Core Concepts
Adolescent Medicine
Richard Rupp MD and Elyssa Yantis MD
Healthcare providers need to be sensitive to the unique physical and emotional needs of adolescents. In this chapter we will review adolescent physical and emotional development, highlight important aspects to consider during the health supervision (or well-teen) visit, and discuss concepts of sexuality and risky behaviors.
Puberty
Adolescence is the transition from childhood to adulthood; puberty is characterized by growth in stature and sexual maturation.
Puberty and adolescence do not necessarily go hand-in-hand. Many girls start puberty before the age of nine but continue to act their chronological age. In contrast, teens with delayed puberty due to hypogonadism (e.g., Turner Syndrome) or constitutional delay (e.g., late-bloomers) mostly act like adolescents.
Teen behavior is popularly attributed to "raging hormones," but sex steroid levels do not correlate with these behaviors, except that testosterone is associated with aggression. Over the last decade it has been found that typical "teenage behaviors" and increased cognitive abilities are due not to hormones but to growth and pruning of the neuronal processes in the brain.
The mean age of puberty has trended downward for decades. Onset of puberty for girls normally occurs between the ages of 8 and 13.4 years. In boys, onset is considered to be normal between 9 and 14.0 years.
In 1962, James Tanner published a Sexual Maturity Rating system that is still in use today. The scale ranges from prepubertal (stage I) to adult (stage V).
For girls, the stages of puberty are based on breast size (B) and shape, and pubic hair (P) development and distribution. For boys, the stages of puberty are based on the genitalia (G) (size and shape of the penis and scrotum) and pubic hair (P) development and distribution.
The onset of breast development in females is called thelarche.
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Stage I (B1) - prepubertal; flat appearance with only the papilla (nipple) raised Stage II (B2) - breast bud is present so that the areola protrudes Stage III (B3) - breast tissue extends past the areola causing the elevation of the breast along with the areola; the contour of the areola is the same as the rest of the breast Stage IV (B4) - areola forms a separate contour from the rest of the breast creating what is referred to as the "mound on the mound" appearance Stage V (B5) - adult; areola flattens down assuming the contour of the rest of the breast |
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Note B= breast, not "boy" |
Staging of male genital development is based primarily on changes in the appearance of the penis and scrotum and not on testicular size, because testicular size varies widely between individuals. In other words, one boy's stage III testes may be the size of another's stage V testes.
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Stage I (G1) - prepubertal appearance; testes are less than or equal to 1.5 cc in volume Stage II (G2) - scrotum becomes pendulous with the skin becoming thinner; testicular volume is from 1.6 to 6 cc Stage III (G3) - scrotum coarsens and the testes are 6 to 12 cc; penis lengthens Stage VI (G4) - penis grows in length and circumference and the testes are from 12-20 cc Stage V (G5) - adult appearance of penis, with testes that are usually greater than or equal to 20 cc in volume |
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Note G= genitalia, not "girl" |
Pubarche refers to the onset of pubic hair growth. The term adrenarche is broader, indicating the increased production of androgens by the adrenal glands. Signs of adrenarche include pubic hair growth as well as other secondary sexual hair (e.g., axillary and facial) and acne. Pubic hair rating is similar for both males and females.
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Stage I (P1) - prepubertal, lanugo may be present in genital area but it is fine and downy Stage II (P2) - sparse growth of pubic hair in the midline, mainly at the base of the penis or along the labia majora Stage III (P3) - more hair grows so that it is visible from several feet, along with coarsening and increased pigmentation in some people Stage IV (P4) - hair now makes a triangle over the pubis Stage V (P5) - adult; hair is outside of triangle, extending up the abdomen and down the thighs |
Eighty percent of females begin with breast development (thelarche) and the other 20% with pubarche. The most common sequence of events is as follows:
P2 > B2 > Peak Height Velocity > B3 > P3 > P4 > B4 > Menarche > P5 > B5
Ninety-eight percent of males begin with enlargement of the testes. This makes sense because the testes are where most of the androgens come from. The most common sequence for males is as follows:
G2 > G3 > P2 > G4 > P3 > Peak Height Velocity > P4 > G5 > P5
Onset of puberty is overtly visible in females. Girls shoot up in height and have visible breast development. Peak height velocity is reached much earlier in girls than in boys. Menarche occurs after peak height velocity is over.
In contrast, the early signs of puberty in males are not visible to the public. It is not until the growth spurt that other outward signs such as the deepening of the voice become apparent.
In both sexes, 20-25% of final adult height is credited to puberty.
Most females grow only an inch or two after the onset of menses. As a group, the final height of males is about 13 cm greater than that of females. This is important to remember when making height predictions based on the mid-parental height equation.
About fifty percent of adult ideal weight is attributable to puberty. Both males and females start puberty at about 80% lean body mass. During puberty, females drop to 70-75% lean body mass and males increase to 90%. Males gain more muscle mass, and females gain more adipose tissue.
An adolescent has four tasks to accomplish to become a well-adjusted adult. These tasks are categorized as: 1) independence, 2) body image, 3) peer relations, and 4) identity.
Adolescence is divided into three periods; early (ages 12-14), middle (ages 15-17) and late (ages 18-21). Some teens will develop faster in one task than others. Some go through the stages smoothly while others do so with lots of turmoil. Of course, no one goes through adolescence exactly as the model may suggest.
