HANDBOOK OF PSYCHOLOGY - PART 8 ppt

References 461 Hurtig, A. L., & White, L. S. (1986). Psychosocial adjustment in children and adolescents with sickle cell disease. Journal of Pediatric Psychology, 11, 411…427. Jacobson, A. M., Hauser, S. T., Lavori, P., Wolfsdorf, J. I., Herskowitz, R. D., Milley, J. E., et al. (1990). Adherence among children and adolescents with insulin-dependent diabetes melli- tus over a four-year longitudinal follow-up: I. The in”uence of patient coping and adjustment. Journal of Pediatric Psychology, 15, 511…526. Janicke, D., & Finney, J. (1999). Empirically supported treatments in pediatric psychology: Recurrent abdominal pain. Journal of Pediatric Psychology, 24, 115…127. Janz, N. K., & Becker, M. H. (1984). The health belief model: A decade later. Health Education Quarterly, 11, 1…47. Jay, S., Elliott, C., Woody, P., & Siegel, S. (1991). An investigation of cognitive-behavioral therapy combined with oral valium for children undergoing medical procedures. Health Psychology, 10, 317…322. Jelalian, E., & Saelens, B. (1999). Empirically supported treatments in pediatric psychology: Pediatric obesity. Journal of Pediatric Psychology, 25, 223…248. Johnson, S. B. (1998). Juvenile diabetes. In T. H. Ollendick & M. Hersen (Eds.), Handbook of child psychopathology (3rd ed., pp. 417…434). New York: Plenum Press. Kagan, J. (1965). The new marriage: Pediatrics and psychology. American Journal of Diseases of Childhood, 110, 272…278. Kanoy, K. W., & Schroeder, C. S. (1985). Suggestions to parents about common behavior problems in a pediatric primary care of“ce. Journal of Pediatric Psychology, 10, 15…30. Kavale, K., & Forness, S. (1996). Social skills de“cits and learning disabilities: A meta-analysis. Journal of Learning Disabilities, 29, 226…237. Kazak, A. E. (1988). Stress and social networks in families with older institutionalized retarded children. Journal of Social and Clinical Psychology, 6, 448…461. Kazak, A. E., & Barakat, L. P. (1997). Parenting stress and quality of life during treatment for childhood leukemia predicts child and parent adjustment after treatment ends. Journal of Pediatric Psy- chology, 22, 749…758. Kazak, A. E., Barakat, L. P., Meeske, K., Christakis, D., Meadows, A. T., Casey, R., et al. (1997). Post traumatic stress, family functioning, and social support in survivors of childhood leukemia and their mothers and fathers. Journal of Consulting and Clini- cal Psychology, 65, 120…129. Kazak, A. E., Blackall, G., Boyer, B., Brophy, P., Buzaglo, J., Penati, B., et al. (1996). Implementing a pediatric leukemia intervention for procedural pain: The impact on staff. Families, Systems and Health, 14, 43…56. Kazak, A. E., & Marvin, R. (1984). Differences, dif“culties, and adaptation: Stress and social networks in families with a handicapped child. Family Relations, 33, 67…77. Kazak, A. E., & Meadows, A. T. (1989). Families of young adolescents who have survived cancer: Social-emotional adjustment, adaptability, and social support. Journal of Pediatric Psychol- ogy, 14, 175…191. Kazak, A. E., Penati, B., Brophy, P., & Himelstein, B. (1998). Phar- macologic and psychologic interventions for procedural pain. Pediatrics, 102, 59…66. Kazak, A. E., Reber, M., & Carter, A. (1988). Structural and qualitative aspects of social networks in families with young chronically ill children. Journal of Pediatric Psychology, 13, 171…182. Kazak, A. E., Reber, M., & Snitzer, L. (1988). Childhood chronic disease and family functioning: A study of phenylketonuria. Pediatrics, 81, 224…230. Kazak, A. E., Simms, S., Barakat, L. P., Hobbie, W., Foley, B., Golomb, V., et al. (1999). Surviving Cancer Competently Inter- vention Program (SCCIP): A cognitive-behavioral and family therapy intervention for adolescent survivors of childhood cancer and their families. Family Process, 38, 175…191. Kazak, A. E., Stuber, M. L., Barakat, L. P., & Meeske, K. (1996). Assessing posttraumatic stress related to medical illness and treatment: The Impact of Traumatic Stressors Interview Sched- ule (ITSIS). Families, Systems, and Health, 14, 365…380. Kazak, A. E., & Wilcox, B. (1984). The structure and function of social support networks in families with a handicapped child. American Journal of Community Psychology, 12, 645…661. Kerwin, M. (1999). Empirically supported treatments in pediatric psychology: Severe feeding problems. Journal of Pediatric Psy- chology, 24, 193…214. Klassen, T. P., MacKay, J. M., Moher, D., Walker, A., & Jones, A. L. (2000). Community-based injury prevention interventions. Future of Children, 10, 83…110. Knutson, J. F., & DeVet, K. A. (1995). Physical abuse, sexual abuse, and neglect. In M. C. Roberts (Ed.), Handbook of pediatric psychology (2nd ed., pp. 589…616). New York: Guilford Press. Korsch, B. M., Fine, R. N., & Negrete, V. F. (1978). Noncompliance in children with renal transplants. Pediatrics, 61, 872…876. Kraus, J. F. (1995). Epidemiological features of brain injury in children: Occurrence, children at risk, causes and manner of injury, severity, and outcomes. In S. H. Broman & M. E. Michel (Eds.), Traumatic head injury in children (pp. 22…39). New York: Oxford University Press. Kraus, J. F., Rock, A., & Hamyari, P. (1990). Brain injuries among children, adolescents, and young adults. American Journal of Diseases of Children, 144, 684…691. Kronenfeld, J. J., & Glik, D. C. (1995). Unintentional injury: A major health problem for young children and youth. Journal of Family and Economic Issues, 16, 365…393. Kumar, S., Powars, D., Allen, J., & Haywood, L. J. (1976). Anxiety, self-concept, and personal and social adjustments in children with sickle cell anemia. Journal of Pediatrics, 88, 858…863. Kupst, M. J., Natta, M. B., Richardson, C. C., Schulman, J. L., Lavigne, J. V., & Das, L. (1995). Family coping with pediatric leukemia: Ten years after treatment. Journal of Pediatric Psy- chology, 20, 601…617. 462 Child Health Psychology Labbe, E. E. (1999). Commentary: Salient aspects of research in pediatric headache and future directions. Journal of Pediatric Psychology, 24, 113…114. La Greca, A. M. (1990). Issues in adherence with pediatric regimens. Journal of Pediatric Psychology, 15, 423…436. La Greca, A. M., & Schuman, W. B. (1995). Adherence to pre- scribed medical regimens. In M. C. Roberts (Ed.), Handbook of pediatric psychology (2nd ed., pp. 55…83). New York: Guilford Press. Lemanek, K. L., Buckloh, L. M., Woods, G., & Butler, R. (1995). Diseases of the circulatory system: Sickle cell disease and hemophilia. In M. C. Roberts (Ed.), Handbook of pediatric psychology (2nd ed., pp. 286…309). New York: Guilford Press. Lemanek, K. L., Horwitz, W., & Ohene-Frempong, K. (1994). A multiperspective investigation of social competence in children with sickle cell disease. Journal of Pediatric Psychology, 19, 443…456. Levin, H. S., Ewing-Cobbs, L., & Eisenberg, H. M. (1995). Neu- robehavioral outcome of pediatric closed head injury. In S. H. Broman & M. E. Michel (Eds.), Traumatic head injury in children (pp. 70…94). New York: Oxford University Press. Manne, S. L. (1999). Commentary: Well-established treatments for procedure-related pain: Issues for future research and policy implications. Journal of Pediatric Psychology, 24, 147. Manne, S. L., Redd, W. H., Jacobsen, P. B., Gor“nkle, K., Schorr, O., & Rapkin, B. (1990). Behavioral intervention to reduce child and parent distress during venipuncture. Journal of Consulting and Clinical Psychology, 58, 565…572. McGrath, M., Mellon, M., & Murphy, L. (2000). Empirically supported treatments in pediatric psychology: Constipation and encopresis. Journal of Pediatric Psychology, 25, 225…254. McGrath, P. J. (1999). Commentary: Recurrent headaches: Making what works available to those who need it. Journal of Pediatric Psychology, 24, 111…112. McGrath, P. J., Humphreys, P., Keene, D., Goodman, J. T., Lascelles, M. A., Cunningham, S. J., et al. (1992). The ef“cacy and ef“ciency of a self-administered treatment for adolescent migraine. Pain, 49, 321…324. McGrath, P. J., & Larsson, B. (1997). Headache in children and adolescents. Child and Adolescent Psychiatric Clinics of North America, 6, 843…861. McQuaid, E., & Nassau, J. (1999). Empirically supported treatments of disease-related symptoms in pediatric psychology: Asthma, diabetes, and cancer. Journal of Pediatric Psychology, 24, 305…328. Mellon, M., & McGrath, M. (2000). Empirically supported treatments in pediatric psychology: Nocturnal enuresis. Journal of Pediatric Psychology, 25, 193…214. Melman, S. T., Nguyen, T. T., Ehrlich, E., Schorr, M., & Anbar, R. D. (1999). Parental compliance with multiple immunization injections. Archives of Pediatric and Adolescent Medicine, 153, 1289…1291. Michaud, L. (1995). Evaluating ef“cacy of rehabilitation after pediatric traumatic brain injury. In S. H. Broman & M. E. Michel (Eds.), Traumatic head injury in children (pp. 247…257). New York: Oxford University Press. Miller, T. R., Romano, E. O., & Spicer, R. S. (2000). The cost of childhood unintentional injuries and the value of prevention. Future of Children, 10, 137…163. Mindell, J. (1999). Empirically supported treatments in pediatric psychology: Bedtime refusal and night wakings in young children. Journal of Pediatric Psychology, 24, 465…481. Miser, A. (1993). Management of pain associated with childhood cancer. In N. L. Schechter, C. B. Berde, & M. Yaster (Eds.), Pain in infants, children and adolescents (pp. 411…434). Baltimore: Williams & Wilkins. Moncher, F. J., & Prinz, R. J. (1991). Treatment “delity in outcome studies. Clinical Psychology Review, 11, 247…266. Morgan, S. A., & Jackson, J. (1986). Psychological and social concomitants of sickle cell anemia in adolescents. Journal of Pediatric Psychology, 11, 429…440. Mulhern, R. K., Crisco, J. J., & Kun, L. E. (1983). Neuropsycholog- ical sequelae of childhood brain tumors: A review. Journal of Clinical Child Psychology, 12, 66…73. Mulhern, R. K., Hancock, J., Fairclough, D., & Kun, L. E. (1992). Neuropsychological status of children treated for brain tumors: A critical review and integrative analysis. Medical and Pediatric Oncology, 20, 181…192. Mulhern, R. K., & Kun, L. E. (1985). Neuropsychologic function in children with brain tumors. III: Interval changes in the six months following treatment. Medical and Pediatric Oncology, 13, 318…324. The National Vaccine Advisory Committee. (1999). Strategies to sustain success in childhood immunizations. Journal of the American Medical Association, 282, 363…370. Nir, Y. (1985). Post-traumatic stress disorder in children with cancer. In S. Eth & R. Pynoos (Eds.), Post traumatic stress disorders in children (pp. 121…132). Washington, DC: American Psychiatric Press. Peterson, L., & Saldana, L. (1996). Accelerating children•s risk for injury: Mother•s decisions regarding common safety rules. Jour- nal of Behavioral Medicine, 19, 317…331. Powers, S. W. (1999). Empirically supported treatments in pediatric psychology: Procedure-related pain. Journal of Pediatric Psy- chology, 24, 131…145. Powers, S. W., Blount, R. L., Bachanas, P. J., Cotter, M. W., & Swan, S. C. (1993). Helping preschool leukemia patients and their parents cope during injections. Journal of Pediatric Psy- chology, 18, 681…695. Reece, R. M. (Ed.). (2000). Treatment of child abuse: Common ground for mental health, medical, and legal practitioners. Baltimore: Johns Hopkins University Press. Ris, M. D., &Noll,R. B. (1994). Long-term neurobehavioraloutcome in pediatric brain tumor patients: Review and methodological References 463 critique. Journal of Clinical and Experimental Neuropsychology, 16, 21…42. Rivara, F. P., & Mueller, B. A. (1987). The epidemiology and causes of childhood injuries. Journal of Social Issues, 43, 13…31. Roberts, M. C., Fanurik, D., & Lay“eld, D. A. (1987). Behavioral approaches to prevention of childhood injuries. Journal of Social Issues, 43, 105…118. Roberts, M. C., & Lay“eld, D. A. (1987). Promoting child passenger safety: A comparison of two positive methods. Journal of Pediatric Psychology, 12, 257…271. Rock, S. M. (1996). Impact of the Illinois Child Passenger Protec- tion Act: A retrospective look. Accident Analysis and Prevention, 28, 487…492. Rodewald, L. E., Szilagyi, P. G., Humiston, S. G., Barth, R., Kraus, R., & Raubertas, R. F. (1999). A randomized study of tracking with outreach and provider prompting to improve immunization coverage and primary care. Pediatrics, 103, 31…38. Rolland, J. S. (1990). Anticipatory loss: A family systems developmental framework. Family Process, 29, 229…244. Rourke, M. T., Stuber, M. L., Hobbie, W. L., & Kazak, A. E. (1999). Posttraumatic stress disorder: Understanding the psychosocial impact of surviving childhood cancer into young adulthood. Journal of Pediatric Oncology Nursing, 16, 126…135. Routh, D. K. (1975). The short history of pediatric psychology. Journal of Clinical Child Psychology, 4, 6…8. Satin, W., La Greca, A. M., Zigo, M. A., & Skyler, J. S. (1989). Diabetes in adolescence: Effects of multifamily group intervention and parent simulation of diabetes. Journal of Pediatric Psy- chology, 14, 259…276. Schneider, B. H. (1992). Didactic methods for enhancing children•s peer relations: A quantitative review. Clinical Psychology Review, 12, 363…382. Schroeder, C. S. (1999). Commentary: A view from the past and a look to the future. Journal of Pediatric Psychology, 24, 447…452. Schwebel, D. C., & Plumert, J. M. (1999). Longitudinal and concur- rent relations among temperament, ability estimation, and injury proneness. Child Development, 70, 700…712. Seagull, E. (2000). Beyond mothers and children: Finding the family in pediatric psychology. Journal of Pediatric Psychology, 25, 161…169. Serrano-Ikkos, E., Lask, B., & Whitehead, B. (1997). Psychosocial morbidity in children, and their families, awaiting heart or heart- lung transplantation. Journal of Psychosomatic Research, 42, 253…260. Shaw, R. J., & Taussig, H. N. (1999). Pediatric psychiatric pretrans- plant evaluation. Clinical Child Psychology and Psychiatry, 4, 353…365. Sherwin, E. D., & O•Shanick, G. J. (1998). From denial to poster child: Growing past the injury. In M. Ylvisaker (Ed.), Traumatic brain injury rehabilitation: Children and adolescents (pp. 331… 344). Boston: Butterworth-Heinemann. Sinn, J. S., Morrow, A. L., & Finch, A. B. (1999). Improving immunization rates in private pediatric practices through physician leadership. Archives of Pediatric and Adolescent Medicine, 153, 597…603. Slater, J. A. (1994). Psychiatric aspects of organ transplantation in children and adolescents. Child and Adolescent Psychiatric Clinics of North America, 3, 557…598. Smith, M. Y., Redd, W. H., Peyser, C., & Vogl, D. (1999). Post- traumatic stress disorder in cancer: A review. Psycho-Oncology, 8, 521…537. Sormanti, M., Dungan, S., & Rieker, P. P.