A. Review the evolution of the concept of adolescence, and explore existing definitions

• primitive to modern cultures
• recent challenges
• WHO definitions, national definitions

Invite audience to define adolescence and to identify markers of adolescence in different societies and for different generations (possibly referring to their own adolescence).

Provide traditional definitions, e.g. Erikson, Piaget, Freud.

Present WHO definition of adolescence and compare with national definitions of adolescence

Note that adolescence can be seen in 3 stages – early, middle and late

Website 1

National definitions

B. Discern the reasons for the variability of the definitions of adolescence

• Operational definitions vs. chronological
• Influence of context
• “Bio-psychosocial” construct

Interactive lecture

Group discussion

Ask group to reflect on the contrast between operational and chronological definitions;
note that different definitions are useful for different purposes (e.g. chronological definitions are necessary for epidemiological purposes).

Note that adolescence contains biological, psychological and social elements, and that multiple definitions exist. Present the following examples and discuss whether they represent adolescents : a 10 year-old with periods; a 15 year-old prepubertal; a 25 year -old living with parents; a 40 year-old with mental age of 12 years.

Highlight the influence that context has on the definition of adolescence, using such comparisons as a 15 year-old Nigerian girl who is married and pregnant versus a 23 year-old English girl who is studying at the university and living with her parents.

Discuss the significance of the constructed adjective “bio-psychosocial”. What is its meaning and use to the health practitioner in dealing with adolescents?

Website 1

National definitions

Ask group members to reflect on their own adolescence and identify the events and feelings they went through to become adults (e.g. identify when and why did you stop feeling like a child and when did you start feeling like an adult? What events do you remember?) Note gap between what actually happened and what is remembered.

Bring these ideas together in plenary review and record responses. Trainer asks group members how they would classify the events; suggest that these can be divided into biological, psychological and social elements of early, mid and late, using the grid in appendix 1.

1. biological: changes in body shape, appearance and function (puberty)
2. psychological: changes in the way of thinking about oneself (identity and sexual identity) and the ability to think about the world (thinking pattern)
3. social: changes in the way young people relate to their families, to other young people, and to the outside world.

Appendix 1

Ref. 1,2

B. Identify the biological events and timings of puberty and growth, the means of assessing these, and consequences for medical management

(See topics to be covered in activities column)

Lecture on normal pubertal development should include the following elements:

• events and timings of puberty and growth, normal variations
• timing of menarche and secular changes over past 30 years (use examples from trainer’s country)
• uses of Tanner staging of puberty
• use of growth reference charts, calculation of growth velocity (growth spurt)
• meaning of BMI changes in adolescence
• bone mineral accretion
• other physiological changes (blood pressure, lipids, haematology, enzyme system maturation, brain effects of sex steroids)
• pharmacological issues i.e. drug doses, contraindications specific to adolescence, drug interactions (e.g. contraception), effects on growth and bone mineralisation

Module B1

Ref. 3,4

C. Identify the psychological events of adolescent development

(See topics to be covered in activities column)

NB. Activity for Objectives C and D. may be done separately or together in the same small groups, with a final plenary review.  Appendix 1 can be used as a record sheet.

Break audience into small groups and set a task to identify psychological aspects of adolescent development.

Case study 1: an 11 year-old girl with relative sexual precocity (menarche at 10) is worrying her parents because she has become aggressive, opposing, and provocative at home. Her parents suspect that the girl is upset because she was the first to get breasts, and she may be afraid of boys and sexuality.

Case study 2: A 15 year-old presents for a vaginal discharge Although quite religious, she recently began having sex out of fear that she would otherwise lose her boyfriend. Although she knows this discharge could indicate an STD, she refuses to consider using contraceptive methods because she intends to breakup with her boyfriend. She says she feels unattractive and will never have sex again.

At plenary review, insure the following are included and explored:

• development from concrete to abstract thinking
• personal identity development  (e.g. challenging parents and the ideal child image, questioning moral and social structures, seeking spiritual paths, developing ideas about the workings of the world and their place in it)
• development of body-image and sexual self (sexual orientation, gender issues, sense of attractiveness, doubt about normality/abnormality)
• development of more variable affect (mood swings, impulses)
• differences in developmental stages between case studies 1 and 2
• linking and interactions of psychological, physical and social components

Appendix 1

Ref 5

D. Identify the events of social development in adolescence

(See topics to be covered in activities column)

Break audience into small groups and set a task to identify social aspects of adolescent development.

