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Most people, the world over celebrate coming of age as a momentous turning point in the life of their child. However the lines become blurred in US culture, since there's no official ceremony as such or formal rite of passage that recognizes when a boy becomes a man and a girl becomes a woman.
As children reach puberty earlier and earlier over the last century or so, researchers are yet to concur on the primary reason behind this phenomenon; though they do agree that it appears to be related to improved child health and body fat percentage, especially in girls.
Since estrogen and a lot of other sex hormones come from fatty products, particularly cholesterol, body mass plays a role in predicting the onset of puberty, because you have to have a certain amount of body fat to hit puberty.
The researchers suggest that the increasing number of artificial hormones present in modern processed foods, improved nutrition, increased caloric intake and decreased melatonin levels (due to the higher exposure to artificial lights emitted from television sets, computer monitors and other lights), could also play a part.
"I've seen menses start in girls as young as nine," says Dr. Akua Afriyie-Gray, OB/GYN at Anna Rural Health, in Anna, IL. "The age can vary with ethnic background. Those who are heavier can also have an early puberty."
The World Health Organization suggests that adolescence can stretch from 10 to 19 years of age. However US statistics point to adolescence beginning between the ages of 12 and 14 and ending around 19 or 20.
Physicals, Pap smears and pelvic exams
The production of ovarian hormones in girls and testicular hormones in boys trigger the development of secondary sex characteristics - breasts in girls and deeper voice in boys.
Yet, it often takes the first period for most parents to figure out that their girl is growing up. Hence it makes sense to ask the doctor how your child is developing, if you visit the pediatrician on a yearly basis, says Afriyie-Gray.
The American Academy of Pediatricians recommends pre-pubertal physical exams every other year. Once puberty hits, a physical exam is recommended every year, since risk factors increase.
Of ten boys are understandably nervous before their first physical exam when the physician may look at and palpate the testes and scrotum, if s/he sees something abnormal. However all physicians first explain what they are about to do, why they need to do it and make the child as comfortable as possible first, before beginning any exam.
Taking your female child for her first pelvic exam or first Pap smear can be an emotional experience as well. With thelarche (breast development) and menarche (the onset of menses) happening at earlier stages, parents need to be alert and sensitive to the changes that are taking place in their child's bodies.
"If the girl is sexually active, if she has irregular periods, or if she just wants to get ahead of the game and better understand what's going on in her body, a pelvic exam can be performed, if desired by the girl and her parents, depending on the condition / reason for visit to the gynecologist," says Afriyie-Gray.
Since the child may not be prepared for what a pelvic exam entails, gynecologists are usually more than willing to meet with the child and parent first and get to know them, all the while preparing them as to what they can expect during the exam, which will take place on the next visit.
"The youngest kid I did a pelvic exam on was probably only about 10 years old," recalls Afriyie-Gray. "We thought it was a mass in her ovary. Luckily it turned out to be a cyst."
"There are very few people in my patient population that haven't had sex by age 21," admits Afriyie-Gray. "The majority come in by age 14-15 for their first pelvic exam, which tells you something about how much the age has dropped for sexual activity to begin."
So when does a girl get her first pap smear? The American College of Obstetrics and Gynecology recommends having a Pap smear by age 21 or within three years of beginning sexual intercourse. This is specifically related to exposure to the human papillomavirus (HPV), which is sexually transmitted and associated with cervical cancer.
Since a lot of girls may be reluctant to reveal to their parents that they are not virgins anymore, Dr. Kristen Jacobs, family medicine physician, specializing in preventative health, women and children's health and anti-aging skincare at Wise Health Solutions, in Mt. Vernon, IL, says she always chooses to send the parent out of the room and ask the adolescent in private, if she is sexually active. Promising confidentiality is a strategy that works with the girls every time, she says.
According to Jacobs, "Parents don't want to think their daughter is sexually active. However teen pregnancies can and do happen and I think it's better to discuss contraception, irregular periods, abstinence, and safe sex with them, any chance I get. The key is to educate and help these kids any way possible, without being judgmental."
The teenage brain
Experts argue that the onset of puberty affects how children perceive and participate in relationships, sexual activity, drugs and other risk taking behavior. There are higher expectations in the home and school setting for adolescents and it can be challenging as they make the biological, psychological and social transition between childhood and adulthood.
"Research says there is a growth spurt in the brain around age 11-12, as pruning and organization take place" says Lynda Killoran, child and adolescent clinical services manager, at Southern Illinois Regional Social Services (SIRSS), in Carbondale, IL. "The brain of a small child is designed in one way where they need mom to pick them up or get milk for them. This slowly drops away and the brain adapts to new needs as they grow older. Planning, strategy and judgment take time to occur, as the teenage brain is still in construction."The "under construction" nature of the adolescent brain helps explain why teenagers can act impulsively and often foolishly. New studies report that the pre-frontal cortex - responsible for planning, organizing thoughts, setting priorities, suppressing impulses, weighing the consequences of one's actions and therefore using good judgment and making wise decisions - usually does not reach a genuine level of maturity until a person reaches their mid-twenties!
