Adolescence (ages 10–19) is a period of profound physical, cognitive, emotional, and social transformation. Leading causes of morbidity and mortality in this age group are largely preventable: unintentional injuries, suicide, homicide, substance use, and risky sexual behavior. Confidential, comprehensive healthcare is essential.
Puberty
Puberty begins with reactivation of the hypothalamic-pituitary-gonadal axis. Girls average onset at 10–11 years (range 8–13). Boys average onset at 11–12 years (range 9–14). Tanner staging (sexual maturity rating) assesses breast development and pubic hair in girls; genital development and pubic hair in boys. Menarche typically occurs 2–3 years after thelarche, at Tanner stage 4, at an average age of 12.5 years in the US. Peak height velocity occurs at Tanner stage 3–4 in boys (approximately 9 cm/year) and earlier, at Tanner stage 2–3 in girls (approximately 8 cm/year). Pubertal timing varies by genetics, nutrition, and socioeconomic factors. Concerns about normal and abnormal pubertal development are common and should be addressed with reassurance or appropriate referral.
Mental Health
Adolescence is the peak period for onset of mental health conditions: 50% of lifetime mental disorders begin by age 14, and 75% by age 24. Depression affects 15–20% of adolescents. Female-to-male ratio increases from 1:1 in childhood to 2:1 in adolescence. Screening with the PHQ-9 (Patient Health Questionnaire) is recommended for adolescents 12 and older. Symptoms may include irritability (more common than sad mood in teens), social withdrawal, declining grades, sleep changes, and appetite changes.
Suicide is the second leading cause of death in adolescents (after accidents). Risk factors: mental health conditions (depression, bipolar, conduct disorder), substance use, previous attempts, family history of suicide, LGBTQ+ identity (if unsupported), bullying (including cyberbullying), and access to lethal means. Screening for suicidal ideation should be direct and routine. The 988 Suicide and Crisis Lifeline provides immediate support.
Anxiety disorders — GAD, social anxiety, panic disorder — are common and impair academic performance, peer relationships, and family functioning. School refusal may be a manifestation of anxiety. Treatment includes CBT and SSRIs.
Substance Use
Early initiation of substance use is a strong predictor of later substance use disorders. Screening with validated tools (CRAFFT for adolescents) is recommended. Vaping/e-cigarettes are now the most commonly used nicotine product among adolescents — nicotine is highly addictive and harms adolescent brain development. Alcohol is the most commonly used substance. Cannabis use during adolescence may impair cognitive development and increase the risk of psychotic symptoms. Prevention strategies: clear parental expectations, monitoring of activities and peers, school-based prevention programs, and modeling healthy behaviors. Treatment for adolescent SUDs includes motivational enhancement, CBT, family therapy, and medication (buprenorphine for opioid use).
Routine Screening and Preventive Care
Confidentiality should be discussed at the beginning of the visit — adolescents need to know what is and is not confidential. The HEADSSS assessment guides psychosocial screening: Home, Education/Employment, Activities, Drugs, Sexuality, Suicide/Depression, Safety. Screening for: depression (PHQ-9), substance use (CRAFFT), STIs (chlamydia and gonorrhea screening in sexually active adolescents), cervical cancer (Pap smear starting at age 21), and immunizations (Tdap, HPV, MenACWY, MenB, influenza, COVID-19).
Common Adolescent Health Concerns
Acne vulgaris. Affects 85% of adolescents. Treatment: topical retinoids (adapalene, tretinoin), benzoyl peroxide, topical antibiotics, and oral antibiotics (doxycycline) for moderate disease; isotretinoin for severe, scarring, or treatment-resistant acne. Spironolactone is effective for hormonal acne in females.
Scoliosis. Lateral curvature of the spine >10 degrees. Screening is recommended in females at age 10–12 and in males at age 13–14. Curves <20 degrees: observation. Curves 20–40 degrees: bracing. Curves >45–50 degrees: surgical correction.
Sports physicals (pre-participation evaluation). Screen for cardiovascular risk (syncope, chest pain, palpitations, family history of sudden cardiac death), musculoskeletal issues, and concussions. The American Heart Association 14-element screening questionnaire identifies at-risk athletes.
Dysmenorrhea. Painful menstruation affects 50–90% of adolescents. Treatment: NSAIDs, heat, exercise, and hormonal contraceptives. Secondary dysmenorrhea (endometriosis) should be considered in those not responding to first-line treatment.
Summary
Adolescent healthcare requires developmentally appropriate, confidential services that address physical health, mental health, and risky behaviors. Puberty is a normal transition with wide variation in timing. Mental health conditions commonly emerge during this period and require screening and treatment. Substance use should be assessed at every visit. Routine screening for depression, STIs, scoliosis, and immunization status is standard. The HEADSSS framework guides comprehensive psychosocial assessment.