idealistic Recreation - Sports, recreational activities, how
- May also be absolutist and intolerant of opposing views often, social networking
- Religious or political groups that promise answers to Spirituality and - Faith beliefs, importance and influence
complex questions may hold great appeal. connectedness of faith, community support
- Older adolescents begin the transition to adult roles in work Threats and - Self harm or harm to others, running
and their relationships. Violence away, cruelty to animals, fights arrest,
- More constancy in their emotions. stealing
- The peer group and peer values recede in importance
- Individual, particularly intimate relationships take HEALTH RISK OF YOUNG PEOPLE
precedence. - Smoking
- Relationships increasingly involve love and commitment - Alcohol consumption
- Career decisions become pressing because an adolescent's - Addiction
self-concept is increasingly bound up in his or her emerging - Physical activities and exercise
role in society. - Endangering Traffic behavior
- Eating disorders
LATE ADOLESCENCE SUMMARY - Interpersonal relationships
SMR - 5 - Sexual Behaviors
Somatic - Physically mature
- Slower growth PROBLEMS IN ADOLESCENCE
Cognitive and - Future-oriented with sense of - Health Issues
Moral perspective o Health Promotion and Maintenance
- Idealism; absolutism o Reproductive Health
- Able to think things through § Pre-marital sex
independently § Adolescent pregnancy
Self- - Attractiveness may still be of concern § Sexually transmitted diseases
concept/identity - Emancipation complete
§ Acute and chronic illnesses
formation - Firmer identity
§ Disabilities and accident
Family - Emotional and physical separation from
- Psychosocial Issues
family increased autonomy
o Child and sexual abuse
Peers - Peer group and values recede in
o Suicide
importance
- Intimacy/possible commitment takes o Substance abuse
precedence o Street children
Sexual - Consolidation of sexual identity o Adolescent labor and employment

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Summary - Try to build a genuine relationship
- Physical Development with your teens
- Cognitive Development
- Psychosocial Development PSYCHOSOCIAL DEVELOPMENT
- Establishing an Identity
PHYSICAL DEVELOPMENT - Establishing Autonomy
RAPID GAINS IN HEIGHT AND WEIGHT - Establishing Intimacy
How it Affects - Teens frequently sleep longer - Becoming comfortable with one’s sexuality
teens? - Teens may have more clumsy because - Achievement
of growth spurts How it Affect - Teens begin to spend more time with
- Teenage girls may become overly Teens? their friends than their families
sensitive about their weight - Teens may began to keep a journal
- Teens may be concerned because they - Teens may become involved in
are not physically developing at the multiple hobbies or clubs
same rate as their peers - Teens may have more questions about
What can we - Encourage teens to get enough sleep sexuality
do? - Encourage and model healthy eating - Teens may become elusive about
habits where they are going or with whom
- Be patient with excessive grooming - Teens may become more
habits argumentative
- Don’t criticize or compare the teens to What can we - Encourage involvement in multiple
others do? groups or activities both within school
or after school
DEVELOPMENT OF SECONDARY SEXUAL CHARACTERISITCS - Praise teens for their efforts as well as
How it Affects - Teens may feel awkward about their abilities
teens? demonstrating affection to the - Help teens explore career goals and
opposite sex parent options
What can we - Be understanding of their need for - Give teens an opportunity to establish
do? physical space their behavioral guidelines and
consequences
CONTINUED BRAIN DEVELOPMENT - Establish rituals to mark significant
How it Affects - Teens may ask more direct opposite passages
teens? questions about sex - Be aware of who your teens’ friends
What can we - Provide HONEST answers to teens are and what they are doing
do? about sex

COGNITIVE DEVELOPMENT
DEVELOPING ADVANCED REASONING SKILLS
How it Affects - Teens demonstrate a heightened level
teens? of self-consciousness
What can we - Don’t take it personally when teens
do? discount your experience

DEVELOPING ABSTRACT THINKING SKILLS
How it Affects - Teens tend to believe that no one else
teens? has ever experienced similar feelings
and emotions

What can we - Get teens involved in discussing their
do? behavioral rules and consequences



DEVELOPING THE ABILITY TO THINK ABOUT THINKING IN A

PROCESS KNOWN AS “META-COGNITION”

How it Affects - Teens tend to exhibit the “it can’t

teens? happen to me” syndrome also known

as “personal table”

- Teens tend to become very cause-

oriented and exhibit a “justice”

orientation

What can we - Provide opportunities for teens to

do? participate in controlled risky behavior Notes from Lecture PPT, Beefcake/Luh Trans
- Talk to teens about their views and be
open to discussing your own

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