1. Independence
Middle adolescents are often hostile towards parents and authority figures. Some openly rebel while others assert their independence secretively when not under adult supervision. Adults, including physicians, find that many decisions teens make are disturbing and the adults feel frustrated at their lack of control over the teen. Because of their rebellious nature and risk behaviors, middle adolescents are the group that society "loves to hate." By late adolescence, most families are comfortable with the youth's individuality and decision making skills. The teen, gaining confidence with the change in stature, increasingly turns to the parents for advice and guidance in decision-making, though this doesn't mean they always do what the parent wants. The parent-adolescent interaction is more on an adult-adult level. The physician should take into account this move toward independence and help parents appropriately give the teen responsibility for medical care. For instance, an early adolescent may need to be reminded to take his daily medication while a middle adolescent should not. By late adolescence, the patient should be encouraged to make his own appointments, monitor medication needs and get prescriptions filled. Failing to recognize this move towards independence makes the physician prone to appearing as an "agent of the parent" and may make it more difficult to gain the confidence of the teen. |
2. Body Image
Middle adolescents are more at ease with the changes and want to make the most of their "new" body. Clothing, jewelry and makeup become big with this group. Taking care of issues such as acne or unwanted hair (e.g., eyebrows) becomes paramount. Weightlifting and dieting become important as well. With the gain in confidence comes increased interest in the opposite sex. This is often the onset of dating and the development of skills and behaviors related to sexual relationships. By late adolescence, teens are comfortable with the changes in their body. Pelvic exams or hernia checks are not as stressful. Many adolescents are now ready to deal with issues such as birth control. Sexual relationships become less exploring and exploitative and more loving and sharing. |
3. Peer Relations
Middle adolescents may share intense personal relationships with the group. As teens become more comfortable with their own decision making and independence, peer groups hold less sway. By late adolescence, peer groups do not demand the same level of conformity. It is all right to attend a party and not drink when others are drinking. Individuality is more acceptable. Often times, late adolescents will grieve over the fact that their relationships with friends are not as close and have become less intense. A useful strategy for providers is to ask about the risk behaviors of the teen's friends, since teens are often more comfortable sharing information about friends than about themselves. This enables the physician to explore the adolescent's feelings and knowledge of risk behaviors. |
4. Identity
The values and morals of the early adolescent are those of the parents. As they attempt to pull away from the family and move closer to peers, teens' values mirror those of their friends. Usually by the end of adolescence, the teens' morals and values come back in line with those of their family.
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photos by photospin.com/MonkeyBusiness and photospin.com/lev dolgachov |
The teen years are the healthiest period of life. By far and away, the major threats to well-being are behavioral.
Adolescents visit health care providers for well exams and sports physicals. As teens do not often seek health services, it is important to make the most of these visits. Below, we will address several unique issues related to providing adolescent health care.
At what age can a teenager consent for healthcare? At what age is there a guarantee of confidentiality? In the USA, the answers depend on state law and the type of healthcare services.
In most states, parental consent is required for minors; and in most states, minor is defined as less than age 18. With this consent comes the right for the parent to have access to the healthcare information.
However, specific to sexual, mental health and substance use issues, most state laws grant the teenager confidentiality by age 14. This means that if the teen does not want information shared with the parents, health care providers have some discretion. For example, a provider may withhold from parents/guardians information that a teen has experimented with alcohol. If however, the teen had an alcohol use problem, the provider might decide that it was in the teen's best interest for a parent to know.
Sometimes the diagnosis determines whether the care can remain confidential. For example, it is impossible for a provider to know beforehand whether the teenage female's abdominal pain is due to pregnancy, pelvic inflammatory disease, appendicitis or psychiatric distress. As the reasons for the pain become more clear, the limits of confidentiality may change (i.e. if the reason falls into the category of sexual, mental health-related, or substance use).
Limits of confidentiality do not apply in circumstances involving abuse or the intention to harm oneself or another person. For example, a physician must report if a fourteen year old patient is having sex with a thirty year old, whether it is forced or not.
In most states, there are special categories of minors (under 18) who can consent for their own confidential care as if they were adults. These groups might include:
The bottom line: it is imperative for the healthcare provider to know the laws of the state.
The HEADS mnemonic is widely used to help remember the important aspects of the psychosocial history. HEADS moves from the least to the most personal areas while building rapport.
Source: Goldenring JM, Cohen E. Getting into adolescents' heads. Contemp Pediatr 1988; 5: 75-9
How are things going where you live? Have you had any recent moves/changes/losses/ stresses in your home environment? Who lives with you/ how do you get on with them? What does the family do together/ eat/ vacation/ go to church? What are your parent's expectations for you? What are the "rules?" What do you get in trouble for? What kinds of restrictions or punishments are given?
Are you doing any study or work at the moment? How's it going? Do you like it? How are your grades/work performance -any recent changes? Any special classes? Do you have any future education/employment plans? Where do you get your spending money and the things that you need? How do you get on with your teachers/boss/school or work mates? Do you miss much work/ school?
Are you satisfied with your weight? Is there anything you would change about your body? What is your usual breakfast/ lunch/ dinner? Do you diet and/or exercise? How much/ how often/ what type? Do you use other methods to control weight (laxatives/ purging)? Have you had any recent and past weight gain/ losses?
What do you like to do for fun or in spare time (e.g. hobbies/ sports/ youth clubs/ parties / church)? Where do you hang out? Do you have any close friends you spend time with, trust or can talk to? How old are your friends? What are they like? What do you do most days? How much time do you spend with the TV or computer?
Many young people experiment with substances (i.e., alcohol, cigarettes, prescription/ illicit drugs). Do any of your friends? How about you? How much and how often? Have you ever had any treatment/ sought help? Have you ever ridden in a car when the driver was under the influence?
Have you ever had a sexual/romantic relationship with a girl or a boy? If never been sexually active, when do you feel it is the right time? If sexually active, do you protect yourself against STIs/ pregnancy? Have you ever been tested for STIs? Do you have any children? Has anyone ever touched you in a way that has made you feel uncomfortable or forced you into a sexual relationship?
Compared to other people, do you think you are happier, sadder or about the same? People sometimes feel down or sad. How about you? Do you feel guilty about things or cry a lot? Have you ever thought about suicide or attempted suicide in the past? What is your sleep like? What is your energy level like?
Do you wear seat belts/ helmets/ eye protection? Do you know how to swim and avoid water hazards? Do you feel safe at home/ school/ neighborhood? Have you carried a weapon? Do you have access to a gun? Have you ever been bullied or bullied other people? Have you ever been shaken down?
The beginning of adolescence serves as a platform for vaccination. The term "platform" is used as the intention is for health providers to discuss with adolescents and their parents growth, puberty and mental development. Discussions with the parents should include communicating with and parenting adolescents, with a segue into vaccinations that provide additional protection for their adolescent.
For adolescents who do not receive an annual influenza vaccine, this set of vaccinations is often met with a great deal of trepidation. This is because the last time they were vaccinated was at 4-6 years of age, which for them was half a lifetime ago. In the interim, vaccination may become extremely painful in their mind and it is not unusual for adolescents to fight being vaccinated or to faint following vaccination. Clinic staff and parents should be reassuring but not be apologetic or castigating.
Currently, the adolescent vaccination platform consists of the Tdap (tetanus, diphtheria, acellular pertussis) booster, HPV9 (Human papillomavirus) series and meningococcal series.