Case study: A boy of 17 has left home because he wants to live with his girl friend in a loft.
He is still studying, receives some money from his parents and always asks for extras.
Although he says his parents do not understand him, he still calls his mother every day. He would like to quit his studies like some of his friends have, but says he does not want to accept any job that is not socially rewarding.

At plenary review, insure the following are included and explored:

• increasing autonomy from parents and integration into peer group (mid-adolescence)
• educational achievement (all adolescent stages)
• financial independence (late adolescence)
• achievement of intimacy (later adolescence)
• challenging of social structures and values
• increasing responsibility within communities

Note that the above psychological and social development does not occur as a smooth process. It involves back and forth movements and paradoxical attitudes that characterize the adolescent crisis.

E. Identify the factors that modify social development in adolescence

• gender
• class
• culture
• family factors

Illustrate the impacting factors using a short video (to be identified by the teacher) or through audience interview.

For audience interview:  Insure that a mix of males and females participate.  If time is limited, ask only a small number of participants.  Note that some participants may not be willing to participate. Suggested questions include,

1. When did you first go on a vacation or overnight trip without your parents?
2. If you drink, when did you first have an alcoholic drink and when did you first drink in front of your parents?
3. Can you briefly describe an adolescent you have met who showed evidence of rapid or slow social development for a particular reason?

Participants discuss what may account for the differences in their personal experiences, especially the speed of social development. Trainer guides discussion to show the influence of the key factors listed at left.

How difficult is it to report on one’s own adolescence and compare with the others?

Ideal: supervised patient experience at local clinics.

Alternative: Case study presented with overheads

Case study:
A 15 year-old boy who is very short and young looking presents at clinic. He has been in trouble at school repeatedly for disruptive behaviour in class and for smoking. He has also been harassing girls in the class. He was a model student until about 14 years of age, when most of his peers started to grow. His parents are divorced and he lives with his mother who is very concerned about his short stature and smoking.
Present an overhead of pictures of his Tanner staging (the boy is G2P2 testes 6ml).

Ask learners to assess Tanner staging and psychosocial development in terms of early, mid or late adolescence.  Explore possible associations between the boy’s biological and psychosocial maturation and his behaviours.

Tanner stages

Appendix 1

Ref. 8

In small groups, examine the consequences of adolescent thinking styles and social development on their health behaviours. Groups formulate examples to be used by the teacher in discussing the relation between a psychosocial characteristic and a particular behaviour.

Alternatively, examples such as the following can be proposed by the teacher for comments by the students: There is tobacco and hashish smoking spreading in the secondary school. List the factors related to psychosocial development that may increase the risk of this behaviour (see appendix 2, Module B8).

At plenary, review:

• development of exploratory /risk behaviours and experimenting with drugs/alcohol/sex/cigarettes/violence (examine rationale for exploratory behaviours including issues regarding future thinking ability)
• effects of mood state (not trait) on behaviour
• poor compliance/adherence with treatment or medical advice
• peer effects
• the strength of media influence
• rebellion against status quo and authority figures

Consider how, in a clinical situation, to target health promotion messages to the individual adolescent. Formulate sentences for delivering the message (can use role play).
Examples of problematic situations:

• A 14 year-old boy binge drinks every weekend with his friends.
• A 16 year-old girl is having unprotected sex; she is sure she cannot become pregnant because her menses are irregular.
• A 16 year-old Muslim boy rides a motorcycle without a protective helmet.

Consider how, in a setting such as a school or youth club, to target health promotion messages to a group of young people. Have the students develop concrete strategies (e.g. small group work on a real scenario). Discuss the following:

1. tailoring the delivery of information about sexual activities for different levels in elementary and secondary school
2. managing of the situation in Goal IIIB of tobacco and hashish use spreading in the school.

At plenary, discuss the following principals:

• Health promotion messages need to be developmentally appropriate i.e. based upon concrete concepts of immediate costs or benefits relevant to young people rather than future consequences/benefits.
• Health promotion messages need to be delivered following strategies adapted to adolescent psychosocial functioning (such as sensitivity to peers).

   Biological    

   Psychological    

   Social