An Overview of Puberty Betsy Pfeffer MD Assistant

An Overview of Puberty Betsy Pfeffer MD Assistant Clinical Professor Pediatrics Morgan Stanley Children’s Hospital of New York Presbyterian Columbia University

Overview of Adolescent Pubertal Development • From a biologic perspective, the beginning of adolescence is marked by the onset of puberty • Cultural influences on puberty include nutrition, the quality of health care and living conditions

Overview of Adolescent Pubertal Development • In the developed world the biologic age of menarche has declined over the past centuries from 16. 6 years in 1840 to 12. 5 years by 1980 • Data on boys, though less reliable, suggest that they may be beginning maturation earlier as well

Sexual Maturity Ratings Tanner developed a scale in 1962 that divides the SMRs into 5 classes based on pubic hair and breasts in females and pubic hair and genitalia in males

Tanner Stages Females

Hormonal Control of the Menstrual Cycle

Tanner Stages Males

Puberty • The normal range in pubertal development is very broad • Early maturation is a positive experience for boys but may be negative for girls • Late maturation is usually more difficult for boys than for girls • Adolescents compare themselves to their peers and internalize the reaction of others to their changing bodies

Sleep: A Complete Mystery • Increased need for sleep at puberty • Adequate sleep is essential to support healthy physical development • During puberty changes in melatonin secretion cause a sleep delay leading to later sleep onset and later waking times • Adolescents need 9 -9. 5 hours of sleep/night • Sleep enhances the consolidation of learning • Insufficient sleep – Irritability/Low frustration tolerance – Difficulties with attention and self control Hazen 2008 Dahl 2009

Tasks of Adolescence • Physical Development/Puberty • Psychosocial Development • Cognitive Development

Stages of Adolescent Development • In all countries adolescence go through the same stages but age ranges may vary • Early Adolescence: USA 1013 years • Middle Adolescence: USA 14 -17 years • Late Adolescence: USA 1721 years

Physical Changes Early Adolescent Girls: • Growth and growth spurts begins • Beginning of pubertal changes breasts/genitalia/pubic hair • Weight changes-body shape and size

Physical Changes Early Adolescent Boys: • Development of the testes and scrotum is usually the first sign of puberty in boys • Pubic hair • Voice changes • Gynecomastia common

Physical Changes Early Adolescent Boys and Girls: • Wide range of normal • Acne • Girls tend to lose less of their body fat than boys • An awkwardness as various body parts grow at different rates • Biologic changes in the brain causing dynamic emotional and cognitive changes

Physical Changes Mid Adolescence Girls: • Breast development – Nipples swell , breasts may feel tender and sensitive – Breasts fill out over three to four years. One breast may grow faster than the other – One or both breasts may secret a small amount of milky fluid • Broadening hips leading to rounded feminine figure

Physical Changes Mid Adolescence Boys: • Growth spurt in height usually occurs • Often the arms and legs lengthen before the trunk of the body, can cause awkwardness • Faster muscle growth in boys leads to greater strength • Penis growth • Development of pubic, facial and body hair. Typically facial and body hair appear about two years after pubic hair.

Physical Changes Late Adolescence • Females – By 16 years most young women have completed puberty, the growth rate slows, there is pubic and body hair, a rounded and curved figure because of widened pelvis, hips and breasts – With a well established menstrual cycle, a young woman at this point is physically able to produce offspring

Physical Changes Late Adolescence • Males – By 16 to 18 years most males have completed puberty, their growth rate begins to slow, their shoulders have broadened, limbs and trunk are muscular and they have adult body and facial hair – Produce sperm and are physically able to produce offspring

Psychosocial Changes Early Adolescent • Begin to separate from parents and identify with peers • Confrontational with parents • Preoccupation with self • Preoccupation with being like peers • Conformity • Same gender in clique

Psychosocial Changes Early Adolescent • • • Interest in other gender for friendship Travel in “packs” Greater need for privacy Still need “down-time” Mood swings/Erratic behavior Lack of impulse control

Psychosocial Changes Mid Adolescence • Peak – Parental conflicts – Peer involvement – Risk taking behavior • Conformity with peer values • Feeling of omnipotence and immortality • Egocentric – Personal fable, belief in own uniqueness and invulnerability • Self centeredness and vanity

Psychosocial Changes Mid Adolescence • • • Increasing independence Less idealistic vocational aspirations Questioning “who is the real me ? ” Behave differently with different people Conflicting view of the self can be troubling – Ability to recognize that they have different roles with different people but don’t yet understand why and this can be troubling

Psychosocial Changes Late Adolescence • Integration of the diverse views of self • Less importance placed on peer group • May accept parental values or develop own • Realistic vocational goals • Less self centered