Tdap VaccineProtection against tetanus, diphtheria, and pertussis with a booster vaccination (Tdap) is important in adolescents. Of the three pathogens, adolescents are most at risk from pertussis because large outbreaks occur annually. Pertussis, caused by Bordatella pertussis, is divided into three clinical stages - catarrhal, paroxysmal, and recovery. The catarrhal stage is characterized by mild upper respiratory symptoms. The paroxysmal stage follows and consists of paroxysms of cough with an inspiratory whoop (at least in younger children) which is why it is commonly known as Whooping Cough. The paroxysms of cough frequently result in posttussive emesis. Symptoms eventually wane over weeks to months in the recovery (or convalescent) stage. In approximately 50% of adolescents, the cough lasts 10 weeks or longer, and antibiotics will not shorten the clinical course. Significant complications can include weight loss, syncope, sleep disturbances, rib fractures, and pneumonia, and can lead to poor school performance and school dropout. Diphtheria is caused by toxigenic strains of Corynebacterium diphtheria with clinical manifestations including membranous pharyngitis, bloody nasal discharge, and laryngotracheitis. Untreated, the case fatality rate is nearly fifty percent but even with treatment, the case fatality rate is 5-10%. Due to vaccination, diphtheria is an exceedingly rare disease although in the 1920s there were upwards of a quarter million cases a year in the United States. Tetanus is caused by neurotoxins produced by Clostridium tetani which result in severe muscle spasms and autonomic dysfunction. The bacterium is introduced into wounds from objects contaminated with dirt or manure containing its spores. Tetanus has also become very rare due to vaccination with only about thirty cases each year in the United States. Tdap should be given as a single dose at 11-12 years of age. If Td (tetanus, diphtheria without pertussis) was previously administered, a single dose of Tdap should be given regardless of the time of receipt of the last tetanus- or diphtheria-containing vaccine. Pregnant adolescents are recommended to receive a Tdap during each pregnancy to protect the infant from Pertussis. In order to maximize placental transfer of antibodies, Tdap is best given at 27-36 weeks of gestation. |
HPV VaccineHuman papillomaviruses (HPV) infect the skin and mucous membranes. Of the more than 150 types known, about forty preferentially grow in the anogenital tract and are primarily transmitted through sexual contact. About half of anogenital HPV types are considered high risk in that they have the ability to cause cancer. Anogenital HPV account for over 17,000 cases of cancer in women and 9,000 cases in men each year in the United States. These include cervical, oropharyngeal, rectal, vulvar, vaginal, and penile cancers. The first generation of vaccines focused on HPV types 16 and 18 as together they account for about 70% of cervical cancer. The first vaccine licensed in the U.S. was Gardasil®, which additionally protects against types 6 and 11 that together account for 90% of the cases of genital warts. Cervarix® is another vaccine licensed in the US. Although Cervarix® is extensively used in other countries; it did not command much of the market in the US. This may be due in part to Cervarix® lacking protection against genital warts. Gardasil®9 was licensed in 2014. In addition to the original four types in the first vaccine, it protects against five more HPV types. The seven high-risk types (16, 18, 31, 33, 45, 52 and 58) bring the protection from cervical cancer up to about ninety percent. The American Academy of Pediatrics and the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention recommend routine HPV immunization of females and males 11 or 12 years of age, although the vaccine can be started as early as 9 years. As of October 2016, a two-dose schedule is recommended for children younger than 15 years of age who are starting HPV vaccination. The second dose is administered 6-12 months after the initial dose. The two-dose regimen is suitable because antibody responses to the vaccine are much higher in young adolescents compared to older adolescents. Adolescents and adults 15-26 years of age should continue to receive three doses of the vaccine on a schedule of 0, 1-2, and 6 months. Adolescents younger than 15 years of age who received two doses less than 6 months apart also require a third dose. If the vaccine schedule is interrupted, the series does not need to be restarted. Follow up studies 8 to 10 years after HPV4 vaccination have shown no waning of protection. Long term follow-up studies are being conducted to determine the duration of effectiveness for all HPV vaccines. Despite the decades of pre-licensure research and large clinical trials demonstrating HPV vaccination safe and effective, providers still face resistance vaccinating adolescents. In fact, under the older (three-doses at every age) recommendation, only 42% of adolescent females and 28% of adolescent males completed the series. Parental concerns include questions about safety (stirred up anti-vaccination groups) and worries that vaccinating gives teens the green light to have sex. Studies show that vaccinated adolescents are no more likely to have sex, obtain a sexually transmitted infection or become pregnant than their peers. Indeed the only things shown to prevent sexual activity in adolescents is clear communications about the subject from their parents and parental monitoring. Monitoring refers to parents knowing where their adolescents are and removing them from risky situations.
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Meningococcal VaccinesMeningococcal infections are caused by Neisseria meningitides and can result in diseases such as meningitis (50% of cases), conjunctivitis, septic arthritis, and most severely, meningococcemia. Meningococcal infections can have an insidious onset appearing like the flu with fever, headache, and body aches. Many providers mistakenly believe meningococcal meningitis and meningococcemia are readily recognizable by their petechial, purpuric or ecchymotic skin changes but such signs exist in only about sixty percent of cases at first presentation. Meningococcal illness can rapidly progress to include symptoms such as photophobia, altered mental status, nuchal rigidity, limb ischemia, hypotension and shock. The disease can be fatal in a matter of hours. The overall mortality rate is between 10 and 15%, with the highest morbidity and mortality rates in adolescents. Transmission of meningococcal infections requires close contact, spreading primarily through respiratory droplets. Adolescents have higher rates of disease due to activities such as kissing and smoking and living in crowded environments such as college dormitories and military barracks. While meningococcal disease remains rare, and the overall annual incidence has decreased, routine immunization of adolescents is recommended. Meningococcal immunization against serogroups A, C, W, Y is recommended for immunocompetent children starting with 1 dose at age 11 through 12 years, with a booster dose given after their 16th birthday. If not previously immunized, the first dose can be given from ages 13-15 years. If the first dose is administered at age 16 years or older, a booster dose is not needed. Serogroups C, W, and Y account for approximately three quarters of cases among adolescents and young adults. Menactra® and Menveo® are the vaccines available to vaccinate adolescents against serotypes A, C, W, and Y. Serogroup B accounts for most of the rest of the cases of meningococcal disease in adolescents in the U.S. There are two licensed vaccines in the U.S., Bexsero® and Trumenba®. The two vaccines are not interchangeable and their dosing schedules differ. Bexsero® requires two doses given at least 1 month apart while Trumenba® is either given in a 2 dose series (0, 6 months) or a three dose series (0,2, 6 months). The AAP and the ACIP of the CDC recommend that people 10 years and older who are at increased risk of meningococcal disease receive this vaccine (people with persistent complement component deficiencies, anatomic or functional asplenia, and people at risk because of an outbreak). MenB vaccination is not routinely recommended for healthy individuals. It may, however, be given to healthy adolescents who wish to obtain short-term immunity at the preferred age of 16-18 years. This is a category B recommendation and thus administration should be discussed between the family and the physician. It is an expensive vaccine and long-term efficacy is still unknown. |
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More Info: HPV Counseling Tips |
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Here are some tips to remember when counseling patients and their caregivers: 1. The HPV vaccine should be treated like all other vaccines. Do not separate the HPV vaccine out making it seem special or different. Say something like, "Your son is going to receive three vaccines today, the Tdap, the HPV and the meningococcal. 2. If a parent hesitates, reinforce the vaccines safety and its necessity to prevent cancer. Reassure parents with a statement like, "The HPV vaccine is not new, and has been recommended for more than 10 years. Hundreds of millions of doses have been given worldwide and if there was a safety problem, we would know." Also let them know that studies indicate vaccinated adolescents are no more likely than other adolescents to be sexually active. 3. Address any specific questions or concerns the parent may have. Give the parent a handout or a trusted website on the subject. |
More Info: immunization schedule from Center for Disease Control
A complete physical should include blood pressure, vision and hearing, and checking the spine for scoliosis.