(1994). Pediatric bone marrow transplantation: Psychosocialissues for parents after achild•s hospitalization. Journal of Psychosocial Oncology, 12, 23…42. Spirito, A. (1999). Introduction to the special series on empirically supported treatments in pediatric psychology. Journal of Pedi- atric Psychology, 24, 87…90. Streisand, R., Rodrigue, J. R., Houck, C., Graham-Pole, J., & Berlant, N. (2000). Parents of children undergoing bone marrow transplantation: Documenting stress and piloting a psychological intervention program. Journal of Pediatric Psychology, 25, 331…337. Stuber, M. L., & Canning, R. D. (1998). Organ transplantation. In R. T. Ammerman & J. V. Campo (Eds.), Handbook of pediatric psychology and psychiatry (Vol. 2, pp. 369…382).Boston: Allyn & Bacon. Stuber, M. L., Kazak, A. E., Meeske, K., & Barakat, L. P. (1998). Is posttraumatic stress a viable model for understanding responses to childhood cancer? Child and Adolescent Psychiatric Clinics of North America, 7, 169…182. Taylor, H. G., Drotar, D., Wade, S., Yeates, K., Stancin, T., & Klein, S. (1995). Recovery from traumatic brain injury in children: The importance of the family. In S. H. Broman & M. E. Michel (Eds.), Traumatic head injury in children (pp. 188…216). New York: Oxford University Press. Todaro, J. F., Fennell, E. B., Sears, S. F., Rodrigue, J. R., & Roche, A. K. (2000). Review: Cognitive and psychological outcomes in pediatric heart transplantation. Journal of Pediatric Psychology, 25, 567…576. Vannatta, K., Garstein, M. A., Short, A., & Noll, R. B. (1998). A controlled study of peer relationships of children surviving brain tumors: Teacher, peer, and self-ratings. Journal of Pediatric Psy- chology, 23, 279…287. Varni, J. W. (1999). Commentary: Brief response to Walco et al. Journal of Pediatric Psychology, 24, 171. Varni, J. W., Blount, R. L., Waldron, S. A., & Smith, A. J. (1995). Management of pain and distress. In M. C. Roberts (Ed.), Hand- book of pediatric psychology (2nd ed., pp. 105…123). New York: Guilford Press. Varni, J. W., Katz, E. R., Colegrove, R., & Dolgin, M. (1993). The impact of social skills training on the adjustment of children with newly diagnosed cancer. Journal of Pediatric Psychology, 18, 751…767. 464 Child Health Psychology Waaland, P. K. (1998). Families of children with traumatic brain injury. In M. Ylvisaker (Ed.), Traumatic brain injury rehabilitation: Children and adolescents (pp. 345…368). Boston: Butterworth-Heinemann. Walco, G., Sterling, C., Conte, P., & Engel, R. (1999). Empirically supported treatments in pediatric psychology: Disease-related pain. Journal of Pediatric Psychology, 24, 155…167. Wallander, J. L., & Thompson, R. J., Jr. (1995). Psychosocial adjustment of children with chronic physical conditions. In M. C. Roberts (Ed.), Handbook of pediatric psychology (2nd ed., pp. 124…141). New York: Guilford Press. Webb, P. M., Zimet, G. D., Mays, R., & Fortenberry, J. D. (1999). HIV immunization: Acceptability and anticipated effects on sexual behavior among adolescents. Journal of Adolescent Health, 25, 320…322. Winogron, H. W., Knights, R. M., & Bawden, H. N. (1984). Neuropsychological de“cits following head injury in children. Journal of Clinical Neuropsychology, 6, 269…278. Wolfe, D. A. (1991). Preventing physical and emotional abuse of children. New York: Guilford Press. Wright, L. (1967). The pediatric psychologist: A role model. American Psychologist, 22, 323…325. Ylvisaker, M. (1998). Traumatic brain injury in children and adolescents: Introduction. In M. Ylvisaker (Ed.), Traumatic brain injury rehabilitation: Children and adolescents (pp. 1…10). Boston: Butterworth-Heinemann. Ylvisaker, M., & Feeney, T. J. (1998). Everyday people as supports: Developing competences throughcollaborations. In M.Ylvisaker (Ed.), Traumatic brain injury rehabilitation: Children and adolescents (pp. 429…464).Boston: Butterworth-Heinemann. Ylvisaker, M., & Szekeres, S. F. (1998). A framework for cognitive rehabilitation. In M. Ylvisaker (Ed.), Traumatic brain injury rehabilitation: Children and adolescents (pp. 429…464). Boston: Butterworth-Heinemann. Zamberlan, K. E. W. (1992). Quality of life in school-age children following liver transplantation. Maternal-Child Nursing Journal, 20, 167…229. Zeltzer, L., Altman, A., Cohen, D., LeBaron, S., Munuksela, L., & Schechter, N. (1990). Report of the subcommittee on the management of pain associated with procedures in children with cancer. Pediatrics, 86, 826…831. Zeltzer, L. K., Dash, J., & Holland, J. P. (1979). Hypnotically- induced pain control in sickle cell anemia. Pediatrics, 64, 533… 546. Zimet, G. D., Mays, R. M., & Fortenberry, J. D. (2000). Vaccines against sexually transmitted infections: Promise and problems of the magic bullets for prevention and control. Sexually Transmit- ted Diseases, 27, 49…52. CHAPTER 20 Adolescent Health SHERIDAN PHILLIPS 465 ADOLESCENT DEVELOPMENT AND HEALTH 465 Physical Development 465 Psychosocial Development 467 Interaction of Physical and Psychosocial Development 468 Interaction between Developmental Issues and Health Care 472 Health Promotion 477 SALIENT AREAS OF ADOLESCENT HEALTH 477 Sexual Activity and Health Consequences 477 SPECIAL SERVICES FOR ADOLESCENTS 480 Legal Consultation 480 School-Based Health Services 480 FUTURE DIRECTIONS 481 SUMMARY 482 REFERENCES 482 Adolescent health is a broad, multidisciplinary “eld encom- passing, at a minimum, clinical and developmental psychology, education, environmental design, law, nursing, nutrition, pediatrics, psychiatry, and social work. The sheer amount of information relevant to promoting adolescent health poses various challenges. Clinically, good patient care requires collaborative efforts among different disciplines, with an overlap of core knowledge that is shared, as well as appreci- ation for the specialized expertise of each professional. Similarly, designing training programs necessitates setting priorities for knowledge and skills for one discipline while drawing from others as well. Advancing our knowledge of adolescent development