Thus a 16-years-old may have a fully developed body, but their brains are still very much in the development phase.
Dr. Ronald Chediak, pediatrician, at Heartland Regional Medical Center, in Marion, IL, puts it aptly, "There's really no difference between a 12-year-old and a two-year-old. A two-year-old can think concretely, so you don't deal with him or her abstractly. A 12-year-old is capable of abstract thought, yet he or she is not capable of using it abstractly as yet. Hence they still need the rules and structure that a two-year-old needs."
Real life conflicts
When your teenager comes bounding down the stairs in completely inappropriate attire, Killoran says you need to be asking your child in a calm and composed voice, "What do you think will be the consequences of wearing those clothes?", instead of screaming shrilly, "What the hell do you think you're wearing?"
Since all teenagers are essentially searching for their identities, striving for independence, wanting to make their own decisions and lead their own lives; the conflict that arises and often escalates between parents and their adolescent kids is tragic in a way, says Killoran. Most parents come from a place of love and caring, only wanting the best for their kids. But from the teenage point of view, the parents are holding them back, reining them in and hence they tend to push their boundaries as much as possible.
Another minefield fraught with emotional conflict is the whole concept of dating. While many parents in the United States, allow their kids to start dating around 14-15 years of age, yet others think 17-18 is a more appropriate age to start.
If for example your 15-year-old daughter says she's going to Bobby's house and you know that Bobby's parents aren't home, Killoran suggests the following strategy. "You could say, "Okay, you can go, but I will check on you anytime," instead of saying, "No way." That way the teenager gets to practice some independence, but within the boundaries you lay out. It's almost like letting out the rope a little at a time, and yanking it right back if there is a problem."
Of course there are certain circumstances when you as a parent do put your foot down and set limits, when you say "No," if for example, your teenager wants to smoke pot or drink and drive with a bunch of friends, says Killoran. Other times there's compromise involved, since it's normal for some of the kids to be negotiating.
Experts say that this is the age when kids learn the art of negotiation, but along with it comes the need to learn responsibility. Parents should be able to and wanting to negotiate.
An interesting analogy would be the road, says Chediak. "While you're free to go wherever you want, you still need to follow the rules to be safe. The same applies to 12-year-olds. They are still not cognitively firing on all cylinders as yet. But we tend to cut them totally loose too soon and they end up making terrible mistakes."
Hence it's important to give your child the opportunity to make decisions, plan and practice good judgment, while you as a parent are still there as a safety net. For having a good role model to emulate, along with the opportunities to see the positive or negative consequences of the choices they make, teaches the adolescent important life skills.
Sex and the teenager
"I've had cases with 14-year-old teenage girls coming to see me, pregnant and not knowing how they got pregnant in the first place," says Afriyie-Gray. "In the past there may have been a cultural taboo with sex talk. But with the times we live in, it's a must to talk and educate your children about their bodies and sex."
Affiliated with Memorial Hospital of Carbondale, Afriyie-Gray sees plenty of adolescents in her clinic everyday, a lot of whom are referred to her from the public health clinics in the area. "They are either seeking information on birth control or about their own general health, with or without their parents' knowledge," she says.
In fact, The National Campaign to Prevent Teen Pregnancy found that nine out of 10 adults (89 percent) believe parents should talk to their kids about sex, but are embarrassed, uncomfortable and uneducated about how to say it, when to start and what to say.
While there has to be a level of trust built between the parent and child, the earlier parents start talking about sex and sexuality with their kids, the better. Experts report that when puberty happens early, kids have not as yet reached the psychological plane they need to be at to deal with what it really means.
While most schools do have comprehensive programs on sex education, it's best not to leave it to the school to cover everything. "Even if they've had sex education classes in school, they are confused about the changes happening to their body and have trouble figuring out why they are 'abnormal'", says Afriyie-Gray.
"As the questions come up, make sure you answer them honestly, as developmentally appropriate to them and their age," advises Killoran. "But don't wait for puberty to answer questions, since by then your kids would have gotten the information, a lot of it possibly wrong, from their peers, the internet and elsewhere."
Sometimes your child may not want to talk to you about it. In that case you can always leave books, pamphlets and educational materials lying around, for them to read privately. If you are uncomfortable talking to your kids, about sexuality, you can always set up an appointment with your physician, nurse, adolescent health center, or the public health department, where they will discuss physical development, sex and sexuality, and impart sex education to your children.
Personal value systems play an important role too. If for example a parent is deeply entrenched in the Church, he or she may approach the whole sex talk from the point of view of abstinence.
A national study from the University of Minnesota confirmed that parents play a critical role in their teen's sexual decision making. The National Longitudinal Study of Adolescent Health studied over 90,000 students in grades 7 through 12 - the largest national study of adolescents ever conducted - and found that positive parent-family relationships help prevent teens from engaging in a wide range of risky behaviors, including early sexual intercourse.