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More on Scoliosis |
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Significant idiopathic scoliosis (cobb angle >20°) occurs in 0.2-0.3% of the population and is much more common in females. The goal is to keep curves under 30° as they are unlikely to progress once growth is finished. Teens with asymptomatic curves less than 20° should be examined every 3-6 months during there growth spurt. Curves ~ > 20° should be referred to an orthopedist for bracing during the growth spurt. Bracing halts progression but can not reduce the magnitude of the curve. Surgery may be considered for curves >40°.
More info: scoliosis from American Academy of Orthopedic Surgeons
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Hypertension is usually asymptomatic but may indicate the onset of conditions such as renal or cardiovascular disease or drug use.
Vision screening is important because myopia (nearsightedness) often develops and progresses rapidly during pubertal growth. Teenagers may not report vision or hearing problems even if they are adversely affecting educational performance.
Hemoglobin and hematocrit should be obtained on young women a year or two after menarche to check for iron deficiency. Other routine labs are not indicated.
Idiopathic scoliosis (lateral curve of the spine) should be checked for during the early teenage years as it may progress during growth.
More info: Cobb's angle from e-radiography.com
Sports Physicals - also called "Pre-Participation Physicals"
States mandate that school athletes have "sports" physicals. The first goal of this evaluation is to ensure the health and safety of the athlete and the second is to maximize athletic performance in athletes with medical conditions.
It is essential to know for which sports or activities participation is anticipated. The potential for injury is different for basketball compared to ping-pong. The level of exertion may be much higher for a cross country runner relative to a Special Olympics runner.
The medical history is the most important tool for evaluating a participant. Some medical conditions may be worsened by participation, or the condition may limit performance. For example, exercise may induce exacerbations of asthma; and of course, poorly controlled asthma will limit endurance. It is important that asthmatics be under good control.
The cardiac examination is extremely important. The athlete should be examined standing as well as supine to listen for murmurs associated with idiopathic cardiomyopathy.
Sudden death during sports is rare but well publicized. In retrospect, many of these individuals had symptoms such as chest pains, palpitations or a history of syncope. The physical examination, however, was normal. For this reason, inquiry should always be made into chest pain, syncope and family history of heart disease/ sudden death.
A complete physical exam should be performed, including measurement of blood pressure. Mild hypertension does not preclude an athlete from participation but should be followed, evaluated and treated if it does not resolve.
Pupil size should be documented as equal or unequal. Following a head injury, one of the first things to be evaluated is the pupil size.
Visual acuity should be evaluated. If there is unilateral uncorrectable poor vision (e.g., a teen with 20/20, 20/100 vision), protective eyewear is necessary for high risk sports such as basketball.
The infamous "hernia check" is important for documenting two normal testes. Males with only one normal testicle should wear a protective cup in sports where there is potential for collision. Finally, orthopedic screening should be performed to evaluate the range of motion and to detect musculoskeletal problems such as scoliosis.
A concussion is a mild traumatic brain injury which results in an alteration in neurologic function or mental status that may (or may not) involve loss of consciousness. Typically, symptoms have rapid onset, are short-lived, and resolve spontaneously. Mild concussions are commonly known as "dings" or "having one's bell rung." It was common practice to return athletes to the same game following a cursory exam and resolution of most symptoms but it is now known that such athletes are less able to protect their head and neck, and are more susceptible to sustaining additional injuries.
Post-concussion syndrome (PCS) is a common sequela of traumatic brain injury manifested by headaches, dizziness, vomiting, fatigue, irritability, difficulty focusing, disorientation, incoordination and memory problems. Symptoms of PCS are greatest in the first 7-10 days following the concussion, with most cases resolving completely by 1-3 months.
Chronic traumatic encephalopathy (CTE) is a concern for athletes who receive repeated concussions. There is some evidence that repeated head injuries cause cumulative damage, with worsening severity and duration after each event. CTE results in chronic neurologic impairments including behavior and personality changes, parkinsonism, and cognitive abnormalities.
Second-impact syndrome refers to a rare condition in which an athlete develops diffuse cerebral edema from a second head injury while still symptomatic from an earlier concussion. The cause is unknown and is frequently fatal. Second-impact syndrome has driven strict return to play recommendations following concussion.
The current standard of care for returning to play after a suspected concussion is based upon the Zurich Guidelines (see table below). The foundation of the protocol requires that athletes become asymptomatic from their head injury before attempting any return to sports. One method of quantifying concussion symptoms during evaluation is to use a symptom checklist such as the Sideline Concussion Assessment Tool (SCAT3).
Once the athlete is asymptomatic, clinicians should initiate a step-by-step return to play process. Each step consists of an increasing level of activity and 24 hours minimum between each phase. If symptoms return during the process, the athlete should rest for at least 24 hours and return to the last successfully completed step before trying again to proceed.
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RETURN TO PLAY - ZURICH GUIDELINES |
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STAGE |
ACTIVITY |
GOAL |
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0 - No activity
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Physical and mental rest |
Recovery |
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1 - Light aerobic exercise
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Walking, swimming, or stationary cycling. Increase heart rate to <70% of maximum predicted
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Increase heart rate |
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2 - Sport-specific exercise
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Non-contact sports activities increasing heart rate >70% of predicted
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Add movement |
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3 - Non-contact training drills |
Non-contact sports activities with more complex drills. May start weightlifting.
