Adolescent Health: Puberty, Mental Health, Substance Use, and Screening

Introduction

Adolescence (ages 10-19) is a period of rapid physical, cognitive, emotional, and social development. Leading causes of morbidity and mortality in adolescents include unintentional injury (motor vehicle crashes), suicide, homicide, substance use, and mental health disorders. Preventive care includes screening for depression, substance use, STIs, and risk behaviors.

Puberty

Tanner Staging (Sexual Maturity Rating)

Stage	Female (Breast)	Female (Pubic Hair)	Male (Genital)	Male (Pubic Hair)
1	Prepubertal (no glandular tissue)	No pubic hair	Testes <2.5 mL, penis <6 cm	No pubic hair
2	Breast bud (thelarche); areolar enlargement	Sparse, long, slightly pigmented hair along labia	Testes 2.5-4 mL; scrotum thinning/reddening	Sparse, long, slightly pigmented hair at base of penis
3	Breast and areolar enlargement (no contour separation)	Darker, coarser, curlier hair spreading over mons	Testes 8-12 mL; penis lengthening	Darker, coarser, curlier hair spreading over pubis
4	Areola and papilla form secondary mound	Adult-type hair but smaller area	Testes 15-20 mL; penis widening in width	Adult type but smaller area
5	Mature breast (areola recedes to contour)	Adult type, spread to medial thighs	Testes >25 mL; adult penis	Adult type, spread to medial thighs

Pubertal Timing

Event	Females (Average Age)	Males (Average Age)
Onset (Tanner 2)	9-11 years (breast development)	10-12 years (testicular enlargement)
Peak growth velocity	11.5 years	13.5 years
Height increase during puberty	25-30 cm (10-12 inches)	28-32 cm (11-13 inches)
Menarche (first period)	12.5 years (range 10-16)	N/A
Spermarche (first ejaculation)	N/A	13-14 years
Growth plate fusion	16-18 years	18-20 years

Precocious and Delayed Puberty

Condition	Definition	Causes
Precocious puberty	Tanner 2 in girls <8 years; boys <9 years	Central (GnRH-dependent): idiopathic, CNS tumor, hypothalamic hamartoma; Peripheral (GnRH-independent): gonadal/adrenal tumors, precocious adrenarche/thelarche variants
Delayed puberty	No Tanner 2 by age 13 (girls) or 14 (boys)	Constitutional delay (most common); Hypogonadotropic: chronic illness, eating disorder, excessive exercise, Kallmann, pituitary tumors; Hypergonadotropic: Turner (girls), Klinefelter (boys), post-chemotherapy

Mental Health

Adolescent Depression

Statistic	Value
Lifetime prevalence (adolescents)	15-20%
12-month prevalence	8-15%
Sex ratio	Female > Male (2:1 after puberty)
Comorbidity	Anxiety (50%), substance use (30%), ADHD (20%)
Suicide - 2nd leading cause of death	Yes (ages 10-24)

Screening (PHQ-9 Modified for Adolescents)

PHQ-A Score	Severity	Action
0-4	None-minimal	No action
5-9	Mild	Monitor; consider counseling
10-14	Moderate	Counseling +/ medication
15-19	Moderately severe	Medication + counseling
20-27	Severe	Medication + counseling; consider referral

PHQ-2 (Brief Screen)

Question	Response (0-3)
Over past 2 weeks: little interest or pleasure in doing things	0 (not at all) to 3 (nearly every day)
Over past 2 weeks: feeling down, depressed, or hopeless	0 to 3

Score	Action
0-2	Negative screen
3-6	Positive screen; administer full PHQ-A

Suicide Risk Assessment

Risk Factor	Acute Risk Factors	Protective Factors
Prior suicide attempt (strongest predictor)	Suicidal ideation with plan and intent	Connectedness to family/school
Mental health disorder (depression, bipolar, substance use, conduct disorder)	Access to lethal means (firearms, medications)	Cultural/religious beliefs against suicide
Family history of suicide	Acute psychosocial crisis	Skills in problem-solving/conflict resolution
LGBT+ identity (especially unsupported)	Agitation or severe anxiety	Access to mental health care
History of abuse/trauma	Command hallucinations	Supportive adults
Chronic medical condition	Hopelessness	Future orientation
Bullying (victim or perpetrator)	Recent loss/humiliation

Responding to Suicidal Ideation

Step	Action
1	Ask directly: “Are you thinking about killing yourself?” (does not increase risk)
2	Assess: thoughts, plan, intent, means, timeline
3	Remove lethal means (guns, medications)
4	Do not leave alone
5	Create safety plan with trusted adult
6	Activate crisis services (988 Suicide and Crisis Lifeline)
7	Emergency evaluation if plan, intent, or means present

Substance Use

Common Substances

Substance	Prevalence (HS Seniors, Past Year)	Age of First Use	Risks
Alcohol	45-50%	14-16 (median 15)	Impaired driving (leading cause of teen death), binge drinking, DUI, legal consequences, addiction
Marijuana	30-35%	15-17	Impaired driving, cognitive impairment (especially <16), cannabis use disorder, psychosis risk
Vaping/nicotine	15-25% (past 30 days)	14-16	Nicotine addiction, lung injury (EVALI), gateway to smoking, brain development interference
Prescription opioids (misuse)	2-5%	Often from own prescription or peer	Addiction, overdose, fentanyl contamination
Stimulants (Adderall misuse)	5-10% (college students higher)	Often for academic performance	Anxiety, psychosis, heart risks
Cocaine	2-3%	16-18	Addiction, cardiac risk, nasal damage

CRAFFT Screening Tool

Question	Yes/No
C - Have you ever ridden in a CAR driven by someone (including yourself) who was high or had been using alcohol or drugs?
R - Do you ever use alcohol or drugs to RELAX, feel better about yourself, or fit in?
A - Do you ever use alcohol or drugs while you are ALONE?
F - Do you ever FORGET things you did while using alcohol or drugs?
F - Do your FAMILY or FRIENDS ever tell you that you should cut down on your drinking or drug use?
T - Have you ever gotten into TROUBLE while you were using alcohol or drugs?