Psychosocial Changes Late Adolescence • Decreased impulsivity and increased ability to compromise • Fully understanding lack of invincibility • Ability to compromise and set limits • Refinement of moral and religious values

Cognitive Development • Much of modern thinking about cognitive development in adolescence is gotten from the work of the Swiss biologist/psychologist Jean Piaget (1896 -1980) • He outlined four main stages of cognitive development from birth to adolescence • The shift from the third stage of concrete thinking to Piaget’s highest stage of cognitive formal operations (the ability to think hypothetically and abstractly) begins around age 11

Cognitive Changes Early Adolescence • Retain concrete thinking • Begin to question authority and societal standards • Conformist morality of childhood • Learning by trial and error • Beginning abstraction • Imaginary audience, on stage all the time, others are thinking only about them

Cognitive Changes Mid Adolescence • Thinking tends to be less childlike, more abstract, introspective and analytic • Begin to realize they are sexual beings • Can consider facts and make better decisions based on knowledge of the consequences of their choices • Sensitive to criticism • Increased openness of feelings and sensitivity to the feelings of others • Continue to be influenced by peers

Cognitive Changes Late Adolescence Conceptualize/verbalize thoughts Full adult reasoning/identity Ability for abstract thinking Understanding consequences of behavioral choices – Increased thoughts about more global concepts such as justice, history, politics, patriotism and their emerging role in adult society – –

Brain Development There may be a biologic basis for the increased risk taking and impulsivity in adolescence – Areas of the brain that are associated with the capacity evaluate risk and reward are one of the last regions of the brain to mature Hazen 2008 – Areas of the brain associated with working memory, emotion regulation and the capacity for long term planning mature during adolescence Hazen 2008

Hardwiring the Brain • According to Dr. Jay Giedd of the NIMH during adolescence – A second wave of overproduction of gray matter occurs – A process called “pruning” occurs where connections among neurons in the brain that are not used wither away, while those that are used stay—the “use it or lose it” principle – Teens may actually be able to control how their own brains are wired and sculpted – Teens who “exercise” their brains by learning to order their thoughts, understand abstract concepts, and control their impulses are laying the neural foundations that will serve them for the rest of their lives

Brain Development • Evidence that some brain changes are linked to puberty while other changes are dependant on age/experience Dahl 2004 • Increase in the volume of white matter facilitating connections between cortical regions occurs into the twenties National Institute of Mental Health 2001

Brain Development • Many important decisions are made by teens in affectively charged environments and because of incomplete myelination, executive brain regions don’t modulate decision making and poor decisions are made Hazen 2008 • Poor decision making in real life situations despite measurable aspects of decision making approach adult levels of competence by age 15 Dahl 2004

Brain Development • When challenges are presented to teens in less emotionally charged settings, they make safer decisions and use higher brain functions more effectively Hazen 2008 • True of adults too • Importance of anticipatory guidance

Putting it All Together • Helpful to determine where a teen “is at” – Understanding the developmental phases of adolescence can help us place the adolescent in an appropriate context – Once we understand the developmental tasks of adolescence and we couple this with the acquisition of skills that aid in the communication with an adolescent • • • Assure Confidentiality Engage the adolescent as a therapeutic ally Active listening and observing Reflective responses Clarify inferences Summarizing statements – Then….

The Goal We can help successfully guide our youth community into making thoughtful and healthy decisions along their journey into becoming responsible and productive adults

Bibliography • • • • Rosen, D. “ Physiologic Growth and Development During Adolescence” Pediatrics in Review 2004 Patton, G. “Pubertal Transitions in Health” The Lancet 2007 Hazen, E. et al“Adolescent Psychological Development: A Review” Pediatrics in Review 2008 Gutgesell, M. “ Issues of Adolescent Psychological Development in the 21 st Century” Pediatrics in review 2004 Ginsburg, K. “ Engaging Adolescents and Building on Their Strengths” AAP Adolescent Health Update 2007 Cavanaugh, R. et al “Managing the Transitions of Early Adolescence” AAP Adolescent Health Update 2008 Bight Futures: Guidelines for Health Supervision of Infants, Children and Adolescents AAP Kreipe, R. “ Introduction to Interviewing: The Art of Communicating with Adolescents” AMSAR 2008 Teenage Brain: A Work in Progress (Fact Sheet) National Institute of Mental Health 2001 Dahl, R. “Beyond Ragging Hormones: The Tinderbox in the Teenage Brain”. Cerebrum: The Dana Forum on Brain Science 2003 Dahl, R. “Adolescent Brain Development: A Period of Vulnerabilities and Opportunities” Annals New York Academy of Science s 2004 Dahl, R. “ The Consequences of Insufficient Sleep for Adolescents” Phi Delta Kappan 1999 Spinks, S. ‘ Adolescents and Sleep” Frontline PBS 2002