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Advance coordination and increase exercise |
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4 - Full contact practice |
Following medical clearance, return to normal training activities |
Restore confidence, assess functional skills by coaching staff
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5 - Return to play |
Full game play |
Full participation
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This section reviews common problems related to sexual development, menstruation, and consequences of risk behavior, including sexually transmitted infections and pregnancy.
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More info: male gynecomastia |
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The onset of pubertal gynecomastia is during Tanner stage II-IV. Onset after puberty is complete (Tanner stage V) is always pathologic. The boy often notes breast development early in puberty and is concerned that he may be abnormal, as little information is shared about this phenomenon between males. All hormones, including FSH, LH, prolactin, testosterone, and estradiol are normal. The breast development rarely persists more than two years. Unfortunately, breast development may also be a sign of a pathologic process. A good history and physical examination are necessary for males with breast development, especially those with large (>4 cm diameter) or female appearing breasts. The history should include details concerning onset of puberty, drug use and systemic illness. The physical should include examination of visual fields, thyroid, breast, abdomen and the genitals. Usually no laboratory studies are necessary. However, if something of concern is found in the history or physical examination, laboratory studies may include FSH, LH, tests of thyroid and liver function, androgens, estradiol, MRI of the sella, chest x-ray for evidence of tumor, karyotype, and tumor markers such as human chorionic gonadotropin (HCG) and alpha-fetoprotein (AFP). The differential diagnosis includes:
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Gynecomastia is breast development in males. It is common during the neonatal and pubertal periods and in old age. Physiologic pubertal gynecomastia occurs in 60 to 80% of normal boys, although may be subtle enough to go unnoticed. Pubertal gynecomastia may involve one or both breasts. It may affect each breast to a different degree and at different times. Tenderness is common but transitory. Male gynecomastia is usually, but not invariably, benign.
Reassurance is the recommended treatment of physiologic pubertal gynecomastia. Hormone therapy and other medications are ineffective. Surgical reduction may be indicated if the breasts are very large and causing emotional disturbance. If breast development is secondary to a pathologic entity, the underlying condition must also be addressed.
Scrotal problems are usually divided into painless and painful.
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Painless |
Painful |
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Hydrocele |
Testicular torsion |
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Spermatocele |
Epididymitis |
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Varicocele |
Torsion of the appendix testis |
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Hernia |
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Testicular tumors |
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The normal menstrual cycle ranges from 21 to 42 days (mean 28 days). The duration of flow ranges from 2 to 8 days (mean 5 days). Blood loss per cycle ranges from 20-80 cc (mean 35 cc).
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More info: differential diagnosis of amenorrhea |
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Hypothalamic
Pituitary
Endocrine
Ovarian
Uterine/cervix/vagina
Cellular
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Primary amenorrhea is defined as:
Secondary amenorrhea is defined as no menses for 6 months or a period of time equal to 3 previous cycles, whichever is shorter, after previous uterine bleeding. If galactorrhea or hirsutism accompany missed menses, the cause should be investigated immediately without waiting for the individual to meet the strict criteria for amenorrhea.
Evaluation of amenorrhea
The history should include information on growth, pubertal development, previous menses, sexual activity, drug use and family history.
Physical examination should include general appearance, pubertal development, evidence of androgen excess (acne, hirsutism), dysmorphism, and testing for visual fields (pituitary tumor) and sense of smell (Kallmann's syndrome). The thyroid should be checked and the abdomen palpated for masses.
Clitoromegaly and imperforate hymen should be looked for on vulvar examination. A pelvic or a recto-abdominal exam may be performed to examine the uterus and adnexa.
Initial laboratory studies should include a pregnancy test along with thyroid studies, prolactin level, luteinizing hormone, and follicle stimulating hormone.
The most common cause of abnormal vaginal bleeding in girls is primary dysfunctional uterine bleeding. This is usually seen in association with an ovulatory cycles occurring in the first two years after menarche. The term "primary" indicates that no pathology is involved.
Other common causes of abnormal bleeding include sexually transmitted infections, use of hormonal contraceptives, and problems with pregnancy.
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More Information: abnormal vaginal bleeding |
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Complications of Pregnancy
Local Pathology
Systemic Illness
Medications
Hypothalamic-Pituitary Dysfunction*
* Many of the same things that cause amenorrhea (no bleeding) can cause dysfunctional bleeding when affecting the hypothalamus and pituitary. When the problem starts there is often dysfunctional or abnormal bleeding which then develops into amenorrhea. |
Evaluation of abnormal vaginal bleeding. History and physical examination are similar to that for amenorrhea with the addition of clinical quantification of blood loss and inquiry about symptoms related to blood loss (e.g., fatigue, dizziness). Studies should include a complete blood ount and depending on the situation, a pregnancy test along with tests for gonorrhea and chlamydia. Other studies that may be considered include prolactin level, thyroid function, FSH/LH, BUN/creatinine, liver functions, and androgen levels.
Therapy. Treatment of abnormal vaginal bleeding is aimed at the underlying condition. In the case of primary dysfunctional uterine bleeding, treatment is determined by the severity of bleeding. This may range from reassurance to iron supplementation to the use of oral contraception.
Primary dysmenorrhea is recurrent crampy lower abdominal pain associated with menstruation. Other symptoms include nausea, headache, thigh pain, backache and diarrhea. The abdominal pain is due to prostaglandins causing contractions of the smooth muscle of the uterus.
Dysmenorrhea can also be due to endometriosis, pelvic inflammatory disease, congenital malformations of the reproductive tract, tumor, or a complication of pregnancy (e.g., ruptured ectopic). Pain preceding or extending past menses, pain on defecation and dyspareunia should cause concern.
In most patients, NSAIDs such as ibuprofen, naproxen, indomethocin, and mefenamic acid provide symptomatic relief. These medications are also inhibitors of prostaglandin synthesis, as is acetaminophen. Aspirin is not indicated as it is no better than placebo and it increases menstrual bleeding. Some patients may require oral contraceptives. Exercise also helps to relieve the pain.
PMS refers to a constellation of symptoms that occur in the second half of the menstrual cycle and resolve with menstruation. Symptoms include fluid retention, bloating, breast tenderness, headaches, irritability, fatigue, anxiety, hostility, depression and/or a craving for sweets, salts or alcohol.
Treatment includes regular exercise, NSAIDs, hormonal birth control agents, and diet modifications such as low salt intake.