and care, and disseminating such information, ideally involves familiarity with “ndings and journals in many “elds. One chapter cannot do justice to this broad array of areas. We focus on those unique aspects of adolescence that have particular salience for teenagers• health and health care. Many aspects of health are therefore omitted. For example, while the treatment of psychiatric disorders is clearly important in adolescence, these mental health needs are not unique to this developmental stage. Similarly, some adolescents require treatment for cancer, heart disease, and a variety of other physical disorders, but such problems are more preva- lent at other ages. This chapter reviews aspects of physical and psychosocial development speci“c to adolescence and their interaction with health care, including major sources of morbidity and mortality, salient areas of health care, and special services for adolescents. ADOLESCENT DEVELOPMENT AND HEALTH Physical Development The onset of puberty in males is typically signaled by subtle testicular changes at about 11.5 years of age, concomitant with the start of their growth spurt. The average duration of puberty is three years, but it can range from two to “ve years. The growth spurt peaks relatively late at about 14 years, when changes in the genitals and pubic hair are very evident. (For further information regarding physical development, see McAnarney, Kreipe, Orr, & Comerci, 1992; Neinstein, 1996a.) Pubertal development begins earlier in females, with the start of their growth spurt at about 8.7 years, followed by the “rst sign of breast development (breast budding) one year later. Their growth spurt peaks at 11.6 years, well before signi“cant changes in breast and pubic hair and before menarche at about 12.3 years. Major changes in body size and composition therefore occur much earlier in girls than boys, with girls reaching their growth peak at about the same chronological age as boys begin their adolescent growth spurt. Even among normal adolescents, the timing and duration of puberty vary tremendously and are thus poorly correlated with chronological age. This prompted the development of a rating scale for sexual maturity (Tanner, 1962), based on pubic hair and breasts for females and pubic hair and genitalia in males. For both sexes, the scale ranges from Stage 1 (completely prepubertal) to Stage 5 (adult secondary sexual 466 Adolescent Health characteristics). Adolescent medicine specialists have pro- moted the routine use of Tanner staging. Clinically, a 12-year- old girl at Stage 1 will have very different concerns and health risks than 12-year-old girls at Stage 4 or 5. Tanner staging is also valuable for research purposes. For example, a study of panic attacks among sixth- and seventh- grade girls reported striking differences in the incidence of panic attacks as a function of sexual maturity, but no differences due to chronological age (Hayward, Killen, & Hammer, 1992). Traditionally, Tanner stage is rated by physi- cians and based on physical examination. Fortunately, Litt and her colleagues (Duke, Litt, & Gross, 1980) found that teenagers can rate themselves with considerable accuracy, and this method has been employed in more recent research. While accuracy appears to be more problematic with abnormal samples (e.g., adolescents with growth retardation), self- ratings seem to be acceptably reliable and valid with normal populations (see Finkelstein et al., 1999). It is impossible to overemphasize the extent of physical change that occurs during the relatively brief period of puberty. Major endocrine changes are associated with the onset of puberty, with three distinct changes in the hypothalamic- pituitary unit and (typically) increased secretion of sex hormones from the adrenal gland. Other changes occur in insulin secretion, growth hormone, and somatomedins. While it seems evident that substantial increases in hormonal levels (especially testosterone) would be related to increased sexual urges and to aggression, the effects on behavior are not yet well understood. What is clear is that teenagers experience major biochemical and skeletal changes during puberty. During childhood (age 5 to 10 years), the average child grows 5 cm to 6 cm per year. In contrast, during the average adolescent growth spurt (24 to 36 months), girls grow 23 cm to 28 cm, and boys grow 26 cm to 28 cm taller„a growth rate of 10 cm to 11 cm per year, twice that of childhood. For both genders, pubertal growth accounts for 20% to 25% of “nal adult height. Weight growth is even more dramatic, account- ing for about 50% of ideal adult body weight. Other physical changes accompany rapid increase in height and weight. Adolescents grow in a concentric fashion, with their extremities (heads, hands, and feet) reaching adult size “rst, followed by their limbs and “nally their torsos. This accounts for the •ganglyŽ appearance of many teenagers, who seem to be •all arms and legs.Ž Teenagers also experience signi“cant changes in body composition. Percentage of body fat changes from about 15% in prepubertal girls (comparable to that of prepubertal boys) to 27% by Tanner Stage 4, along with pelvic remodeling and the emergence of breasts and hips. In contrast, lean body mass increases in boys to about 90% at maturity, largely re”ecting increased muscle mass. During puberty, boys also experience a sevenfold increase in the size of the testes, epididymis, and prostate, while the phallus usually doubles in size. Given these signi“cant changes in body size and shape, adolescent medicine clinicians joke that young teenagers are obsessed with their hair because it is the only part of their bodies that they recognize from one month to the next. Indeed, it is remarkable that adolescents are able to remain suf“ciently coordinated to be able to play a variety of sports. Spermarche, the onset of seminal emission, appears to be an early pubertal event for boys (median age 13.4 years) al- though there is considerable variation (range 11.7 to 15.3). It precedes peak height velocity in most boys and may occur with no evidence of pubic hair development. Some sperm are usually present in the ejaculate by Tanner Stage 3 but fertility is generally not reliable until Tanner Stage 4. Menarche, the onset of a girl•s monthly period, has been studied much more extensively than spermarche, presumably because it is a discrete and salient event unlike the more subtle sexual development of boys. American girls experience menarche at about 12.3 years (with normal variation from 9 to 17 years). A secular trend has been observed over the last century, with a gradual decrease in the age of menarche both in the United States and in European countries. This decrease is hypothesized to re”ect improved nutrition and appears to have leveled out with little decrease from 1960 to the present. For individual girls, the age of menarche is a function of factors such as race, socioeconomic