Score	Category	Action
0	No use or no risky use	Positive reinforcement
1-2	Some risk	Brief counseling, education
3-6	High risk	Full assessment, referral

Acne Vulgaris

Severity Classification

Severity	Type	Lesions	Treatment
Mild	Comedonal (whiteheads, blackheads)	<20 comedones, <15 inflammatory lesions	Topical retinoid (tretinoin, adapalene) +/- benzoyl peroxide
Mild-moderate	Comedonal + papular	20-100 comedones, 15-50 inflammatory lesions	Topical retinoid + benzoyl peroxide +/- topical antibiotic
Moderate-severe	Papular, pustular, nodular	50+ inflammatory lesions, 5+ nodules	Topical + oral antibiotic (doxycycline 50-100 mg BID, minocycline) +/- combined OCP (in females)
Severe/cystic	Nodulocystic	Numerous nodules, cysts, scarring	Oral isotretinoin (Accutane)

Isotretinoin (Accutane) Key Points

Aspect	Detail
Indication	Severe nodulocystic acne, failed other treatment
Dose	0.5-1 mg/kg/day for 4-6 months
Monitoring	LFTs, lipids, CBC monthly; pregnancy testing (iPLEDGE program)
iPLEDGE	REMS program to prevent pregnancy (teratogenic)
Common side effects	Cheilitis (100%), dry skin, epistaxis, myalgias, photosensitivity
Serious risks	Teratogenicity (fetal malformations), depression/suicide (controversial), pseudotumor cerebri, IBD exacerbation

Scoliosis Screening

Aspect	Detail
Screening method	Forward bend test (Adam’s test)
Equipment	Scoliometer
Positive screen	Trunk rotation asymmetry >5-7 degrees
Age of screening	Girls: 10-12 years (twice); Boys: 13-14 (once)
Diagnostic imaging	Standing posteroanterior spine radiograph (EOS preferred)
Curve measurement	Cobb angle

Cobb Angle	Management
<10 degrees	No treatment; follow-up in 1 year
10-20 degrees	Observation; X-ray q6-12 months if immature
20-25 degrees (skeletally immature)	Brace (Boston, Milwaukee, Charleston) 16-23 hours/day
25-40 degrees (immature)	Brace treatment
40-45 degrees (immature)	Brace; consider surgery
>45-50 degrees	Consider surgical correction (posterior spinal fusion)

Sports Physical (Preparticipation Physical Evaluation - PPE)

Timing and Frequency

Aspect	Recommendation
Frequency	Annually
Timing	6-8 weeks before season to allow treatment
State requirements	Varies (most require every 1-2 years)
Comprehensive vs focused	Comprehensive at entry to MS/HS; focused with interval history

Key Components

Component	Assessment
Medical history	Prior injuries, hospitalizations, surgeries, chronic illness, allergies, medications
Cardiac history	Chest pain, palpitations, syncope, shortness of breath, prior murmur, family history of sudden cardiac death, cardiomyopathy, Marfan, long QT
Neurologic history	Concussion(s), head injury, neck injury, stingers, seizures
Musculoskeletal	Prior fractures, sprains, dislocations, surgeries, joint pain/swelling
Menstrual history (female)	Age of menarche, regularity, amenorrhea (female athlete triad)

Cardiac Screening (AHA 14-Element Checklist)

Personal History	Family History	Physical Exam
Chest pain/discomfort with exercise	Family member with sudden cardiac death <50	Heart murmur (auscultation: supine + standing)
Unexplained syncope/near-syncope	Family history of hypertrophic cardiomyopathy	Femoral pulses (coarctation)
Excessive exertional dyspnea/fatigue	Family history of long QT, WPW, or other channelopathy	Stigmata of Marfan (arm span, wrist/thumb signs, pectus)
Heart murmur or high blood pressure	Family history of coronary artery disease <50	Blood pressure (both arms)
Prior restriction from sports

ECG as Screening Tool

Aspect	Recommendation
Routine ECG for all athletes	Not recommended (AHA, AAP) - high false positive rate
ECG with abnormal history or exam	Indicated
Cardiologist referral for abnormal ECG	Yes

Common Disqualifying Conditions

Condition	Restriction
Hypertrophic cardiomyopathy	No competitive sports (except low-intensity)
Myocarditis	No sports until resolved (3-6 months)
Long QT syndrome	Depends on subtype and symptoms
Concussion (acute)	No sports until cleared by medical professional
Fever	No sports until afebrile 24 hours
Uncontrolled hypertension	No power lifting until controlled
Single kidney	Assess contact sports (shared decision making)
Single testicle	Protective equipment recommended
Mononucleosis (splenomegaly)	No contact sports until spleen normal (3-4 weeks)
Diabetes	OK if well-controlled; monitor glucose during activity