Seventy percent of adolescents have engaged in intercourse by age 19. In general, contraceptives controlled by the individual (e.g., oral contraceptives, condoms) have higher failure rates among teens because of incorrect or sporadic use. Of options readily available for teens, only abstinence is 100% effective!
Hormonal agents may benefit dysmenorrhea and decrease menstrual flow. Unwelcome effects include nausea, bloating, and edema. Major complications are rare but include thromboembolism, cerebral vascular accident, pulmonary embolism, and cholestatic jaundice. Progestin only methods may lead to symptoms of estrogen deficiency such as depression, hot flashes, acne, and atrophic vaginitis. These are similar to menopausal symptoms.
Caution: concurrent use of certain medications may reduce the efficacy of hormonal contraceptives. Antacids, cholesterol binding agents and some antibiotics decrease intestinal absorption of contraceptive hormones. Anticonvulsants, sedatives and some antibiotics may increase the hepatic metabolism of the hormones leading to low serum levels.
Oral contraceptive pills usually contain both estrogen and a progestin although the "minipill" is progestin only. The major drawback to the pill is that it must be taken daily.
The patch (OrthoEvra) and the vaginal ring (NuvaRing) release both estrogen and progestin. They avoid the first pass metabolism through the liver which occurs with oral agents. The patch requires weekly placement while the ring is replaced monthly.
Medroxyprogesterone (Depo-provera) requires an intramuscular injection every twelve weeks. It causes irregular bleeding which progresses to amenorrhea in many women. Prolonged use of Depo-provera has been associated with reduced bone density.
One of the advantages of barrier contraceptives, such as condoms, is that they provide some protection from sexually transmitted infections. The disadvantage is that the methods must be used in relation to coitus unlike hormonal methods which are administered unrelated to the actual act.
Male condoms
Female condoms
Diaphragm
Cervical cap
Sponge
Intrauterine devices (IUD)
Sexually active teens have the highest rate of sexually transmitted infections (STIs) of any age group. If a person is identified to have one STI, it is always important to check for others as the risk factors are similar for all. Since it takes "two to tango", it is important for partners to get treated as well.
1. In males, a common presentation of STI is urethritis (gonorrhea, Chlamydia, Trichomonas, Ureaplasma urealyticum). Symptoms may include dysuria, urgency, frequency, discharge and inflammation of the meatus. Less often, males develop orchitis or epididymitis with swelling and pain of the testis and epididymis.
2. Women may develop vaginal discharge, pruritus, or dysuria (Trichomonas). Many vaginal complaints are not related to sexually transmitted pathogens.
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VAGINAL DISCHARGE AND IRRITATION CHART |
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Diagnosis |
Complaint |
Exam |
pH |
Well Mount |
KOH |
Rx |
Comments |
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Physiologic "leucorrhea" (not STI) |
Discharge Inconvenient |
Clear, white, slightly yellow discharge that dries brown, otherwise normal |
< 45 |
Epithelial cells, |
negative |
reassure |
May occur prior to menarch or during cycle |
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Candidiasis (Not STI) |
Pruritius, Dysuria |
Milky white, curded discharge, erythema, edema, may affect folds skin of thights |
< 45
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Epithelial cells, may see pseudohyphae. budding forms |
Pseudohyphae budding forms
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"azole" topical per label: fluconazole¹ 150mg po X 1 dose (¹avoid during pregnancy) |
Increased risk if imunosuppressed, diabetic, recent antibiotics, pregnant. |
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Bacterial vaginosis |
Mild pruritus, Mild dysuria, Odor |
Graywhite discharge |
>45
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Epithelial cells, > 20%
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"whif" test amine odor |
Metronidazole 2gm po X 1 or 500 po bid X 7 days or topical qd x 5 days; clindamycin 300mg po bid X 7 days or topical qhs X 7 days |
Related to hygiene as well as sexual activity; high concentrations of anaerobic bacteria (e.g., Prevotella sp., Mobiluncus sp.), G. vaginalis and Mycoplasma hominis) |
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Trichomonas |
Pruritius, Dysuria, Odor, Abdominal pain |
green-gray frothy discharge, erythema, strawberry spots |
>45 |
Epithelial cells, white cells, Trichomonads
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Negative |
Metronidazole 500 po bid X 7 days |
Treat partner, sensitivity of web mount 60-80% |
3. Some sexually transmitted pathogens may cause cervicitis (gonorrhea, Chlamydia and Herpes Simplex Virus 1 or 2). The symptoms may include vaginal discharge, abdominal pain, irregular or painful bleeding with a mucopurulent discharge from the cervix.
4. Pelvic inflammatory disease often presents as cervical motion tenderness, and uterine or adnexal tenderness. It is an ascending infection involving the uterus, fallopian tubes, ovaries and/or peritoneal tissues. If the inflammation is around the liver, it is called perihepatitis or Fitz-Hugh-Curtis syndrome. The infection is thought to be initiated by sexually transmitted pathogens, but it often becomes polymicrobial. Only 50-70% of cases have a positive test for chlamydia or gonorrhea. The long term sequelae include infertility, ectopic pregnancy and chronic abdominal pain due to adhesions.