status, heredity, nutrition, culture, and body composition. For example, menarche tends to occur at a later age in rural families, in larger families, and at higher altitudes. Also, amenorrhea (the absence or cessa- tion of periods) is commonly found among girls who are un- derweight and/or have an unusually low percentage of body fat, such as athletes or ballerinas who train intensively. Despite the apparent stability of the age of menarche, however, there have been reports that the onset of secondary sexual characteristics is occurring at an earlier age for many American girls. After observing breast development in a number of young female patients (age 7 to 9 years), a pedia- trician launched a large study of 17,000 girls. This investigation con“rmed the clinical observation, and it does appear probable that American girls are developing secondary sexual characteristics at an earlier age than they did in the 1960s, even through the age of menarche remains unchanged (Herman-Giddens et al., 1997). This “nding has prompted intense speculation regarding the reason for the change, with the most popular culprit hypothesized to be the increased fat in the American diet: It may be that even mild obesity is pro- viding the trigger for very early sexual development. Alterna- tive hypotheses focus on environmental changes, including increased hormones in milk and other animal products Adolescent Development and Health 467 TABLE 20.1 Developmental Tasks of Adolescence Gain independence from family. Expand relationships outside home: Other adults. Same-sex peers. Opposite-sex peers. Have realistic self-image. Handle sexual drives. Concrete to abstract thought. Develop value system. Make realistic plan for social and economic stability. (see Lemonick, 2000). Whatever its origin, this physical trend prompts concern among both parents and health profes- sionals regarding the potential impact on girls• psychosocial development. Psychosocial Development The developmental period of life that we term adolescence is somewhat elastic in its boundaries, but generally includes children from 12 to 20 years of age. It is bounded by biology at one end (the onset of puberty) and by social and legal con- ventions at the other end (the age when one is considered an adult). For individual children, the perception that they have entered adolescence may be triggered by their own pubertal changes or by changes evident in their peers, hence the lack of a clear-cut boundary. The end point is also unclear, with American children being considered suf“ciently adult to drive at age 16, vote at age 18, and drink only at age 21 (de- pending on the state where they live). Transition times also vary in health care settings, with pediatric services typically including age 12 to 20 (except for college health) while psychiatric services designed for adolescents are generally unavailable after their eighteenth birthday. Adolescents have a number of developmental tasks to accomplish during this relatively brief period of life (see Table 20.1). They must learn to function as independent adults, separate from their families, while not severing ties to the family. They also become increasingly oriented to others outside the family as they develop signi“cant relationships with other adults (e.g., teachers, coaches) and with peers of both sexes. Their self-image is consolidated and incorpo- rates their sexual identity (e.g., What does it mean to be a woman? How am I the same as, and different from, a man?). Self-image includes body image, which many believe is crystallized during adolescence.A host of new sensations and feelings emerge, and adolescents must come to terms with their sex drives and determine how to manage them. The transition from concrete operations to formal operations not only paves the way for learning higher order mathematics and other abstractconcepts,but also providesadolescentswith new tools and interests as they increasingly contemplate their own lives and the human condition. Finally, adolescents need to develop a plan for their future, establishing a direction, goals, and appropriate training for a career. This is a daunting list of tasks to accomplish in eight years, reinforcing the traditional, psychoanalytic view of adolescence as a tumultuous, troubled time of life. Yet, a considerable amount of more recent data (Offer, Ostrov, & Howard, 1981) reports that about 75% to 80% of teenagers experience adolescence as a positive and pleasant period of life. How do adolescents manage this, with so many developmental tasks to accomplish? One reason is that many of these tasks are not begun de novo in adolescence. For example, children have been gain- ing increased independence throughout childhood as they learn to feed and dress themselves, choose preferred activities, stay overnight at a friend•s house, and go away to camp. In a study of 483 children and adolescents, Larson and Richards (1991) reported that the amount of time children spend with their families decreases from about 50% at Grade 5 to about 25% at Grade 9. While this is a considerable decrease, it is not an all-to-none change. Similarly, many aspects of self-image have been developed by the end of childhood, and preadolescents can identify their assets and weaknesses. The task in adolescence is to re“ne this self- image and to incorporate sexual identity. Finally, development continues past the age of 20 as the completion of adolescent tasks continues in young adulthood. Another reason adolescents manage their developmental tasks with relative ease is that they focus on different issues at different times, reducing the number that they must address simultaneously.As Table20.2 shows, developmental theorists divide adolescence into different periods: preadolescence and early, middle, and late adolescence. Note that boys• progress TABLE 20.2 Focus of Development at Different Stages of Adolescence Age Grade Developmental Focus Preadolescence: Females: 9…11 years 5…7 Same-sex peers Males: 10…12 years Early adolescence: Females: 11…13 years 6…8 Independence Males: 12…14 years Same-sex peers Body image Abstract thought Middle adolescence: Females: 13…16 years 7…10 Opposite-sex peers Males: 14…17 years Sexual drives Sexual identity Morality Late adolescence: Females: 16…20 years 11… Vocational plans Males: 17…20 years College Intimacy 468 Adolescent Health through these phases lags behind that of girls, just as with physical development. One major focus during early adolescence is the desire for increased independence from family, combined with a rapid rise in the importance of peers. Need for conformity with peers peaks in preadolescence and early adolescence, followed by a gradual decline through late adolescence. Such conformity includes dress, hairstyle, music, and language. Abrupt changes in these areas can startle parents as they see their child turn into someone they barely recognize. Yet this new orientation toward peers (versus family) does not repre- sent a total transformation. Young teenagers certainly respond to peer in”uence, especially that of same-sex peers, in areas where they (probably correctly) perceive that their parents will not be knowledgeable about what constitutes •coolŽ clothing, •inŽ music, and appropriate patterns of interaction with same- and opposite-sex peers. However, they typically respond to parental in”uence regarding educational plans and aspirations, moral and social values, and understanding the adult world. For example, one large-scale study of two groups of boys (blue-collar versus upper middle class) in Chicago revealed that each group•s values and expectations were more similar to those of their parents than they were to their peers in the other socioeconomic group (Youniss & Smollar, 1989). Another major focus during early adolescence is body image, hardly surprising given the massive physical changes that occur during this time. Young teenagers evidence intense interest in and often dissatisfaction with speci“c parts of their bodies. A classic study (Douvan & Adelson, 1966) asked seventh graders what one aspect of themselves or their lives they would change if they could, and 59% selected a speci“c body part. This suggests that disease, illness, trauma, or even deviations in normal development, which have obvious physical consequences, will pose even more psychological challenges for young adolescents than for older teenagers. Another implication is that it is particularly important for young adolescents to receive detailed feedback during routine physical examinations, reassuring them that their physical development is proceeding normally and encouraging them to express concerns and questions that almost certainly are present but which they often are too embarrassed to raise spontaneously. The developmental focus shifts in mid-adolescence because most teenagers begin to date between the ages of 13 to 15, with the onset of dating being in”uenced by gender and social status. With increasing interaction with the opposite sex, teenagers concentrate on sexual identity, dating behavior, communication skills, and rules for interaction with peers of both sexes. These early relationships are often brief and shallow, with physical appearance and skills playing a major role in choice of partner. The transition to abstract thought, which has typically occurred during early adolescence, paves the way for new cognitive activity in mid-adolescence. It is generally during this time that adolescents display increased interest in abstract concepts and even thinking per se; one teenager in- formed the author that •I•m thinking about the fact that I•m thinking about the fact that I•m thinking.Ž Morality, justice, and fairness become a focus, both regarding teenagers themselves (and those who inhabit their world) and society in general. Teenagers in mid-adolescence thus often devote time and thought to rules and laws (school and national), social structure, and systems of government. To address the “rst major task of late adolescence, teenagers begin to focus seriously on career plans, which often are unstable until the age of 16. By 17, most adolescents have at least established an initial direction for their future career and made plans to implement appropriate education and training to achieve these goals. However, com- pleting such training and alteration in career goals often continues throughout young adulthood. The second major task of late adolescence is development of intimacy in personal relationships, especially with an opposite-sex partner. Older teenagers focus on different aspects of dating, moving beyond external appearance, as they develop true sharing and caring. Establishing a personal support system of friends, partner, and meaningful adults (e.g., teacher or boss) is as important as economics in allowing teenagers to function separately from their families. The developmental task of independence from family is thus frequently not fully completed until well after adolescence. Interaction of Physical and Psychosocial Development Timing of Puberty The onset of puberty occurs at a mean age of 11.2 years for girls and 11.6 years for boys with evident physical changes at mean ages of 12.2 years and 12.9 years. Because of the tremendous variability present among normally developing adolescents, however, visual evidence of puberty (Tanner Stage 3) can range from age 10.1 to 14.3 (girls) and 10.8 to 15 (boys). These age ranges are within two standard deviations from the mean and considered medically normal. Extreme delay or precocity (2 standard deviations above or below the mean) requires medical evaluation to determine potential hypothalamic, pituitary, or gonadal dysfunction; undiagnosed chronic illness; or chromosomal abnormality (see •Special ConditionsŽ in a following section). However, even teenagers Adolescent Development and Health 469 who do not meet medical criteria for abnormality may appear very different from the majority of their peers: girls who still have completely prepubertal bodies at the age of 13 or who are fully developed before the age of 12, and boys who are still prepubertal at 15 or appear fully adult by the age of 12.5 (references are to Tanner Stage 1 versus Tanner Stage 5; see •Physical DevelopmentŽ). Adolescents who are in the lowest 10% to 15% and the highest 10% to 15% of this distribution are considered to be early versus late maturers, normal variations of development that most likely re”ect their genetic inheritance. A series of classic studies beginning in the 1950s (see Conger & Galambos, 1997) found that early maturation provided a psychosocial advantage for boys, who more often took leadership roles andwere perceived by teachers and peers as more mature and responsiblethan boys maturing •on time.ŽIn contrast,late maturing boys were more likely to act •the class clown,Žwere perceived as being more immature and self-conscious by teachers and peers, and were less likely to be popular or to be leaders. Nottelmann et al. (1987) con“rmed that adolescent adjustment problems were more common for late-maturing boys, and Crockett and Petersen (1987) report a linear rela- tionship between timing of puberty and self-esteem. These differences are hypothesized to re”ect the fact that early maturing boys are taller, heavier, and more muscular, all of which are advantageous for sports (an asset highly prized by peers at this age) and makes them closer in size to girls of the same age. Also, their more adult appearance presumably encourages adults and peers to treat them differ- ently, giving them more responsibility and turning more to them for assistance. Analogously, late-maturing boys cannot •throw their weight around,Ž both literally and “guratively, to the same extent. In a longitudinal follow-up, which continued through age 38, men whohadmatured early retainedtheir psychosocial advantage (Livson & Peskin, 1980). As adults, early