Experts suggest that whatever way you may want to approach it, ensure you deliver a clear message which properly integrates your values and beliefs; so that your teens are armed with all the knowledge they need to get through this life stage without any hiccups.
Remember that parents can be extremely influential in their child's decision making, regardless of whether they made good or bad choices as teens themselves.
Don't blame puberty on behavioral problems!
While there's a direct connection between mood disorders and aggression, it's a myth however that puberty brings about behavioral problems.
"70 to 80 percent of people who report back to pubertal times do not report it as stressful," says Dr. Ajay Mayor, the region's only child and adolescent psychiatrist, at Illinois Centre Behavioral Health, in Marion, IL. "Puberty is blamed more than it should be."
While behavioral problems like aggression can be the presenting symptom of some kids, the underlying cause can be anything from depression, anxiety, to drug abuse and/or any significant stress at home says Mayor. Puberty can be just another added stressor to a situation like this
Sometimes pubertal age kids whose ADHD has been undiagnosed till now, start self experimenting with drugs and hallucinogenic substances to self correct the problem, says Mayor. Something like this can in turn result in aggression, self-harm, damaging property, and/or violence towards others.
While this kind of behavior can frustrate parents, sometimes it can go as far as the child being ostracized when the school expels him or her for unacceptable behavior.
"There's a lot of depression, anxiety and drug abuse that's not detected at the right time in this age group," says Mayor. "The luckier ones end up in the doctor's office. Others may end up in juvenile detention."
One of the solutions to this conundrum lies in the school setting itself. "Some kind of screening for kids and an educational system for both parents and kids is what we desperately need in every school today," says Mayor. "Kids may need some counseling, but unless we identify them it's not going to get any better."
Statistics show that currently only around two percent of schools in the country screen all kids for mood and behavioral disorders, while only about seven percent of schools screen hi-risk kids. In their defense, schools cite lack of funds and say they have to often struggle with parental consent after identifying a problem.
It's not unheard of for a parent to dismiss a problem with an, "Oh, but he's just a normal 14-year-old," despite the fact that the child in question may have just beaten up a classmate so badly that an ambulance had to be called in to the scene of aggression.
Mayor cautions that it's not normal 14-year-old behavior to beat up classmates for example, since most people go through this stage of life without any significant mood problems or legal issues.
As a parent or teacher, if you notice any significant changes in your child's behavior: irritability, anger, self-harm, untoward aggression, sleep pattern changes, its best to get help - individual counseling, family counseling and medications (in that order).
The physical changes that occur
"Puberty can start in girls between 9 and 12 years of age, and in boys, between 9 and 14 years of age," says Dr. Ronald Chediak, pediatrician, at Heartland Regional Medical Center, in Marion, IL.
In boys, the first physical signs of puberty begin with testicular and penile enlargement, says Chediak. As the testes drop, and hair begins to appear in the groin, underarm and facial area, the boy begins to experience growth spurts. The average age of pubic hair development in a boy is around 12 years of age.
"Height velocity typically peaks at age 14 in boys," says Chediak. The body shape begins to change as the boy's shoulders broaden and he gains weight and muscle.
As the vocal cords become longer and thicker and the voice becomes lower, it is not unusual for a boy's voice to change pitch abruptly or 'crack' at times. Soon the boy begins to experience spontaneous erections of the penis, and it is normal to have wet dreams.
In girls, the first sign that they will start menstruating within the next year or so is when breast buds start developing says Dr. Kristen Jacobs, family medicine physician, at Wise Health Solutions, in Mt. Vernon, IL.
Hair begins to appear in the underarm and vaginal area and a small amount of hair may even appear on the areola. Girls will experience growth spurts which typically peak at around age 11-11 1/2, accompanied by changes in body shape.
"The average age of pubic hair development in a girl is 11.2 years," says Chediak. "However you don't want to define puberty in girls by hair development, whereas hair growth is directly related to puberty in boys."
In both boys and girls there may be slight behavioral changes as well as a tendency to be more prone to acne and pimples, since the hormones and oil glands become more active during puberty.
New guidelines define 'normal' menstruation cycle
A new clinical report, published in Pediatrics, the official journal of the American Academy of Pediatrics (AAP), aims to help clinicians educate adolescents and their parents about what to expect of a first period, including average cycle length and timing of subsequent periods.
The report says that once an adolescent begins menstruating, her cycle should be assessed as a vital sign since it can be an indicator of other possible medical problems. According to the report, the age when a girl has her first period has remained relatively stable at between 12 and 13 years of age.
Among the information clinicians should share with patients: the menstrual cycle is from the first day of a period to the first day of the next period and may vary in length, with some girls experiencing four-week cycles and others more or less than four weeks.
Also, clinicians should convey that girls will likely get their first period about two to two and a half years after breast development begins.
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