5. Ulcers and warts may present similarly in males and females. These include:
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More Information: ulcers and warts |
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Herpes Simplex Virus (HSV) in the genital areas is more commonly type 2 although type 1 occurs as well. Painful grouped vesicles develop into pustules and then erode into ulcers. Bilateral tender adenopathy usually occurs. Commonly, a primary genital outbreak is accompanied by flu-like symptoms in individuals without previous exposure to either HSV 1 or HSV 2. The diagnosis is made by Tzanck prep, viral culture or fluorescent antibody stains. The ulcers are self limited but antivirals such as acyclovir may be used to hasten resolution. HSV is not curable and a few individuals will have reoccurrences. Antivirals may be used to reduce the number and severity of recurrences. The name of the ulcer caused by Treponema pallidum is "chancre." Classically, it is a single painless indurated ulcer with non-tender regional adenopathy. Unfortunately, the picture can become confused if the ulcer becomes secondarily infected. Blood tests such as Rapid Plasma Reagin (RPR) or Venereal Disease Research Laboratory (VDRL) may not be positive when the ulcer first occurs. The serous fluid from the base of the ulcer can be sent for dark field microscopy or fluorescent antibody staining. Although the ulcer is self limited, systemic infection may occur causing secondary and tertiary syphilis. The ulcer is usually treated with an intramuscular injection of penicillin. Hemophilus ducreyi is the cause of chancroid. Usually there are multiple painful ulcerations with scalloped edges and a red halo. Tender regional adenopathy occurs in about 60% of cases and may suppurate forming buboes. Laboratory tests are not readily available. The Centers for Disease Control recommends presumptive treatment. A one time dose of azithromycin or ceftriaxone is often used. Lymphogranuloma venereum (LGV) is rare in the United States. It is caused by LGV serovars of Chlamydia trachomatis. Often the initial papule or ulcer goes unrecognized. Buboes (swollen, fluctuant lymph nodes) may develop. The best test is the serum complement fixation titer but it is only 80% sensitive. Treatment consists of twenty-one days of doxycycline or erythromycin. Most genital warts are condylomata acuminata, caused by the human papillomavirus (HPV). "Acuminata" refers to the finger-like papillae that compose most warts giving them their cauliflower like appearance. There are many different HPV types. Some types are predisposed to causing condylomas while others are more likely to cause cervical dysplasia and anogenital malignancies. Condylomas are often diagnosed clinically but specimens can be sent for pathology. They resolve over time but can be treated with lasers, chemicals (e.g., podophyllin, trichloroacetic acid), or liquid nitrogen. Condyloma lata are a much less common cause of genital warts. They are a form of secondary syphilis and are usually flat and moist. They are diagnosed by clinical appearance along with a positive RPR. They resolve over time but may progress to tertiary syphilis and so are treated with a intramuscular injection of penicillin |
More info: Treatment of STI's from the CDC
As adolescents begin individuation from their parents and become increasingly concerned about peer acceptance, they are especially vulnerable for engaging in risky behaviors. In the sections above, we have discussed concepts related to sexual behaviors. In this section, we will add key concepts related to substance use and eating disorders
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More info: stages of drug use |
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Stage 1- experimentation Use is in social settings and is often the result of peer pressure. The substance comes from friends. The user is often inept and injury can occur from overdosage or accidents. Outside the consequences of getting caught, usage does not affect family life and school performance. Most providers treat information shared by teens at this stage confidentially and provide counseling. Stage 2- actively seeking The adolescent in this stage are seeking the effect of the substance. They often maintain their own stash and use may occur in non-social contexts. The teen may get "high" to reduce test stress instead of studying or to cope with psychosocial issues. Use begins to affect family life and school performance. Teens in this stage need to be followed closely and helped with issues related to use. Once aware of the problem, the physician may need to enlist the aid of parents to intervene if the minor teen does not abstain on their own. Stage 3- preoccupation This is the classic "drug addict." The teen's entire life revolves around the issue of obtaining substances and getting "high." Use is compulsive, even in the face of problems with the family, school and the law. Often they are into poly-drug use. The quantity of drugs used may be expensive and lead to criminal activity such as drug trafficking, theft or prostitution. Teens in this stage should be referred to experts in the field as treatment is complicated and the users are often devious. Stage 4- burnout This stage is rarely seen in teens as it usually takes years of use to cause enough damage. Some substances are more neurotoxic and can lead quickly to this stage (e.g., inhaling carburetor cleaning fluid). Substances are used to prevent the negative effects of withdrawal or just to feel normal. Often the teen has no family or work life left. Even when off the substances, most people will identify these individual as abnormal because of their flattened affect, sluggish processing and slowed speech. Again, these individuals should be cared for by experts in the field. |
Alcohol, nicotine (cigarettes or chewing tobacco) and marijuana are the substances used most commonly by teens. Other drugs are used by less than 10% of the adolescent population. Drug use can be divided into phases: experimentation, active seeking, preoccupation, and burn out. Determining the stage or pattern of use can help the provider determine what additional intervention is appropriate.
Parents are often the first to be concerned as the teen withdraws from family activities or begins flouting family rules. Declining grades, truancy and withdrawal from extracurricular activities are other signs of drug use. Some medical conditions may become exaggerated, such as asthma from smoking marijuana. Dysphoria, confusion, irritability and low tolerance of frustration may occur along with self-destructive behaviors. Stealing and other criminal behaviors may get the teenager in trouble with the law.
A good history and physical exam are the most sensitive tools for diagnosing substance use. Substance users are often seductive liars, making it is important to corroborate the history with a family member. Parents are usually unaware of the specifics of use but can detail associated behaviors such as truancy or changes in behavior.
Drug testing is specific but not very sensitive and does not reveal the pattern of use. A positive test for marijuana does not discern the teen who smoked it once from the one who smokes seven times a day.
The pattern of use determines the treatment. When caught, teens try many different ploys. It is best to warn the parents beforehand. Common statements from teens include, "You don't really think I would use that stuff do you," "Someone put it in my drink," "I was holding it for a friend," "It was second hand smoke," and "Everyone else does it." Parent reactions vary from denial, outrage aimed at the physician, sadness, guilt and fear. Substance use may be a chronic problem requiring long term follow up with periods of exacerbation and improvement.
Adolescence is the primary time for the development of eating disorders. The interaction of puberty and the issues surrounding body image place teens at risk. Early recognition of unhealthy eating habits makes treatment easier and improves outcomes. Counseling teens on nutrition and appropriate weight management may go a long way in preventing these disorders.
In the past, the Diagnostic and Statistical Manual of Mental Disorders 4 (DSM-4) only specified two eating disorders, anorexia nervosa and bulimia nervosa. This left more than half of patients in the category of Eating Disorders Not Otherwise Specified (EDNOS). In the fifth edition of DSM-5, the chapter Feeding and Eating Disorders now includes the following six disorders: anorexia nervosa, bulimia nervosa, binge-eating disorder, avoidant/restrictive food intake disorder (ARFID), rumination disorder, and pica. EDNOS has been replaced with Other Specified Feeding or Eating Disorder and Unspecified Feeding or Eating disorders. This review will focus on anorexia nervosa and bulimia nervosa.