maturing males were found to be more responsible, cooperative, socia- ble, and self-contained(althoughlate maturers werenottotally without assets, being moreinsightfuland creatively playful).It is important to note that this advantageous effect was main- tained despite the fact that, on the average, late-maturing boys eventually attain greater adult height than early maturing boys because they continue to grow at a childhood rate before beginning their growthspurt; little additionalgrowth occurs after the conclusion of the growth spurt. Greater height clearly pro- vides a psychosocial advantage for American males and yet the advantage of early maturation appears to outweigh the advantage of greater height in adulthood for late maturers. The evidence regarding female development is mixed, with some reports that both extremes are disadvantageous, especially for early maturing girls (Susman et al., 1985), while other studies report no substantial effects for girls (Nottelmann et al., 1987). Simmons, Blyth, and McKinney (1983) report that pubertal status appears problematic when it places a girl in a different or deviant position from her peers. The impact of early or late puberty may well vary as a function of a girl•s socioeconomic status and the degree of tolerance and acceptance of her appearance within her social environment. From a psychosocial standpoint, early physical maturation is advantageous for American boys whereas the ideal for girls is to mature exactly at the average time and rate. How- ever, adolescents cannot design the nature of their pubertal development, leaving late-maturing boys (especially) and early maturing girls at potential risk for adjustment problems and dif“culties with peer status and body image. In addition to appearing unusually immature, late-maturing boys have a disadvantage in addressing their developmental tasks: It is dif“cult to incorporate one•s new sexuality in self-image or body image until one has developed some degree of sexual maturity, or learn to handle sexual drives before they are ex- perienced. These developmental issues are delayed and thus add to the number of tasks that must be addressed simultaneously at a later chronological age. Late maturers do not have the same option as other teenagers to focus sequentially on different developmental tasks and thus face an additional challenge. In the absence of data to guide intervention, clinical experience suggests that even brief therapy can be helpful for late-maturing boys. Goals for treatment include (a) developing skills that are valued by peers (e.g., sports that are less dependent on size, computer skills, and video games), (b) participating in organized activities (e.g., Scouts) where leadership responsibilities (based on abilities rather than appearance) are conferred by adults, and (c) enhancing social skills, especially with peers. With early-maturing girls, publicity regarding the increasing incidence of early development (Lemonick, 2000) has prompted increased attention to the plight of girls with clear outward evidence of sexual maturity at ages 6, 7, and 8. Endocrinologists are increasingly more reluctant to slow development with hormone therapy, as they did previously with girls under 8, leaving young girls with bodies that are considered normal medically but which are obviously very different from their peers. In this case, goals for therapy include (a) parents remaining alert to potential sexual harassment and abuse, (b) promoting the choice of clothing, books, music, and activities that are appropriate for a girl•s chronological age, (c) developing skills and talents that are unrelated to physical appearance, (d) enhancing social skills with female 470 Adolescent Health peers, and (e) strengthening relationships with family and female friends. Body Image Considerable evidence indicates that American girls in general are less satis“ed with their bodies than are boys (with weight satisfaction being the largest gap) and that boys•satisfaction increases with age while girls• does not. In fact, gender differences in depression were virtually eliminated by controlling for negative body image and low self-esteem in a study of White high school students (Allgood-Merten, Lewinsohn, & Hops, 1990). In general, body image affects overall self-image and self-esteem, especially for girls. A report by the American Association of University Women (AAUW, 1992) found that con“dence in •the way I lookŽ was the most important contributor to self-worth among White schoolgirls whereas boys more often based self-worth on their abilities. Results of a multiethnic study of 877 adolescents in Los Angeles (Siegel, Yancey, Aneshengel, & Schuler, 1999) sug- gest that body image and even the impact of pubertal timing vary considerably as a function of both gender and ethnicity. Asian American boys and girls reported similar levels of body satisfaction whereas boys were more satis“ed than girls for all other ethnic groups of teenagers. Overall, African American girls had the most positive body image and, in sharp contrast to the other ethnic groups, were not dissatis“ed with their bodies if they perceived themselves as being early maturers. As with African American boys, African American girls were least satis“ed with their bodies if they perceived themselves as late developers. Given that boys• body image improves with age, that Asian American girls appear less concerned about physical appearance than girls in other ethnic groups, and that African American girls have a relatively positive body image, the authors conclude that the most problematic teenagers are White and Hispanic girls, both of whom evidence dissatisfaction with their body image, which becomes increasingly negative with age. Special Conditions Gynecomastia is a benign increase in male breast tissue associated with puberty, not the fatty tissue often seen with obese patients. It is found in about 20% of 10.5-year old boys, with a peak prevalence of 65% at age 14 (mean age of onset is 13.2). About 4% of boys will have severe gynecomastia, with very evident, protruding breasts, that persists into adulthood. Gynecomastia is thought to result from an imbalance between circulating estrogens and androgens, thus representing a normal concomitant of hormonal change during puberty. The condition usually resolves in 12 to 18 months but can last for more than two years. Given that more than half of adolescent boys experience this condition, and at a developmental stage when concerns about their bodies and relationships with their peers are at a lifetime peak, it is remarkable that so little data are available regarding psychological impact and treatment. Clinical experience indicates that many young adolescent boys are seriously concerned about their breast development and its implications for their sexual development and identity, often prompting them to avoid sports or other activities that require them to remove their