The prevalence of anorexia nervosa among young females is approximately 0.4%. Females outnumber males 10:1. Anorexia nervosa occurs across culturally and socially diverse populations, though there is an increased risk among first-degree biological relatives of individuals with
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More Info: Diagnostic Criteria Anorexia |
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A. Restriction of energy intake relative to requirements, leading to a significantly low body weight in the context of age, sex, developmental, trajectory and physical health. Significantly low weight is defined as a weight that is less than minimally normal or, for children and adolescents, less than that minimally expected. B. Intense fear of gaining weight or of becoming fat, or persistent behavior that interferes with weight gain, even though at a significantly low weight. C. Disturbance in the way in which one's body weight or shape is experienced, undu influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight. Specify whether: (F50.01) Restricting type: During the last 3 months, the individual has not engaged in recurrent episodes of binge eating or purging behavior. (i.e. self-induced vomiting or the misuse of laxitives, diuretics, enemas). This subtype describes presentations in which weght loss is accomplished primarily through dieting, fasting and/or excessive exercise. (F50.02) Binge-eating/purging type: During the last 3 months, the individual has engaged in recurrent episodes of binge eating or purging behavior (i.e. self-induced vomiting or the misuse of laxitives, diuretics, enemas). |
the disorder. Patients with anorexia nervosa are also at increased risk of suicide.
The primary features of anorexia nervosa include a severe energy intake restriction, an intense fear of gaining weight or becoming fat, and a disturbance in self-perceived weight or shape. The requirement for amenorrhea was eliminated in DSM-5, which increases the likelihood for diagnosis in males and premenarchal females. See below for full DSM-5 criteria.
Most laboratory tests in patients with eating disorders are normal, and may provide false reassurance to families and providers. Severe cardiac complications can still occur despite normal lab results. Findings which may support a diagnosis of anorexia nervosa include: leukopenia, electrolyte abnormalities, elevated liver enzymes, and a low T3 and low-normal T4. Sinus bradycardia on electrocardiography is common; prolonged QT and arrhythmias can also be seen.
Treatment involves a multi-disciplinary approach involving physicians, mental health providers and registered dietitian nutritionists. Hospitalization may be necessary. Common psychotherapies used to treat patients include cognitive behavioral therapy (CBT) and family based therapy (FBT), with some evidence suggesting that FBT is the most effective treatment for adolescents.
The prevalence of bulimia nervosa among young females is approximately 1-1.5%. Again, females outnumber males 10:1. Bulimia nervosa occurs across similar populations as anorexia nervosa, and while genetic vulnerabilities for the disorder may be present among families, known
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More Info: Diagnostic Criteria Anorexia |
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A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:
B. Recurrent inappropriate conpensatory behaviors in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise. C. The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for 3 months. D. Self-evaluation is unduly influenced by body shape and weight. E. The disturbance does not occur exclusively during episodes of anorexia nervosa.
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risk factors include childhood obesity and early pubertal maturation. Mortality is less common in patients with bulimia compared to anorexia nervosa, though patients with bulimia also have an increased risk of suicide.
The primary features of bulimia nervosa include recurrent episodes of binge eating, recurrent inappropriate compensatory behaviors to prevent weight gain, and self-evaluation that is overly influenced by body shape and weight. Bulimics are much less likely to come to medical attention than anorexics. Occasionally, bulimics will come to the physician seeking prescriptions for laxatives or diuretics. Dentists are more likely to pick up bulimics due to the damage done to the teeth by purging. Unlike patients with anorexia, patients with bulimia may have a normal or above-normal BMI-for-age. See below for full DSM-5 criteria.
Laboratory testing is most likely to be abnormal in a patient with bulimia due to purging behaviors. Abnormalities include hypokalemia, hypochloremia, hyponatremia, and potentially life-threatening cardiac arrhythmias. Vomiting may produce a metabolic alkalosis due to loss of gastric acid, while laxative and diuretic abuse can lead to metabolic acidosis.
Treatment should be focused on the underlying self-esteem and psychiatric issues such as depression. Pharmacotherapy has more evidence-based support in bulimia than anorexia, and may provide additional benefit when combined with CBT or FBT. Common sense approaches like not stocking binge foods in the home can help. The physician should help with appropriate weight loss methods if the patient is overweight.
Canty, Greg; Nilan, Laura. Return to Play. Pediatrics in Review 36 (10), Oct 2015.
Rome, Ellen; Strandjord, Sarah E. Eating Disorders. Pediatrics in Review. Pediatrics in Review, 37 (8), Aug 2016.
Schunk, Jeff E; Schutzman, Sara A. Pediatric Head Injury. Pediatrics in Review. 33 (9) Sept. 2012.
RedBook Online
UpToDate Online
Immunization Schedule. Center for Disease Control
Scoliosis. American Academy of Orthopedic Surgeons
Scoliosis and Cobb's Angle. e-radiography.com
Tanner Staging and Breast Development. teenpuberty.com
Tanner Staging and Female Breast Development. afraidtoask.com/breasts
Tanner Staging and Female Genital Development. afraidtoask.co/vulva
Tanner Staging and Male Genitalia Development. afraidtoask.com/penis
The move for independence creates the largest amount of distress for parents. Early adolescents begin to pull away from their parents and show less interest in family activities. For example, the teen may refuse to go with the family to the movies or may demonstrate his or her own will by refusing to do chores on the parent's schedule. Early adolescents are often moody, alternating between being pleasant and nasty toward their families. Usually, the teen is mainly antagonistic towards the most "controlling" parent. Early adolescents crave privacy and desire to control their personal information as they carve out a life separate from that of their parents.
Adolescents become aware of their physical development and the fact that it portends adulthood. Most early adolescents are not sure what to think of the changes in their body and accompanying hygienic responsibilities. Body odor, axillary hair, acne and menstrual cramps are not exactly thrilling. Being "normal" is a huge concern to early adolescents and leads to constant comparisons to others. Common questions include "is my penis long enough?", "are my breasts large enough?", and "is it normal for one testicle to hang lower than the other?" Pubertal gynecomastia or physiologic vaginal discharge can be terrifying to a teen.
Peers become extremely important during adolescence. As they pull away from their family, early adolescents are not strong enough to stand on their own and they turn to their peers for guidance and support. By mid-adolescence, the peer group exerts a huge influence over the teen. At this time, peer groups demand that members conform as this reduces stress related to decision-making. If the group wears black clothing and lipstick, then the all the members must do the same. To do otherwise would risk exclusion from the group. Unfortunately, this also includes risk behaviors such as sexual activity or substance use, and participation in gangs.
Identity development includes the emergence of abstract reasoning along with personal values and morals. Early adolescents tend to be concrete and see things in black and white. A girl, taught that she will get pregnant if she has sex, assumes she does not have to worry about birth control because she had unprotected sex once and did not get pregnant. The limited ability to think abstractly makes it hard for a teen to see another's point of view and also makes compromise difficult. Lack of abstract thinking also encourages feelings of invulnerability. Teens believe that nothing bad will happen to them no matter what. They trust that they can have sex, use drugs, smoke, or drive recklessly without consequence.