shirts. At a minimum, explanation and reassurance is required. Medical intervention is limited, largely due to concern about side effects, but Tamoxifen (especially) and Testolactone may provide relief for adolescents with signi“cant psychological sequelae. Surgery is another useful option for boys with moderate to severe gynecomastia or in cases where the condition has not resolved after an extended period of time. Surgery may not be an option, however, for many boys because it is considered to be cosmetic surgery and not generally covered by health insurance. Abnormal maturational delay is de“ned statistically as those 5% of teenagers who fall at least two standard deviations above the mean onset of puberty. Physical examination and laboratory tests are employed to screen for a variety of disorders that may cause delay: hormonal de“ciencies (including growth hormone), chromosomal abnormalities, and chronic illness (e.g., cystic “brosis, sickle cell anemia, heart disease, or in”ammatory bowel disease), which may be undiagnosed. In some cases, medical intervention can promote catch-up growth and sexual development but the effects are irreversible in most cases. However, 90% to 95% of delayed puberty represents constitutional delay rather than an under- lying disease or abnormality. Neinstein and Kaufman (1996) report (anecdotally) that it is, not surprisingly, most often male adolescents who com- plain about delayed puberty. Treatment with hormones often can increase growth velocity without excessive bone age ad- vancement, but potential side effects, such as the possible attenuation of mature height, must be considered. It is not only psychological sequelae that are of concern. Adult men with a history of constitutionally delayed puberty have decreased radial and spinal bone mineral density, suggesting that the timing of sexual maturation may determine peak bone mineral density (Finkelstein, Neer, & Biller, 1992). Delayed menstruation (primary amenorrhea) is de“ned as the absence of spontaneous uterine bleeding and secondary sex characteristics by age 14 to 15, or by 16 to 16.5 regardless of the presence of secondary sex characteristics. Such delay [...]... Approximately onethird of 1 4- to 17-year-olds does so versus one-half of 1 8- to 20-year-olds, with males and out -of- school teens being substantially more likely to display multiple high-risk behaviors (Brener & Collins, 19 98) The line of demarcation is not always clear, with a continuum of risk often existing even for the same behavior For example, some high school students (23% of males and 15% of females) and... treatment of excessively tall boys Journal of Pediatrics, 88 , 116…121 CHAPTER 21 Adult Development and Aging ILENE C SIEGLER, HAYDEN B BOSWORTH, AND MERRILL F ELIAS WHAT HEALTH PSYCHOLOGISTS NEED TO KNOW ABOUT AGING 488 What Do We Know from a Person’s Age? 488 Disease Prevalence in Aging 488 Age-Related Changes in Functioning 488 Deﬁning Normal Aging 488 INTERACTIONS WITH OTHER DISCIPLINES 489 Geriatric... subtest in 491 the Wechsler Adult Intelligence test in a 7 0- to 79-year-old cohort, but no signi“cant correlations for 6 0- to 79-year-old cohort However, no evidence of age times blood pressure interactions was obtained in a large-sample cross-sectional study involving three age cohorts of 1,695 men and women (55 to 64, 65 to 74, and 75 to 88 years) participating in the Framingham Heart Study (P Elias et... 62, 284 …300 Lemonick, M D (2000, October 30) Teens before their time Time, 66…74 484 Adolescent Health Livson, N., & Peskin, H (1 980 ) Perspectives on adolescence from longitudinal research In J Adelson (Ed.), Handbook of adolescent psychology (pp 47… 98) New York: Wiley Mann, E B (1 981 ) Self-reported stresses of adolescent rape victims Journal of Adolescent Health Care, 2, 29…37 Manne, S L (19 98) Treatment... period of time) is often confused with prevalence (number of cases at a designated time) Descriptions of designs (e.g., case study, prospective cohort, retrospective cohort) are often used incorrectly in the psychological literature Psychologists should become familiar with these terms A number of texts offer this background (Fletcher, Fletcher, & Wagner, 1 988 ; Hennekens, Buring, & Mayerent, 1 987 ; Sackett,... analyzed articles published in the Journal of Adolescent Health Care 1 980 to 19 98, reporting an increase in annual numbers of articles (69 to 169), decreased proportion of medical topics (61% to 38% ), and increased proportion of psychosocial issues (23% to 50%) This change re”ects increased awareness of •the new morbidityŽ and recognition of the relevance of psychosocial considerations to health risks,... life-span perspective (pp 173… 188 ) Hillsdale, NJ: Erlbaum Cromer, B A., & Stager, M M (2000) Research articles published in the Journal of Adolescent Health: A two-decade comparison Journal of Adolescent Health, 27, 306…313 Delamater, A., Davis, S., Bubb, J., Santiago, J., Smith, J., & White, N (1 989 ) Self monitoring of blood glucose by adolescents with diabetes: Technical skills and utilization of. .. tends to be young, with the peak age being 16 to 20 and 66% of all rapists being between the ages of 16 and 24 (Neinstein, Juliani, et al., 1996) A rare study of 122 adolescent rape victims (Mann, 1 981 ) judged the impact of the rape to be severe more often for parents (80 %) than for the teenagers themselves (37%) Rather disturbingly, 80 % of the teenagers reported having problems with their parents... D., Susman, E J., Inoff-Germain, G., Cutler, G B., Loriaux, D L., & Chrousos, G P (1 987 ) Developmental process in early adolescence: Relationships between adolescent adjustment problems and chronologic age, pubertal stage, and puberty-related serum hormone levels Journal of Pediatrics, 110, 473… 480 Offer, D., Ostrov, E., & Howard, K I (1 981 ) The adolescent: A psychological self-portrait New York: Basic... Eds.), Handbook of child and adolescent psychiatry Vol 3: Adolescence: Development and syndromes (pp 407…412) New York: Wiley Phillips, S A., Moscicki, A B., Kaufman, M., & Moore, E (19 98) The composition of SAM: Development of diversity Journal of Adolescent Health, 23, 162…165 Phipps, S., & DeCuir-Whalley, S (1990) Adherence issues in pediatric bone marrow transplantation Journal of Pediatric Psychology, . Approximately onethird of 1 4- to 17-year-olds does so versus one-half of 1 8- to 20-year-olds, with males and out -of- school teens being substantially more likely to display multiple high-risk behaviors (Brener. dropped out of school (Comerci & Schwebel, 2000). The drop-out rate is about 25% nationally but 50% to 80 % in some inner cities (Scales, 1 988 ). Finally, 49% of adolescent boys and 28% of adolescent. ADOLESCENTS 480 Legal Consultation 480 School-Based Health Services 480 FUTURE DIRECTIONS 481 SUMMARY 482 REFERENCES 482 Adolescent health is a broad, multidisciplinary “eld encom- passing, at

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